Home --> Health Equity Toolbox --> Upstream Strategies for Community Health --> Implementing PBIs - Recommendations &Lessons Learned
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Implementing PBIs:
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1. Identify priorities in collaboration with the community.
Professionals must remember that residents themselves understand, better than anyone else, what their needs and assets are, and what will work in their community. Traditional public health surveillance, assessment strategies, and data sources provide valuable information, but cannot replace local knowledge and the “lived experience” of residents. Often many interrelated problems exist simultaneously and quantitative, data-driven assessments can help inform prioritization. However, community members’ perceptions and understanding of problems are equally important and communities often know best what is needed to address those problems. Therefore, when providing technical assistance or other kinds of support to community groups, public health agencies and other professionals should work in true partnership with community members.
Sample Strategy
Community members in Alameda County, California led a community assessment process to assess and identify priorities. According to the BARHII Health Equity and Community Engagement Report (2013), local agencies involved in promoting health equity consistently engaged community members in assessments, program planning, and implementation of strategies. Community concerns regarding a lack of educational support and activities for youth led three agencies to create after-school, summer, and evening programs, including community leadership training. Similarly, community concerns about neighborhood violence led to the organization of violence prevention workshops that include dialogue between the local police department and community members. For more information about Alameda County’s health equity efforts, including lessons learned and ongoing challenges, visit: http://barhii.org/download/publications/hecer_alameda.pdf.
2. Embrace a broad definition of health and promote a comprehensive approach.
Health is more than the absence of disease. A healthy community is one that promotes physical, mental, and social vitality. It is important to view health holistically, and consider the various factors that impact the health of the community. This may mean that health professionals need to support efforts that are not defined by health or may appear to be outside the scope of traditional health-related efforts.
Sample Strategy
It is often useful to educate partners about the health impact of their work, but it is not necessary to make everything explicitly about health in order to create positive change. An example of this approach is the role of the Boston Public Health Commission (BPHC) in advocating for the “Jobs not Jails” program in Massachusetts. “Jobs not Jails” is a campaign to reform the state’s criminal justice system by focusing more attention on prevention, treatment, and rehabilitation. The BPHC recognizes that by addressing problems related to incarceration and recidivism, “Jobs not Jails” will indirectly have major implications for health equity. Notably, the BPHC acknowledges that the health equity-oriented impacts that may result from the program may not be the main drivers of the reform effort. Instead, the BPHC supports the effort on the principle that health equity will be an indirect result of the program, in addition to the intended outcomes of reducing the numbers of people being incarcerated and increasing the number of people who are employed (B. Ferrer, personal communication, June 1, 2009). For more information regarding “Jobs not Jails” see http://jobsnotjails.org/jnj/.
3. Maintain a focus on equity.
Healthy communities benefit everyone. However, without attention to equity and the factors that create inequity, we are likely to improve the average health of different population groups without closing the gaps between them. The resources needed for health are not equally distributed across communities, and health professionals and other local leaders must focus on creating a level playing field for all communities. This becomes particularly important when identifying priority communities for interventions and investments. As mentioned earlier, all communities could benefit from healthier living conditions and more attention to the SDOH. However, state agencies and community-based organizations considering PBIs should look first to those communities with the greatest needs and the greatest opportunities for improvement. Similarly, leaders should recognize that not all communities will be affected in the same way by standardized or statewide policies and programs, and to close the gaps, they must consider the impact on the most vulnerable communities rather than the average or typical community.
Sample Strategy
In Delaware, the IM40® initiative exemplifies an approach to targeting communities using an equity lens. IM40® is a partnership between AstraZeneca, the United Way of Delaware, and several community-based organizations. It is a comprehensive approach to positive youth development designed to improve academic performance and overall well-being of Delaware’s youth aged 12 through 15. As of April 2015, the initiative had been launched in three target regions: Eastside Wilmington, North Dover, and Seaford/Bridgeville/Laurel. These communities were identified through a comprehensive assessment of the needs in those communities, resources available to address those needs, and the recognition that youth living in these areas face a disproportionate number of challenges to healthy development relative to those living in other communities. Similarly, community-based organizations were identified in each of the target areas to implement the initiative, which reflects an appreciation for the unique nature of communities, the importance of relationships in those communities, and the fact that a “one size fits all” approach is less likely to work.
4. Build community and multi-sector partnerships.
Partnerships are necessary to identify and prioritize concerns and to actualize solutions for remedying them. A network of partnerships should mirror the complexity of the community and the priorities identified by the community. Therefore, the network will likely need to include stakeholders from multiple and diverse sectors: health care, public health, government, law enforcement, education, faith-based organizations, non-profits, transportation, agriculture, etc. It is important to create buy-in with partners so they understand how their organization and assistance are keys to achieving the overall goal and how their organization might benefit from participating. Once stakeholders identify mutual areas of interest, those interests can be leveraged to create healthier communities. Specific projects or mechanisms for collaboration can facilitate partnership development, often leading to long-term relationships. Multi-sector partnerships and collaborations across community agencies can generate collective impact, such that the whole is greater than the sum of the parts. Such collaboration is necessary to address complex social problems such as health inequities. The CTB includes several tools to support partnership development, such as the National Association of County and City Health Officials’ “Mobilizing Action through Planning and Partnerships” (MAPP) process. MAPP is an effective way to garner stakeholder and community engagement to improve community health. More information about MAPP can be found in the CTB and here.
Sample Strategy
An example of a strong network of partnerships can be seen in a local advocacy project in San Mateo County, California. According to the Bay Area Regional Health Inequities Initiative (BARHII) Health Equity and Community Engagement Report (2013), a local health partnership, with training and support from the San Mateo County Health System, organized mobile home park residents to advocate for and establish a rent control ordinance. The partnership persuaded an affordable housing management company to purchase their mobile home park. Where residents were previously subject to an owner who constantly raised rents beyond what was affordable, ignored resident input, and neglected the grounds, they were now empowered as local leaders. According to BARHII (2013), “This community-driven project was sustained over time, led to increasing community pride, and resulted in environmental changes such as a renovated playground, pool, and community center.” For more information about San Mateo County’s health equity efforts, click here
5. Build awareness and appreciation for the social determinants of health.
Residents from low income or disempowered communities inherently understand the social determinants of health because they regularly experience the impacts of poverty, discrimination, poor quality schools, and inadequate access to other resources needed for health. Policy-makers and the general public, on the other hand, generally view health through a medical or behavioral lens without appreciating the social and environmental context for health and health inequities. It is important to raise awareness of the SDOH and the role of public policy in determining the distribution of the resources needed for health.
Sample Strategy
The Unnatural Causes campaign is a national effort, launched in 2008, explicitly to enlighten the public about social inequities in health. The campaign includes a website (www.unnaturalcauses.org) with a large collection of resources and a seven-part documentary film series, titled “Unnatural Causes: Is Inequality Making Us Sick?” Originally broadcast on public television in the fall of 2009, the film series has since been used in thousands of community events across the country. The Unnatural Causes film series is an effective tool for increasing awareness of the SDOH and equity and can be used to facilitate a community dialogue about change. California Newsreel, the producer of the film series and leader in the broader Unnatural Causes campaign, is currently developing a follow-up campaign and film series focused on the role of early childhood development in health and equity (www.raisingofamerica.org).
6. Leverage successful PBIs for regional and state level changes.
Communities are unique in their needs, assets, resources, and culture. Nonetheless, regional and state level initiatives can support local efforts and help bring successful efforts to scale. Similarly, state level policy changes can often address community needs that are beyond the reach of community stakeholders and/or can address health inequities more systematically.
Sample Strategy
Delaware’s Help Me Grow (HMG) program is a partnership of many statewide organizations that promotes healthy early childhood development. Launched in Delaware in 2012, HMG began as a pilot program in a single community in Hartford, Connecticut in 1998. The initial pilot yielded such promising results that the Connecticut legislature funded a statewide replication of the Hartford program in 2002. In 2010, the W. K. Kellogg Foundation funded the establishment of the HMG National Center to promote widespread implementation and impact.
Currently in Delaware, HMG offers a comprehensive, upstream approach to promote maternal and child health. It is a result of strong partnerships and support from many components of Delaware’s early childhood community including the Delaware Early Childhood Council, the Division of Public Health’s Maternal and Child Health Program, the Race to the Top Early Learning Challenge grant, the United Way of Delaware, Nemours Health and Prevention Services, American Academy of Pediatrics, and many others. Each partner is working to promote strong-parent child relationships, safety, child development and overall family health and well-being. With technical assistance from the National Center, Delaware’s HMG program is supported at the state level and reaches across every community statewide.
Additional information about the HMG National Center can be found at http://www.helpmegrownational.org/index.php. Information specific to HMG in Delaware is available at http://dethrives.com/help-me-grow.
Currently in Delaware, HMG offers a comprehensive, upstream approach to promote maternal and child health. It is a result of strong partnerships and support from many components of Delaware’s early childhood community including the Delaware Early Childhood Council, the Division of Public Health’s Maternal and Child Health Program, the Race to the Top Early Learning Challenge grant, the United Way of Delaware, Nemours Health and Prevention Services, American Academy of Pediatrics, and many others. Each partner is working to promote strong-parent child relationships, safety, child development and overall family health and well-being. With technical assistance from the National Center, Delaware’s HMG program is supported at the state level and reaches across every community statewide.
Additional information about the HMG National Center can be found at http://www.helpmegrownational.org/index.php. Information specific to HMG in Delaware is available at http://dethrives.com/help-me-grow.
7. Build skills and capacities of health professionals.
Workforce development is important to creating healthy communities because new and different kinds of work are required of health professionals. Similar to community residents, many health professionals inherently appreciate the SDOH, often because the needs of their patients or target population are beyond the scope of their professional practice. In a recent survey, four out of five physicians in America and 95 percent of physicians serving low-income urban communities say that patients’ social needs are as important to address as their medical conditions; however, only one in five are confident in their ability to address these needs (Robert Wood Johnson Foundation, 2011). For instance, clinicians often recognize that their asthma patients suffer due to poor housing conditions. They prescribe effective medications to treat asthma symptoms, and can do much to alleviate pain and suffering. However, many clinicians are frustrated by their limited ability to help their patients avoid unhealthy living conditions that trigger asthma symptoms. In another example, health educators and other public health professionals recognize that nutrition education is inadequate if their audience does not have access to affordable fruits and vegetables.
The skills needed to build multi-sector partnerships or to advocate for environmental and other policy changes are often not taught in medical schools or schools of public health. Professionals need additional training to build the knowledge and capacity for new approaches to promoting community health. These new skills and capacities should be institutionalized in public health and medical education programs and professional development.
The skills needed to build multi-sector partnerships or to advocate for environmental and other policy changes are often not taught in medical schools or schools of public health. Professionals need additional training to build the knowledge and capacity for new approaches to promoting community health. These new skills and capacities should be institutionalized in public health and medical education programs and professional development.
8. Be flexible and plan ahead for new ways of working.
The kinds of changes needed to promote healthy communities rarely happen quickly. Managers should explore ways in which staff may have more flexibility and consider different kinds of performance expectations. Similarly, traditional approaches to funding health-related projects (e.g. disease-specific efforts) may not be conducive for a place-based approach. Flexible funding streams can facilitate efforts to target living conditions underlying many interrelated health problems. Finally, funders should consider investing for the long-term, instead of funding short-term projects.
Sample Strategy
Many national grant-making organizations are embracing upstream approaches to community health which recognize the importance of social determinants and community engagement. The Annie E. Casey Foundation’s Making Connections initiative was a 10-year, $500 million investment to strengthen families and communities through place-based initiatives. Although the program recently concluded, an evaluation of the effort showed improvements in the capacity for community change. However, evidence of widespread impact on population outcomes was limited (Annie E. Casey Foundation, 2013). Many important lessons were learned from Making Connections that can be applied to funding strategies in Delaware. For instance, evaluation findings revealed an even greater need for sustained, sufficient investments. Similarly, it is important for funders (and those working in communities) to do a better job of defining success for place-based community change, and identifying the models and strategies that will produce measureable impacts. Additional information about these and other lessons learned from Making Connections may be found at http://www.aecf.org/m/blogdoc/aecf-CommunityChangeLessonsLearnedFromMakingConnections-2013.pdf#page=6. Examples of other upstream funding initiatives include those of the California Wellness Foundation (http://www.calwellness.org/) and the Kresge Foundation (http://kresge.org/programs/health).
9. Document and disseminate success stories.
Evaluating community health efforts is important for continuous improvement and expansion. Unfortunately, evaluation is particularly difficult due to the complex nature of PBIs and collaborative upstream strategies, coupled with the long timeframe that is often needed to see the health impacts of changes in the SDOH. Therefore, success stories become important as do other kinds of qualitative and innovative approaches to evaluation (more about evaluation is found in Section 7). Champions should be celebrated to raise awareness about successful approaches.
Sample Strategy
Many national grant-making organizations are embracing upstream approaches to community health which recognize the importance of social determinants and community engagement. The Annie E. Casey Foundation’s Making Connections initiative was a 10-year, $500 million investment to strengthen families and communities through place-based initiatives. Although the program recently concluded, an evaluation of the effort showed improvements in the capacity for community change. However, evidence of widespread impact on population outcomes was limited (Annie E. Casey Foundation, 2013). Many important lessons were learned from Making Connections that can be applied to funding strategies in Delaware. For instance, evaluation findings revealed an even greater need for sustained, sufficient investments. Similarly, it is important for funders (and those working in communities) to do a better job of defining success for place-based community change, and identifying the models and strategies that will produce measureable impacts. Additional information about these and other lessons learned from Making Connections may be found at http://www.aecf.org/m/blogdoc/aecf-CommunityChangeLessonsLearnedFromMakingConnections-2013.pdf#page=6. Examples of other upstream funding initiatives include those of the California Wellness Foundation (http://www.calwellness.org/) and the Kresge Foundation (http://kresge.org/programs/health).
10. Be patient and persistent, and be willing to take risks.
A long-term commitment to community change is vital. Building trust and authentic partnerships takes time. Changing conditions and policies that affect those conditions also takes time. Seeing a difference in health outcomes can take even longer. Therefore, recognizing the need for a long-term commitment at the outset is important to preventing unrealistic expectations.
Lessons learned from Marin County, California reveal the importance of health department staff having a sustained physical presence in the community. According to the Bay Area Regional Health Inequities Initiative (BARHII) Health Equity and Community Engagement Report (2013):
Lessons learned from Marin County, California reveal the importance of health department staff having a sustained physical presence in the community. According to the Bay Area Regional Health Inequities Initiative (BARHII) Health Equity and Community Engagement Report (2013):
“Physical presence in the communities served was among the keys to success discussed by both community representatives and LHD [Local Health Department] staff alike. One community representative stated that it is important when the LHD is “Being present, accountable, and genuine when ‘showing up’ and actually doing what is said that will be done.” Another community member shared that, the LHD “Showing up consistently on ‘non-health’ events, makes a lot of difference.” Some of these non-health events include food banks, PTA meetings, and school registration nights.” (for more details, click here)
When projects appear to be stalled or losing momentum, community champions and health professionals need to demonstrate leadership in the form of persistence and ongoing commitment. Part of that commitment is to advance social justice and equity, which is not always a popular or easy topic. Public health, as a field grounded in social justice, can play an important leadership role in this endeavor. Furthermore, partnerships can protect individuals and/or individual agencies or organizations from standing alone on difficult issues.