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The Role and Potential of Communities in Population Health Improvement: Workshop Summary (2015)

Chapter: 5 How Institutions Work with Communities

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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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5


How Institutions Work with Communities

The third panel of the workshop considered the role of institutions (academic, government, and private) in working with communities to build capacity and support change. An example of how a university can partner with community-based groups was provided by Jomella Watson-Thompson, an assistant professor in the Department of Applied Behavioral Sciences and the associate director for Community Participation and Research and the University of Kansas (KU) Work Group for Community Health and Development. Renee Canady, the chief executive officer of the Michigan Public Health Institute, discussed achieving collective impact through collaboration from her perspective as a former county health officer. Individual participants then discussed the importance of engaging the private sector as partners, the importance of collecting data with utility in mind, and, again, how to scale community organizing efforts. The discussion was moderated by Melissa Simon, an associate professor in obstetrics and gynecology, general and preventive medicine, and medical social sciences at the Northwestern University Feinberg School of Medicine.

MULTISECTOR PARTNERSHIPS

KU partners with various community-based groups, from grassroots neighborhood-based organizations to state and local departments, to build community capacity to support change and improvement, said Watson-Thompson from KU. Referring to a famous quote from Margaret

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Mead—“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed it is the only thing that ever has.” Watson-Thompson said that such small groups of individuals can be found in neighborhoods, in agencies and universities, and in organizations, including faith communities.

The Power of Partnerships

Watson-Thompson described to the workshop her first personal experience with capacity building, which took place in 1997. A father of four young children in the Ivanhoe neighborhood of Kansas City had become frustrated with the ills in his neighborhood, which included crime, drugs, and vacant housing, and he and his wife began to organize prayer vigils and other activities in the community. The couple then began to work with other groups that had expertise in community organization and mobilizing. The KU Work Group for Community Health and Development1 provided technical support and training. Seventeen years later, the Ivanhoe Neighborhood Council2 is still committed to neighborhood improvement. Echoing the comments of other presenters, Watson-Thompson said that a key element in the success of that effort was the provision of adult development (community education, training, and capacity-building activities) to help those in the community come together, solve their own problems, and sustain progress after the technical advisers left.

Watson-Thompson described how more than 100 block leaders came together to develop block-level plans to support change and improvement. These leaders also engaged in multi-sector partnership with academia (the KU Work Group), businesses, government agencies, schools, and residents. The KU Work Group facilitated 117 community changes, which led to improvements in various community outcomes, including housing and crime. Over a 4-year period, there was a 54 percent increase in housing loan applications, a 17 percent decrease in violent crime, and a 20 percent decrease in non-violent crime. After addressing the most pressing needs, the Ivanhoe Neighborhood Council moved on to other community needs, such as parks and farmers markets. This is an example of a general principle in community organizing, Watson-Thompson said: If one person in a community steps up and leads, others will join.

In another multisector partnership, the KU Work Group worked with the Kansas Department of Social and Rehabilitation Services and with community coalitions in 14 Kansas counties to address underage drinking using the Kansas Strategic Prevention Framework State Incentive Grant. Overall,

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1 For more information see https://communityhealth.ku.edu (accessed August 15, 2014).

2 See http://www.incthrives.org (accessed August 15, 2014).

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

Watson-Thompson said, there were 802 program policy changes implemented through engaging 12 sectors of the community, which resulted in a 9.6 percent decrease in self-reported 30-day alcohol use by youth in the 14 counties. This initiative has become a model in Kansas for how to support prevention work, Watson-Thompson said. Another example is the Latino Health for All Coalition, which works to address disparities in cardiovascular disease and diabetes in Kansas City by providing access to healthier foods, safe activities, and health care. The collaborative partnership supported 41 program, policy, and practice changes over the initial 3-year program period.3

Watson-Thompson said that each of these successful efforts adhered to three key principles for supporting population-level improvement:

  • Focus on the outcome. Work with community partners to identify the behaviors that need to be changed at the community and population levels.
  • Change the environment. Transform the community conditions to promote health and well-being.
  • Support the change process. Take action to assess, plan, act, intervene, evaluate, and sustain.

A Collaborative Action Framework for Population-Level Improvements

To guide the process of working with community partners, the KU Work Group adapted the Institute of Medicine (IOM) Framework for Collaborative Public Health Action in Communities (IOM, 2003, p. 178) (see Figure 5-1). All activity is implemented based upon the direction of the community partners, Watson-Thompson said. The key responsibility of the academic partner is to support the ability of other partners to implement these processes (see Table 5-1). Watson-Thompson stressed that this is not prescribing the process to the other partners, but rather providing the support so that they can implement and maintain the processes (Fawcett et al., 2010).

Change and improvement in communities is the result of comprehensive interventions. While single-dose (i.e., one-program) interventions are important, Watson-Thompson said that addressing complex and interrelated problems requires an influx of program, policy, and practice changes. When these community- and system-level changes are of suf-

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3 A review of collaborative partnerships may be found at http://www.ncbi.nlm.nih.gov/pubmed/10884958 (accessed July 25, 2014).

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

images

FIGURE 5-1 Framework for collaborative action for improving health and development.
SOURCE: Watson-Thompson presentation, April 10, 2014, adapted from IOM, 2003, Figure 4-1, p. 178.

ficient intensity and penetration, they can achieve population-level outcomes (Fawcett et al., 2003).

Watson-Thompson highlighted several core principles, assumptions, and values that guide the KU Work Group on community and health development. Improvements are directed toward the population and require change both in behaviors of groups of people and in the conditions of the environment. Issues should be determined by those most affected, she said, and attention should be on the broader social determinants of health. Because these are influenced by multiple interrelated factors, single interventions are unlikely to be sufficient. Change requires

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

TABLE 5-1 Best Processes for Capacity and Change Identified by Watson-Thompson and Others


Framework Components Collaborative Processes

Assess, prioritize, plan
  • Analyze information about problem/goal
  • Establish a vision and mission
Implement targeted action
  • Develop framework/model
  • Develop and implement strategic plan
  • Define organizational structure
  • Develop leadership
Change community conditions
  • Community mobilization
  • Implement effective interventions
  • Assure technical assistance
Achieve widespread behavior change
  • Document progress and use feedback
Improve population-level outcomes
  • Sustain the work
  • Make outcomes matter

SOURCE: Watson-Thompson presentation, April 10, 2014, adapted from Fawcett et al., 2010.

engaging diverse groups across sectors as well as collaboration among multiple partners. Finally, she concluded, partners are catalysts for change, building the capacity to address what matters to people in the community.

Challenges and Opportunities for Academic Institutions

In closing, Watson-Thompson said that the community members are the experts and the researchers are co-learners in the process. It is important to build trust and rapport with community partners and to assure early wins to build shared success and empower the community. This requires an infusion of resources and a commitment over time and across people (i.e., across changes in leadership). It is important to stay at the table and to be part of the process and, as noted by others, also to make sure to contribute to the community. Academia is a base for supporting change and improving the community, and it is the collective responsibility of academics working with communities to have collective impact, she concluded. The key aim, Watson-Thompson said, is to have “community-engaged scholarship” where collaborative research, teaching, and public service is integrated.

COLLABORATION AND COLLECTIVE IMPACT

Canady shared her perspectives on collaboration and collective impact based on her prior experiences as health officer for the Ingham County, Michigan Health Department. Collective impact is “long-term

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

commitments by a group of important actors from different sectors to a common agenda for solving a specific problem,” she said. “Their actions are supported by a shared measurement system, mutually reinforcing activities, and ongoing communication, and are staffed by an independent backbone organization.”

Collaboration is not the same as community engagement, which is not the same as community organizing, which is not the same as collective impact, she said. Citing Edmonson (2012), she explained that collaboration is about convening around programs and initiatives while declaring neutrality, whereas collective impact is more about working together to move outcomes. While collaboration uses data to prove things, collective impact tries to improve things. Collaboration is usually something in addition to what people already do, while collective impact entails integrating practices that get results into everyday work. Finally, collaboration is often about advocating for ideas, while collective impact advocates for what works. As an example, Canady said that when public health practitioners were focused on childhood obesity, the community responded that if children do not live to be 10, it does not matter if they are fat. In other words, violence and safety were the primary concerns of the community, and public health officials needed to shift their focus to address that. As defined by the Leadership Development National Excellence Collaborative,4 collaborative leadership in public health means that all the people affected by the decision are a part of the process, and the more that power is shared, the more power all of us working together have to use, Canady said.

Authentic Collaboration Between Institutions and Communities

Canady described three spheres of influence in a model of authentic collaboration between institutions and communities: leadership, the community, and the workforce. There is endorsement by leadership; engagement of, or advocacy by, community members who want to create change; and a workforce that is empowered to respond and to challenge the status quo. Collectively, the impact of the three together is greater than that of any one alone. In many cases, Canady noted, one person represents more than one sphere.

As an example, Canady said that in 1998 the Ingham County Health Department received a grant from the W.K. Kellogg Foundation’s Community Voices: Healthcare for the Underserved initiative to increase access to health care through community engagement. As part of its funded work, Ingham County began facilitated dialogues to discuss how

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4 See http://www.collaborativeleadership.org (accessed July 24, 2014).

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

to get community groups, organizations, and neighborhoods to see health department resources as their assets and how to get the health department to view the community’s assets as its greatest resource. Canady characterized these dialogues as emerging out of the need to recognize the “web of mutuality” between health departments and communities.5 An outgrowth of these dialogues was the establishment of institutions and organizations that began to work with the health department on these issues, including the African-American Health Institute, the Lansing Latino Health Alliance, and others. These exist, Canady said, because the community drove the health department to use its power to establish those entities. Relationships were also established with leadership in the Mayor’s Initiative on Race and Diversity.

Another example of establishing relationships to mobilize community assets for change in Ingham County is the Power of We Consortium (see Figure 5-2). Canady described how the directors of different human services agencies met regularly to ensure there was no redundancy in their services. Canady said that likely because of the mutual dialogue and learning they received individually and institutionally, they realized that others should be at the table joining them. Over time, what was called the human services collaborative, was opened up to the community and the Power of We Consortium was formed. The consortium, Canady said, is a network of networks, comprised of 12 issue-based coalitions as well as other community partners and stakeholders which come together once per month to work on issues of common interest and to hold each other accountable.

Canady also described two current activities in Ingham County that are part of a statewide push for public health professionals to partner with community organizers and to view the community as partners rather than as clients. The Building Bridges Initiative is focused on mobilizing community partnerships to identify and solve health problems and on informing, educating, and empowering people about health issues. The Power to Thrive movement is building a shared culture for change and action, bringing together local health departments, the state department of health, and community organizing entities to consider public health issues in a local context. Canady explained that the movement’s goal is to establish a model of synergy that allows for candid and authentic conversations and discussions that move toward action.

____________

5 Canady mentioned Martin Luther King, Jr., and was likely referring to King’s “Letter from Birmingham Jail,” where he discussed the “network of mutuality” in which whatever threat is faced directly by one, indirectly affects all. Available at http://mlk-kpp01.stanford.edu/index.php/resources/article/annotated_letter_from_birmingham (accessed July 16, 2014).

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

images

FIGURE 5-2 The Power of We Consortium structure.
NOTE: This figure has been updated since Canady presented it at the workshop, courtesy of the Power of We Consortium.
SOURCE: Provided by Power of We Consortium, 2014.

Facilitated Dialogue as a Vehicle for Change

Ingham County used facilitated dialogue as a vehicle for change. In implementing this methodology, it was important to establish what a dialogue is and to distinguish it from debate, training, or conversation. In a debate, Canady said, competing factions use persuasion to convince others of the “best” solution. In contrast, dialogue focuses on a common purpose, emphasizing listening, in order to identify multiple, complementary solutions. Training is a unidirectional flow of information, embracing what is known and teaching new solutions. Dialogue is a mutual exchange of information, embracing what is not known and discovering new solutions together. A conversation is a casual, undirected exploration where differences are marginalized. Dialogue, on the other hand, is a vigorous and directed exploration that welcomes differences (without debating them). The philosophy of the facilitated dialogue, Canady said, is that institutions should “get out of the way” and allow the solutions to emerge according to each community’s vision for being healthy and whole.

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

DISCUSSION

Melissa Simon, the panel moderator, summarized some of the key points from the panel presentations, and she noted that some of what was discussed circled back to what keynote speaker Manuel Pastor articulated earlier in the day about sharing power to harness more power (see Chapter 2). Simon noted that both panelists demonstrated the power of “we,” and how sharing power among partners—be they organizers, academics, social and health service providers, policy makers, youth, fathers or mothers—speaks to the power of communities. This idea of network building from one person to many, helps propel this work and to scale it. Building powerful communities and community partners is an authentic part of creating change by establishing relationships that involve long-term commitment, mutuality, and shared visions and dreams that need to be reinforced and maintained over time.

Simon continued that it is apparent from the presentations that building a new narrative through facilitated dialogue involving a diversity of community partners can be a vehicle for change. This involves breaking down silos and building relationships with people across sectors. It also involves having authentic dialogues with people and moving beyond the surface to listen and learn from another person’s story, she added. Simon also noted that concealed stories (as discussed by Karen Marshall in Chapter 3) needed to be heard more widely so they could be part of the dialogue shaping a shared vision for change. Simon added that achieving the kind of change discussed by the presenters may best be accomplished by rethinking how ecosystem partners can use their relationships strategically to amplify and champion this work through understanding that both the community and academic institutions have resources and assets to help each other.

Engaging the Private Sector

A participant stressed the importance of engaging private sector community partners in a meaningful way. Canady concurred and said that inviting small business owners and representatives to the table is important for discussions about fostering personal responsibility (e.g., what can be done structurally in stores to make sure that the healthy choice is the easy choice, rather than one that requires additional effort or resources). She mentioned the California Pay for Success/Social Impact Bond Initiative as an example of meaningful engagement of private partners.6

____________

6 Private investors fund preventative or interventional social services, and, if the program is a success, the government reimburses the investors with a return on their investment. See http://nonprofitfinancefund.org/pay-for-success (accessed July 24, 2014).

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

Collecting Data with Utility in Mind

Many participants discussed the challenges of balancing academia’s need for robust data with community members’ weariness with data collection on issues that they think may be obvious (e.g., everyone in the community already knows they have limited access to fresh food). Phyllis Meadows remarked that community members often feel they can tell the researchers the answers to the questions they are researching, but the researchers end up simply describing the community’s problems over and over, in different ways, or gathering data that does not seem useful to the community and does not help them advance.

Watson-Thompson agreed that there is a tension between the data that academic partners need to collect and the interpretation of that work by communities. She reiterated the value of engaging the community at the beginning of the process in identifying the questions that need to be examined, the different ways in which to examine them, and how best to share and use the results. The researcher’s perspective on the types of data that are appropriate may differ from the community’s perspective on what is meaningful or helpful to them. Data are only good if used, so sharing the data in a way that is understandable to the community is also essential. Traditional academic formats may not be an effective approach. The quantitative piece is more meaningful when matched with the qualitative (i.e., the stories). Watson-Thompson suggested that validity testing is needed to determine if what is being presented has meaning and utility for those it is intended to serve. She also noted the need to be bi-directional with learning and information-sharing processes. It is important to engage the community to educate academia about ways in which information can be presented and disseminated that are meaningful to them and to establish a culture of data-informed decision making that matters for both parties or entities involved. Canady added that the publish-or-perish mentality of academia also affects how researchers work with communities (see Chapter 6 for additional discussion on this topic). Simon reiterated the need to build a pipeline of research scientists, academics, and leaders coming from (and hopefully returning to) these communities.

Scale

As in other sessions, many participants in this session asked questions about how to take community aspirations and efforts to promote health to scale. Canady responded that although everyone is eager for rapid change, it took time to make the progress seen today, and it will take time to understand and achieve long-term change. The process, when done correctly, is leading toward something, she said. Citing the united

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
×

efforts to respond to H1N1 pandemic influenza as an example, she said that agencies, institutions, and organizations have to come together, recognizing that each has its own agenda or self-interest, but understanding that there will be greater benefit from collective effort. As a community, we need to hold ourselves accountable to demonstrate what is different today compared to 6 months ago, 1 year ago, or 3 years ago, Canady said.

Organizing for Better Health Care

A question was raised about the potential role of community organizing in addressing the waste in health care in order to free up resources for population health and health equity. A participant suggested that patients and people in the communities need to push for quality care. Equity comes from quality across all metrics. Another participant said that organizing people around the cost efficiency of hospitals is not particularly interesting for most people, but there is a lot of public anger concerning costs that can be tapped.

Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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Suggested Citation:"5 How Institutions Work with Communities." Institute of Medicine. 2015. The Role and Potential of Communities in Population Health Improvement: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18946.
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The Role and Potential of Communities in Population Health Improvement is the summary of a workshop held by the Institute of Medicine Roundtable on Population Health Improvement in April 2014 that featured invited speakers from community groups that have taken steps to improve the health of their communities. Speakers from communities across the United States discussed the potential roles of communities for improving population health. The workshop focused on youth organizing, community organizing or other types of community participation, and partnerships between community and institutional actors. This report explores the roles and potential of the community as leaders, partners, and facilitators in transforming the social and environmental conditions that shape health and well-being at the local level.

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