A recurring point raised across the case study presentations summarized in Chapters 6–10 was the extent to which the work on these initiatives is “a very human process of building community” and engaging people and establishing trust, commented David Fukuzawa, program director for health at The Kresge Foundation. He moderated a discussion session on the five cross-sector initiatives with all the workshop speakers, steering the conversation to points that had emerged throughout the day. Speakers focused on strategies for talking about health equity, means of building relationships in communities and across sectors, direct versus indirect approaches to addressing obesity, measurement and evaluation issues, and ways of sustaining the work of initiatives with the next generation of leadership.
STRATEGIES FOR TALKING ABOUT HEALTH EQUITY
Equity can be a difficult issue to raise, Fukuzawa said, whether it is around race, class, or people who are marginalized in a community. What possible actions did the speakers suggest for raising the equity issue in the process of building a community collaborative?
Mildred Thompson of PolicyLink replied that “when we think about equity, the words that we use matter.” If the word “fairness” is used, everyone will likely agree that all people deserve to be treated fairly, but talking about race and class tends to make people feel concerned, she said. However, she suggested that “there is a way that we can talk about race without calling someone racist.” If organizers of cross-sector projects are mindful of
this and carefully consider their framing and terminology in entering into a conversation, they may encounter less defensiveness.
James Bloyd of Cook County PLACE MATTERS added that it may be easier to broach the topic of equity—particularly when disparities clearly align with income levels, neighborhoods, and racial/ethnic lines—by stating from the outset that the issue is not about individual responsibility or behavior. In his initiative, for instance, Bloyd shows people that neighborhood residential segregation in the 1930s was a root cause of many conditions leading to certain behaviors. But it is difficult for leaders at the local, state, and federal levels to shift from an individual focus toward a social determinants focus on those root causes, he said.
Keeping the focus on children is another way to navigate the equity issue, suggested Helen Riley of St. Michael’s School in Delaware, because it is “easier for people to have some empathy for children.” It helps to remind people “that every child is born with potential, every child is deserving of an opportunity,” she said. “If we provide the resources, and we provide the training that they need, then everyone benefits.”
Felipe Tendick-Matesanz of Restaurant Opportunities Centers United had a different perspective on the discussions around equity. The public health community often talks about poor people, but it shies away from talking “about the labor conditions they are in and how to improve those conditions, or even measure those conditions,” he noted. “Nobody wants to talk about it,” he said, perhaps because the subject gets into politics and questioning capitalistic models. He challenged the workshop participants to start having those conversations.
MEANS OF BUILDING RELATIONSHIPS IN COMMUNITIES AND ACROSS SECTORS
From the audience, Bob Grist of the Institute of Social Medicine and Community Health commented that the presented cross-sector initiatives illustrate a level of cooperation very different from the way society functions, with processes that can be more equitable and more responsive to human needs. Some health care companies, such as Kaiser Permanente and HealthPartners, and federal Community Transformation Grants are investing in these processes. Yet, he said, “I haven’t heard any talk . . . about the potential of this process for transforming our health care delivery system that responds to all of these symptoms of inequality.”
In reply, Susan Damour of the U.S. General Services Administration and the National Prevention Council spoke about the power of bottom-up collaborations that are taking place in communities. While the senior leaders of her agency in Washington, DC, say they must cut their budget and staff, Damour plans to keep doing what she is doing—building relationships
with different partners on the ground to undertake projects together. “You do have people of passion in your communities,” she told the workshop attendees. “People know what the problems are. Don’t ask for permission. Go find them, and then find out what you want to work on. Make it reasonable, measurable, and achievable. Then just build from there.”
Marna Canterbury of Lakeview Health in the St. Croix Valley added that a welcoming communication strategy—one that is positive, inclusive, and nonjudgmental—also is important in creating a movement toward better health. “We have a bunch of communication rules: no ‘shoulds,’ no ‘healthy,’ et cetera.”
DIRECT VERSUS INDIRECT APPROACHES TO ADDRESSING OBESITY
Fukuzawa commented that in several of the case study initiatives, obesity was not actually the starting point. Organizers instead focused on larger themes such as population health or equity. Is obesity just a symptom of the places where we are living, as Bloyd pointed out, or is it the problem itself? he asked.
Donna Zimmerman of HealthPartners responded that in the St. Croix Valley PowerUp project, the Health and Wellness Committee was not interested in using the words “children’s obesity initiative” because community members felt it was negative messaging that did not energize anybody. What energized people was a more open-ended mission of “Let’s do something to let all children in the valley have an opportunity to be healthy.” Obesity is in part a by-product of not being healthy or not having access to healthful food, Open Gyms, or other programs, she said.
For Bonnie Rateree, her collaborative work in Harvey, Illinois, is motivated by the 14-year difference in life expectancy between her neighborhood and northern Cook County. Many factors combine to cause that shorter life expectancy, including obesity and related chronic illnesses such as heart disease. Obesity became an issue for Rateree when she saw it in the young people around her. Her granddaughter is a smart, overweight child who spends most of her time on the computer. Compared with when Rateree was growing up, the community is not as safe for children to go out and play.
If one starts with where the community is and what it needs, benefits in countering obesity and improving public health will follow, suggested Debra Oto-Kent of the Health Education Council. All of the various factors involved are connected. For instance, addressing a problem with loose dogs on the streets makes it safer for people to be physically active in the neighborhood, Oto-Kent noted.
MEASUREMENT AND EVALUATION ISSUES
Fukuzawa asked whether speakers had encountered any issues related to measuring progress in their prevention work other than those raised in the workshop presentations. For example, he noticed a Tweet that questioned whether Kaiser Permanente’s concept of measuring “doses” of impact from health interventions was “medicalizing” the process.
Kaiser Permanente’s Pamela Schwartz replied that her team tried changing the language they used many times, but it always came back to “dose” because that resonated for people, even if some thought it sounded too medical. “They get the concept of ‘reach a lot of people, touch a lot of lives’ with something that matters.” However, she added, “there are so many barriers to building something that is more impactful in the time period that we fund.” Also, having conversations about measuring dose and impact is difficult because “it can actually come across as insulting if we say your work, as it stands, is not impactful enough for what you signed up for,” Schwartz said. Her team still has to work on its messaging.
Mary Kate Mouser, from Nemours in Delaware, said that the question of how best to carry out evaluation remains the topic of much discussion for her team, now 10 years into their initiative. Much of the focus at the workshop was on measuring such factors as physical activity and healthy eating, but Mouser believes it will be necessary to somehow combine all of those factors into one broader population health metric instead of looking at them separately. Evaluation “is a huge area to continue to learn and figure out,” Mouser said.
WAYS OF SUSTAINING THE WORK OF INITIATIVES WITH THE NEXT GENERATION OF LEADERSHIP
A final question came from Bill Purcell of Jones Hawkins & Farmer, PLC: Who will carry on the work of these initiatives into the future?
Thompson responded that it is critical to create succession plans and groom the next generation, noting that PolicyLink has many bright, enthusiastic young people whom she tries to engage as much as possible. “We have a responsibility to share, and not hold onto, our knowledge and our experiences,” she said.
Rateree said all the things she is working on now are on her “bucket list.” She is looking to find 10 people to take up the torch when she retires. Last May, the PLACE MATTERS national team announced a partnership with The Children & Nature Network to improve community health through greater access to green spaces. This initiative includes a fellowship program for training young leaders to share the outdoor world with their communities, Rateree said. A young woman from Cook County partici-
pated in that program and is now planning family nature activities in her community. “Hopefully, this young lady, and nine more people, will allow me to really retire,” Rateree said.
“If the goal is to have a culture of health in America, that means we have to all come together because it is a benefit for all Americans to deal with the problems of childhood obesity.”
—Dwayne Proctor of the Robert Wood Johnson Foundation
