Building on previous National Academies of Sciences, Engineering, and Medicine workshops that explored how safe and healthy communities are a necessary component of health equity and efforts to improve population health (IOM, 2014, 2015), the Roundtable on Population Health Improvement wanted to explore how a variety of community-based organizations came together to achieve population health. To do so, the roundtable hosted a workshop in Oakland, California, on December 8, 2016, to explore multisector health partnerships that engage residents, reduce health disparities, and improve health and well-being. Sanne Magnan, co-chair of the roundtable, opened the workshop by emphasizing that understanding how local stakeholders from all sectors at the community level build partnerships to improve health is an issue that transcends politics. “In framing these partnerships,” she said, “some might be interested in how they involve disadvantaged populations to achieve health equity, while others might be interested in how it decreases the size of government and gives power back to citizens to determine next steps.” From her perspective, “everyone is interested in these goals that create life, liberty, and the pursuit of happiness for our families, neighborhoods,
1 The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.
towns, and the states in which we live, and finding common ground will require us to listen deeply to the wisdom in communities and the multiple perspectives from which it comes.”
In providing an overview of the workshop, George Flores of The California Endowment explained that the topic of community health partnerships encompasses such a broad array of initiatives that it would be impossible to cover all of these types in 1 day. He emphasized that this workshop would provide a sample of the depth and range of the individuals and institutions that come to these partnerships to work together to improve health and well-being in communities with the aim of understanding the following:
- Common elements, including measurements, evaluation tools, methods, and strategies, that these partnerships use and that can be shared with others.
- Models or strategies that engage residents on a continuum from the initial engagement through leadership development and sustained participation in community health improvement over time.
- Strategies or infrastructure that contribute to overcoming health disparities and improving overall community health and well-being, particularly for the most vulnerable residents.
- Potential co-benefits that accrue to communities and institutions that participate in multisector partnerships.
To gain this understanding, the roundtable appointed an ad hoc committee to plan and convene a workshop to explore the infrastructure of multisector community health partnerships. The committee’s charge is described in Box 1-1. Flores, who served as the chair of the planning committee, explained that he and the other members of the planning committee (Anne De Biasi, Mary Lou Goeke, David Kindig, Marcie Parkhurst, Soma Stout, and Jomella Watson-Thompson) intended the workshop to serve as a way to explore how community health partnerships participate in the creation of health and in improving the health of populations.2
2 The choice of communities and speakers featured in this workshop proceedings was the result of a combination of factors. Once the planning committee discussed the scope of the workshop, individual members noted that communities involved in the Building Healthy Communities initiatives, Spreading Community Accelerators through Learning and Evaluation (SCALE) communities, and Robert Wood Johnson Foundation Culture of Health prize communities might serve as good examples of what communities can accomplish in effective multisector community health partnerships. There are many other communities involved in each of these initiatives, and, in part, the individual speakers and communities featured were based on availability and also a desire to feature different-sized communities that reflect urban, rural, and suburban communities from different
The workshop participants heard from speakers from a range of multisector partnerships with the goal of learning about what makes those partnerships and initiatives effective and of understanding the challenges that these partnerships have had to overcome in order to create change in their communities. The workshop also engaged the participants in a structured discussion to develop strategies for sharing power and engaging with different partners in developing and sustaining multisector collaborative relationships.
To set the context for the day’s discussions, Flores reviewed some of the key terms used in talking about multisector community partnerships (see Box 1-2). The issue of equal opportunity, he said, is fundamental to health and to how communities perceive health, and it is important to ask how it is that a nation legally committed to equal opportunity for all, regardless of race, religion, national origin, or gender, produces and supports inequities. Equity, he explained, equals fairness in terms of everyone having access to the same opportunities, while equality is providing everyone the same thing. “We must ensure equity before we can enjoy
parts of the United States. Because the workshop was held in California—and, in particular, the San Francisco Bay Area—there was a deliberate attempt to reach out to speakers in that area in order to highlight local initiatives in the vicinity of the meeting location.
equality because equality only works if everyone starts from the same place,” Flores said.
Racism, sexism, or any other kind of -ism, he continued, is tolerance of an unequal relationship between social groups and is based on the privileged access to power and resources by one group at the expense of another. Flores explained that structural racism is a system for allocating
social privilege and that historically in the United States, white males and wealth are the default settings for power. He added that in the current pyramid-shaped power structure, a few elites in the society hold most of the power and are able to use laws, myths, norms, and institutions for their benefit, with diluted power flowing down to the people who form the majority of the population in a society (Moyer, 2001).
People power, on the other hand, turns the pyramid upside down, puts people at the top of the power structure, and allows power to flow to the power elites from the will of the people (Moyer, 2001). Agency, Flores explained, is a sense of control over one’s life and having the requisite capacities, opportunities, and connections to things that make one feel healthy. It is what makes people feel healthy, and it goes beyond biomedical health and encompasses concepts such as safety, financial security, and relationships. Community agency is collective control, connections, capacities, and opportunities, including partnerships with shared decision-making and mutual accountability. This notion of agency and of including the population and people in making decisions and setting priorities for action, rather than just relying on institutions and government, is often left out of the paradigms and models of how to improve health, Flores said (Bridging Health and Community, 2016).
Ending the culture of privilege and the consolidation of power in the hands of a few, Flores said, will require positioning people so that they can solve their own problems. Ending the culture of privilege would multiply opportunities for people to engage in genuine relationships without fear or prejudice, to expand personal and professional networks, and to enrich the human experience. “Ending a culture of privilege would allow each of us to stand unwaveringly on our hard-earned accomplishments, knowing that without the benefits of privilege we will be more resilient when faced with adversity,” Flores said. “This is an end goal for community partnerships” (Burke, 2016).
With regard to activism, Flores outlined a number of effective and ineffective roles (see Table 1-1) and defined social movements as collective actions in which the populace is alerted, educated, and mobilized to challenge the power holders and the whole society and to redress social problems or grievances and restore critical social values (Moyer, 2001). “Community-building partnerships, therefore, engage authentic community residents and focus on capacity building among change agents,” Flores said. “They identify key policies and practices that need reform and develop alliances that have the power to change [those policies and practices] and counter popular assumptions that work to reproduce the status quo” (Aspen Institute Roundtable on Community Change, 2004). In participatory democracy, he concluded, social movements and the general
|Effective Roles||Ineffective Roles|
|Empowered and hopeful||Disempowered and hopeless|
|Positive attitude and energy||Negative attitude and energy|
|People power: Participatory democracy||Elitist: Self-identified leaders or vanguard|
|Coordinated strategy and tactics||Tactics in isolation from strategy|
|Nonviolence; means equals ends||Any means necessary|
|Promote realistic vision and social change||Unrealistic utopianism or minor reform|
|Assertive/cooperative (win/win)||Passive or overly aggressive/competitive|
|Feminist/relative truth/nurture/adaptive||Patriarchal/absolute truth/rigid ideology|
|Faith in people||Put the “masses” down|
|Peace paradigm||Dominator paradigm|
SOURCE: Flores presentation, December 8, 2016.
public influence power and power holders by alerting, educating, inspiring, and involving the population at large (Moyer, 2001).
This proceedings summarizes the presentations and discussions that occurred during the workshop (see Appendix B for the agenda) about community-driven and community-centered partnership initiatives and approaches to improving health and well-being. Chapter 2 describes the theory and practices of community-driven partnerships supported by The California Endowment through its Building Healthy Communities initiatives. Chapter 3 explores approaches used in SCALE (Spreading Community Accelerators through Learning and Evaluation) communities to shift power to residents so that they can participate in creating solutions to community problems. Chapter 4 highlights some of the community engagement concepts and strategies used by the communities that won the Robert Wood Johnson Foundation Culture of Health Prize. Chapter 5 summarizes the small-group discussions that were held during the workshop with the aim of brainstorming collectively about strategies for sharing power and engaging with different partners in developing and sustaining multisector collaborative relationships, and Chapter 6 provides the roundtable members’ and workshops participants’ reflections on the day’s discussions. Highlights from the day’s presentations are provided in Box 1-3.
In accordance with the policies of the National Academies of Sciences, Engineering, and Medicine, workshop participants did not attempt to
establish any conclusions or recommendations about needs and future directions, focusing instead on issues identified by the speakers and workshop participants. In addition, the planning committee’s role was limited to planning the workshop. The Proceedings of a Workshop was been prepared by workshop rapporteurs Darla Thompson and Joe Alper as a factual summary of what occurred at the workshop.
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