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Community Power in Population Health Improvement: Proceedings of a Workshop (2022)

Chapter: 7 Amplifying the Empirical Base Linking Community Power and Health Equity

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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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7

Amplifying the Empirical Base Linking Community Power and Health Equity

The final session of the workshop explored how evidence can be used in improving community-building practices, policy, and funding decisions. Because power building is a complex, dynamic enterprise involving local control, new methods of generating evidence are needed to assess and

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

inform practice. Panelists discussed the limitations of traditional research methods in evaluating power building, provided case studies of responsive assessment approaches, and outlined the work needed to create more effective community-building research tools. Hanh Cao Yu, chief learning officer at The California Endowment (TCE), moderated the session.

Yu remarked on the need to support community power efforts to achieve racial and health equity; this work should be guided by humility. Research and theory linking community power and health equity is nascent and largely conceptual, rather than empirical. Funders can build long-term, sustainable power infrastructures to support the work of communities by increasing investment and improving partnerships, said Yu. At the same time, strengthening the empirical evidence base linking health equity with community power can facilitate insights that can be applied to knowledge, practice, and power-building research.

PERSONAL DRIVE FOR POWER BUILDING

Yu asked each panelist to speak about his or her passion around community power. Paul Speer, professor and chair of the Department of Human and Organizational Development at Vanderbilt University, replied that he works to address the injustices taking place around the world by understanding community power and supporting groups that are developing and exercising it. Tia Martinez, chief executive officer at ForwardChange, said that her work is rooted in making meaning of the suffering and survival of her family and community. Using an analysis of power to make sense of the unequal distribution of suffering can help to unlock that dynamic and begin the healing process, she suggested.

Bill Wright, executive director at the Providence Health System Center for Outcomes Research and Education, remarked that systems change is too rare. Even with recognition that a system is not working for all people, it is common to address barriers by creating programs or altering an aspect of how people move through the system, rather than considering that the system itself may not be adequately adaptive to meet the needs of the people it is designed to serve. A systems change approach involves asking fundamental questions about how systems should be designed and about who should determine that design. Too often, service gaps are defined as “systems failures,” when in actuality, some systems were designed to exclude specific populations, said Wright. In such cases, the system is functioning according to its original design. He added that regardless of the intentions under which a system was designed, attention should be given to identifying people that ought to have a role in designing the system. Power-building work embraces asking fundamental questions about how systems are constructed.

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

Teresa Cutts, professor at the Wake Forest School of Medicine’s Public Health Sciences Division, recounted growing up in the Mississippi Delta in a community facing deep poverty. The hard-working people in her community lacked power, money, status, and higher education. She was born in a clinic approximately 500 feet from the burial site of civil rights activist Fanny Lou Hamer. Cutts recalled the unkindness, hatred, and abuse faced by African American children integrated into her community’s schools during her childhood. She said she strives to undo some of that harm by offering kindness, respect, and humility. Her grandmother owned a dry goods store in a predominantly African American part of town, and Cutts helped in the store every Saturday throughout her childhood. She noted that this was an unusual experience for a white child to have; it led her to develop a deep, abiding respect for African American culture, which is full of authenticity, warmth, kindness, and community power. Cutts also witnessed the abject poverty experienced by community members despite their working 6.5 days each week, their fingers swollen from picking cotton in the hot Delta fields. She described the community as having transcended these hardships and challenging existence through the joy they shared with one another. Cutts added that her grandfather was a sharecropper who faced difficulties that contributed to her desire to shift the power differential early in her life.

Laura Parajón, professor and executive director of the Office of Community Health at the University of New Mexico, said that love is a steadfast commitment to the well-being of others. Quoting American philosopher Cornel West, she said “Justice is what love looks like in public.” She added that she is driven by love, service, and empowerment, with community power being an integral part of her motivation. Yu remarked that she came to the United States as a refugee from Vietnam and is emboldened in her work by the devastation of colonialization and the Vietnam War.

CHALLENGES AND TENSIONS IN THE EXERCISE OF COMMUNITY POWER: PRACTICE IMPLICATIONS FOR RESEARCH

Speer noted that his presentation draws from work performed with his colleagues from Vanderbilt University, Jyoti Gupta and Krista Haapanen, and with Hahrie Han, professor and director of the Stavros Niarchos Foundation (SNF) Agora Institute at Johns Hopkins University.

Features of Power and Community Change

Speer outlined three features of power pertinent to understanding community power: source, nature, and instruments. The source is the

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

basis of power that is exercised, and it may take the form of people or money. The nature of power involves how power operates, whether this be in a cooperative or conflictual fashion. Instruments of power are the mechanisms through which power is expressed. These include reward, punishment, and the ability to shape awareness and public debate. Minimally, community power requires developing a source of power, an understanding of how power works, and strategies through which to exercise it, said Speer.

A focus on power should be coupled with community change, or the ultimate effect of exercised power, said Speer. Change resulting from the exercise of power can take three forms: symbolic, incremental, and restructuring. Symbolic change involves a shift in outward appearance with stability in behavior. For instance, a person who trades their red shirts for blue ones, but does not alter any other behaviors, would exhibit symbolic change. Interventions resulting in symbolic change do not increase a community’s resources.

In contrast, incremental change does involve an increase in valued resources, yet the overall distribution of a valued resource between the “haves” and “have-nots” remains stable. For example, in the 1960s the children’s program Sesame Street was designed to address the gap in school readiness between impoverished and middle-class children (Ball and Bogatz, 1970). Intended to improve children’s recognition of letters, words, colors, and numbers, Sesame Street increased school readiness for low-income children. However, middle-class children also watched it and improved their capacities, said Speer. Thus, this intervention increased a valued resource for both low- and middle-income children, but given the persisting school readiness gap, it did not change the overall distribution of resources. The third form of change is restructuring change, in which a shift in the distribution of a valued resource does take place. Speer noted that a restructuring change occurred with tax policy that has redistributed wealth in the United States since the late 1970s. In this case, a smaller number of people have a greater amount of wealth; thus, the restructuring change has created greater inequity. He and others working in the field of health equity are working toward more evenness in the allocation of resources, said Speer. Some research, Speer stated, focuses on individual behavior change as the outcome of interest and does not focus on systemic change. Behavior change generates symbolic or incremental change. In contrast, research indicates that systemic change with a focus on health equity generates access to better health and greater equity across populations, resulting in restructuring change. Therefore, advancing health equity requires altering the distribution of valued resources, and altering this distribution requires exercising community power, Speer commented.

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

Diversity and Dynamics of Power-Building Practices

In determining how local community-organizing groups can best build and develop power, Speer and his colleagues examine the activities or processes groups use to generate community power and the outcomes of these efforts. Overlaying this information with understandings of the dimensions of power and the forms of change results in a complex framework that indicates a high level of nuance in community interventions. Speer called for greater research attention to the complex processes that local community-building efforts engage in. He presented an overview of various dimensions and examples of community-based practice; these processes for developing community power include a wide range of strategies, tactics, and orientations (see Table 7-1). Studies can be shaped to capture these diverse power-building practices in order to draw distinctions and learn what is most effective, said Speer. He continued that critical differences in tactics, locus of intervention, and other key dimensions of community-based practice must be conceptualized and measured.

Adding to the complexity of power building, the implementation of any given practice is not static. The local community context—including the internal developmental goals of the organization—drives implementation. For instance, some organizations tend to participate in staff-driven decision making, while other groups engage in participatory leadership. Most groups do not fall singularly into one category or the other; rather, a tension and dialectic are present. At different points in time for various external reasons staff or local leaders may take a larger role. To understand how power is built, developed, and exercised, attention must be given to the practices taking place on the ground, said Speer. The tensions and dilemmas inherent in community dynamics can drive strategic decisions, and research in this area can inform best practices for building community power.

Implications for Community Power Research

Speer noted several implications for community power research. First, measurement of community power-building processes should be a priority for researchers. He provided an example that charted the distribution of staff organizers meeting with community members in groups of various sizes. Some organizations focus on small meetings held with one or two individuals at a time, while other groups work to develop a broader range of relationships through meeting with small groups. He added that the distributions of meeting size can affect the outcomes of building power. Second, a greater focus on the relational qualities of both power building and community change is needed, he recommended.

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

TABLE 7-1 Diverse Practices for Developing Community Power

Dimensions Descriptions/Common Alternatives
Source of problems
  • Problems arise from deficits of people or lack of skills and/or motivation
  • Problems arise from conditions of environment
  • Problems arise from systems of exploitation and the powerlessness they produce
Change strategies
  • People solve their own problems rather than looking to institutions to solve their problems for them
  • Communities seek experts to address problems; need for technocratic solutions
  • People form collective power and demand changes
Change tactics
  • Consensus building, better communication, educate people, social marketing
  • Seek others—experts, elected officials, hierarchical figures—and through respect, kindness, and appreciation relinquish community responsibilities to elites
  • Confront those with power about hypocrisy on values, stated claims, democratic principles; conflict and direct action when necessary; negotiate with power to achieve outcomes
Orientation to power structure
  • Collaborators and partners in common goals
  • Employers, sponsors, meritorious elites
  • Actors external to community with divergent interests from residents
Boundary definitions
  • Target geographic area
  • Target relational communities
  • Target identity-based alignments (gender, race, ability, class)
  • Target existing group memberships (school, faith group, workplace)
Role of organizer
  • Teacher, catalyst, booster, problem solver, broker, planner, analyst, expert, program implementer, activist, advocate, agitator, partisan, negotiator
Locus of intervention
  • Point of production—site of exploitation (strikes, pickets, slowdowns)
  • Point of consumption—visible endpoint of exploitation (boycotts, demonstrations)
  • Point of destruction—where there is harm (strip mine, landfill)
  • Point of decision—site where elites determine policies (board meeting, slumlord office)
  • Point of assumption—challenges unreflected-upon beliefs
Outcomes valued
  • Expressive action—focus on communicating values, culture, or emotions
  • Valued instrumental actions—focus on tangible change and achieving goals

SOURCE: Adapted from Speer presentation, January 29, 2021.

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

For instance, the distribution of young to middle-aged men in the community has a curvilinear relationship to violent crime, where the higher proportion of young to middle-aged men is associated with more violent crime in the community. Thus, relational qualities (in this example, intergenerational relationships) can be critical to power-building and change efforts, said Speer. Third, research methods that examine longitudinal and multilevel relationships are key, he stated. Such research enables comparisons to be made among the same group over time and with other groups, providing a basis for determining the effectiveness of change efforts.

Speer added that organizational practices to generate community power are not fixed processes. They are dynamic processes that are influenced by local community context and require additional research to be better understood in creating power-building outcomes.

THE CALIFORNIA ENDOWMENT: BUILDING HEALTHY COMMUNITIES

Martinez discussed the evolution of TCE’s Building Healthy Communities (BHC) project over the span of a decade. While many place-based programs focus on service saturation, such as the Harlem Children’s Zone, BHC targeted power building and policy and systems change in 14 neighborhoods. The BHC theory of change proposes that building power leads residents to push for policy and systems change, which in turn improves the opportunity environment. Over time, the improved opportunity environment affects social determinants of health, eventually resulting in a change in population-level health status.

Presenting a timeline of BHC initiatives from 2010 through 2019 at the various neighborhood sites, Martinez highlighted the substantial amount of innovative experimentation conducted by BHC grantees and TCE leadership and program managers. The rapid rate at which TCE learns and adapts can be challenging to keep pace with, but its processes are focused on delivering outcomes. In 2010, the BHC framework was structured around the “big four results:” (1) to provide a healthy home for all children, (2) to reverse the childhood obesity epidemic, (3) to increase school attendance, and (4) to reduce youth violence. As BHC progressed, change drivers such as people power, youth leadership, narrative change, and policy innovation emerged, leading to the development of the BHC theory of change in 2013.

Lessons Learned in Centering Grassroots Power Building

Over the next several years, BHC shifted its focus and practices in response to an evolving understanding of power building. While

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

continuing to use multiple approaches and methods in policy advocacy and legal efforts, the foundation determined that grassroots power building must be placed at the center its efforts, said Martinez. Furthermore, grassroots efforts for racial justice were made primary. Originally, the mission for the project was “health equity equals health justice for all.” With the shift toward power building and racial justice efforts, the mission evolved to “building voice and power for a healthy and inclusive California.” Internal power was realigned from prioritizing funder “grass-tops” leadership to prioritizing grassroots leadership. Martinez noted a midpoint evaluation conducted by the University of Southern California Program for Environmental and Regional Equity (USC PERE) was instrumental in BHC’s pivot. This evaluation found that:

During the first half of BHC, an emphasis has been on … achieving health equity through professional advocacy and communications efforts bolstered by community voice and mobilization…. The health equity equation should lead with community organizing, leadership development, and grassroots advocacy—and then bolster those efforts with professional advocacy and communications. (Ito and Pastor, 2018)

The recalibration of BHC’s focus elevated power building from a secondary instrumental driver—a method to achieve health equity—to a primary driver and ultimately an end in itself, she added.

Lesson 1: Evolve the Definition of “People Power”

Martinez stated that when BHC began, the working definition of “people power” was resident engagement. In this model, the residents affected by an issue provide input, bolster public debate, and influence policy decisions. The role of the community is to draw attendance to events such as board meetings and city council meetings. This method views power as the aggregation of many individuals’ efforts, and thereby more people speaking at an event equates to more power. When the project got underway in 2009–2010, BHC worked from this construct and viewed the foundation as responsible for setting results and desired outcomes and then soliciting feedback from the community on how to achieve those preset goals.

The foundation quickly realized that power exercised by community is more complex and nuanced than its original understanding, said Martinez. During the period from 2011 to 2015—the early implementation phase of BHC—the definition of “people power” shifted from resident engagement to resident agency. Instead of a conglomeration of individuals speaking at an event, this framework views the role of residents as

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

collectively collaborating to shape campaigns and programs to proactively demand a response from policy makers and system leaders. This construct implies the need for strong organizations that are responsible for recruiting members and developing their skill sets, creating policy agendas, and exercising power. The role of community then pivots from residents providing input to organizations possessing agency. Rather than independently setting goals, the foundation brings together grassroots organizations, service organizations, and system leaders to collaboratively build solutions.

During BHC’s midpoint review phase (2016–2018), the definition of “people power” once again shifted, this time to a “seeds of people power” understanding. This approach expands beyond community members shaping campaigns to community-led initiatives gaining traction and flexing their leadership in the strategy process, determining the issues to focus on and the approaches to use in addressing them. Martinez remarked that at this stage, community organizations did away with goals set by TCE and created their own path forward. For instance, community organizations decided to move their work in schools away from a focus on truancy prevention to healing justice efforts. In this iteration, BHC shifted from bringing community partners to the table to becoming a node for resident-led formations to connect, build relationships, and access resources for growth.

The final evolution of BHC’s working definition of “people power” came in 2019 with the transition planning phase. Martinez explained that this construct involves a power-building ecosystem in which diverse community-led initiatives align toward greater mutuality and complementarity while centering grassroots organizing for racial justice. In this framework, the roles of residents, the community, and the foundation are encompassed within the ecosystem.

Lesson 2: Building Power Requires an Ecosystem

The ecosystem model centers grassroots groups supported by a robust network of allies from diverse disciplines (see Figure 7-1). USC PERE described this ecosystem:

Organizing and base building alone are insufficient to influence those who have the authority, resources, and power to make the kinds of decisions that will improve the lives of historically excluded people and reduce inequities.… A broader ecosystem of organizations with diverse capacities, skills, and expertise—and with reach from the local to regional to the state levels—is required to get to the big goal of health and justice for all. (USC PERE, 2018)

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×
Image
FIGURE 7-1 Power-building ecosystem.
SOURCES: Martinez presentation, January 29, 2021; USC PERE, 2018.

Martinez emphasized that this framework continues to feature advocacy, research, and leadership development as necessary components, but they are ancillary to the centralized element of organizing groups and helping them to build up their base.

Lesson 3: The Crucial Role of Healing in Social Movement Work

After the power-building ecosystem model was developed, BHC identified healing and personal transformation supports as a missing component, said Martinez. Through ongoing communication between BHC program managers and grantees, BHC established that structural change through power building is always imperative, but removing or reforming harmful structures will not automatically undo the psychological, spiritual, and physical damage done to bodies, souls, and minds over generations. Structural change will not address the internal wounds already inflicted on people by systems, history, and each other. Without

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

attention to healing, organizers, advocates, and community members can turn on one another or turn on themselves and self-destruct, continued Martinez. Rage can motivate people, but it can also become destructive and undermine the movement if directed at colleagues and allies. By proactively addressing past and current wounds, building a health-centered movement enables those most affected—and hence the most hurt by—oppressive systems to fully participate as advocates and leaders in the movement, while at the same time building the critical consciousness needed to interpret the world and act to transform it.

Lesson 4: Putting Narrative Strategy in Service of Grassroots Power Building

As BHC processes shifted to allow communities to have agency, strategy around narrative change also transformed. Initially using a traditional strategy, TCE led the effort to change social norms and partnered with big media consulting firms in this work. Martinez noted that with deeper understanding of power building, TCE learned that narrative change should be led by the community and deeply embedded in the greater grassroots power-building effort. Narrative change is not a communications strategy separate from power, but a part of power itself. An essential component of community organization, establishing narrative change is part of the power-building ecosystem. By pivoting from a top-down approach in which media firms direct narrative change strategy, BHC acknowledged the inherent power of historically marginalized communities developing their own cultural and narrative change strategies.

Lesson 5: Align Lessons with the Faces of Power Model

Martinez outlined the alignment of the lessons BHC learned with the Grassroots Policy Project’s “three faces of power” model, which identifies: (1) the power to win demands, (2) the power to drive the agenda, and (3) the power to shape common sense. The power to win demands applies to BHC’s focus on “people power” as the change engine. The power to drive the agenda relates to the understanding that building power requires more than strong organizations—it requires an ecosystem. The power to shape common sense pertains to putting narrative strategy in service of grassroots power building.

Rethinking the Funder Role

The lessons gleaned over the decade of BHC initiatives led TCE to rethink its role as a funder, said Martinez. To move away from a position of telling or leading organizations in their course of action—thereby

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

having power over them—TCE has shifted to having power with the grantees in allowing the movement to lead. She stated that funders are not always transparent or consistent, vacillating from having too little involvement to being too heavily involved. To avoid this, TCE has created a feedback loop with grantees to listen to them and to adjust as necessary. This allows TCE to maintain a level of involvement that grantees value. Martinez remarked that funders often measure grantee success based on factors such as rapid response, highly visible policy wins, ability to leverage the insider track, and superficial metrics (e.g., numbers of residents attending events). Instead, TCE is shifting toward measuring success by assessing systems transformation that is deeply rooted in the most affected communities and in generational change, as well as developing new metrics for authentic power building. Lastly, the core competency of TCE program managers is their ability to pivot from strengthening individual organizations to learning how to cultivate a robust ecosystem for health-centered movements.

BUILDING EVIDENCE FOR POWER AND HEALTH: THE BHC INITIATIVE AS A LEARNING ENGINE

Using the BHC initiative as a case study, Wright outlined the challenges faced in generating evidence of the efficacy of power building, as well as generating evidence of the work being done to address those challenges. Both the scope and nature of BHC make it difficult to evaluate the program using traditional methods. As an ecosystem of efforts, BHC involves $1.8 billion spread over more than 10,000 grants, with activities in 14 cities and complementary statewide work, all of which is centered on power building. Based on the concept that communities are best able to resolve their own key health challenges, BHC operates with a theory of change that sees power building as the key strategy for addressing health equity, Wright noted. Instead of investing in specific programs or services, the role of the initiative is to help those communities build the power needed to make changes in policies and systems that affect community health outcomes. Related activities and strategies are led by local partners, whose approaches are not prescribed.

Limitations of Traditional Evaluation Methods for Application to Power Building

This represents a fundamental shift in approaching community health, and the traditional scientific tool kit is ill equipped to generate evidence for this new approach, said Wright. The vast majority of scientific tools are used for inference, where attribution of effect is predicated on comparing

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

variation across boundaries. Careful methods of defining boundaries—be they time intervals, groups, or other distinctions—are used to ensure that comparisons are fair. These range from fully randomized designs to observational studies involving case matching. In the context of BHC, typical studies might examine BHC sites and similar sites where BHC is not active to compare trends of key outcomes over time. These data then inform an evaluation of whether BHC “worked,” Wright remarked. However, such methods rely on a degree of certainty about what happened on either side of the inference boundaries. He noted that a central feature of power-building initiatives is that researchers do not control what takes place. Instead, the boundaries, the approach to goals, and even the goals and strategies themselves are permeable by design and are ultimately determined by communities. Thus, different BHC communities may focus on different goals or strategies at various times.

For instance, any given body of work within the scope of BHC may be adopted by different BHC sites at various times and to varying degrees. For instance, site A may have focused on that work from the start, site B may have begun that work halfway through their grant period, and site C may have used an entirely different approach. Wright remarked that evaluating an intervention monolithically would bias findings toward the null by including factors on the treatment side of the inference boundary that actually belong on the comparison side. The importance of factoring in local context that Speer described is relevant to this example, Wright noted. In programmatic approaches, the “who, what, when, where, and how much” of interventions are typically known. In contrast, in the context of building power, the people on the ground in communities determine those factors; by design, researchers do not control them. Thus, the boundaries that are well defined in traditional research are permeable in power-building work. Boundaries of place are permeable because power, policy, and systems changes are not neatly contained by location. Boundaries of time are permeable, as described above and in communities that have long engaged in power building. The boundaries of who and what are permeable in the locally run nature of efforts tailored to each community.

Building Context-Rich Approaches to Power-Building Data

More thoughtful inference boundaries are needed to evaluate powerbuilding initiatives, said Wright. Moving beyond a simple boundary—such as whether or not a location was a BHC site—a more granular approach can be used in identifying what happened, where it happened, how much of it happened, and who it happened with. Within a community power-building framework, decisions are made locally and emerge as

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

the work progresses, signifying that context will vary across sites. Wright stated that scientists typically consider variation in an intervention as unwelcome noise. In a context-rich approach, variation is viewed as a source of strength and an engine for learning. Once methods of learning from variation are developed, elements of the traditional research tool kit can then be used, he noted.

To translate a data-rich approach to an empirical tool set, BHC begins with potential outcomes—for instance, disparities in school discipline rates—and then identifies related investments and activities that took place and indexes when they took place. Contexts in the community related to the specific issue are explored, and inference boundaries are then built around context-specific subsets of data. Time becomes a set of fixed intervals relative to index dates that represent when context-specific activities happened, explained Wright. Designs such as comparative interrupted time series can be used to assess and compare changes in the trends of key outcomes over time across inferential boundaries (see Figure 7-2). Thus, scientists can use familiar tools in a context-informed way.

Wright noted that this approach required the construction of an integrated mixed-methods engine to create a context-rich analytic environment. Much of the data needed for this type of approach comes from narrative reports, such as grant descriptions and grant reporting. BHC developed a method of collapsing narratives, coding them into discrete data that summarizes key aspects of the “who, what, when, where, and how much” of what took place in the community work. More structured

Image
FIGURE 7-2 Example of comparative interrupted time series design.
SOURCE: Wright presentation, January 29, 2021.
Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

outcome data from surveys and administrative datasets are collected for all relevant geographies and subgroups. A universal coding framework serves as connective tissue between the disparate elements of the data ecosystem. Every element of data—whether it is discrete data from a state dataset or survey or narrative data from a report or interview—is then coded and tagged with attributes. The attributes can include time, place, population, intended domain of effect, and any other factors that may link data points. Wright explained that for any given question, the elements most appropriate to the specific context can be selected from the data ecosystem. Elements may include BHC investments and activities, measures of power building, policy or systems change, and outcomes indicators. The universal coding framework enables data to be linked together in the context of the theory of change and allows for the production of outcomes models.

Overlaying the universal coding framework on the BHC theory of change facilitates understanding of direct and indirect effects of power building, Wright noted. Using this approach, one can determine how much variation in any given outcome over time can be attributed to various potential effect pathways, including power building. For instance, one can examine how much variation is associated with being a BHC site or how much variation is associated specifically with changes in power-building indicators. Moving through the stages of BHC’s theory of change, every set of indicators can be positioned as an outcome or as a mediator/moderator; an indicator that is an outcome at one stage can become a potential mediator in the following stage. For any given BHC campaign, estimates can be produced by assessing how much variation is attributable to each potential effect pathway, thus elucidating the mechanisms that created change.

Creating Learning Architecture

Wright remarked that this approach moves beyond a pass/fail evaluation to create a system for learning. Tracing each point of the data overlaid on the theory of change, evidence will either support or fail to support the hypothesized relationship. In testing different effect pathways across the theory of change, patterns will emerge. These patterns will inevitably vary for different contexts and outcomes, which leads to learning, said Wright. The nuanced stories accompanying these patterns create enormous variation across the BHC ecosystem. Instead of treating variation like a bug, this approach uses variation as a feature in the creation of a rigorous learning architecture. The knowledge gained through the use of such learning architecture informs the role of power building in addressing health and equity, he noted.

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

To illustrate what this process looks like in practice, Wright provided an example from a BHC analysis. It began with a foundational question: Were BHC investments in resident organizing associated with more active, civically engaged communities over time? They coded all 10,615 BHC grants with the universal coding framework to capture the “who, what, when, where, and how much” of components in each grant. Next, they identified a set of potential indicators representing community engagement from various sources, such as voting records and community surveys. Then they tagged investments, activities, and contextual factors related to resident organizing, voting rights, community voice, and representation in positions of power. Creating a visual representation of how these elements may relate to one another, they plotted an analytic pathway connecting the areas of engagement. They then used the inference framework to build a series of multivariate models to test the responsiveness of the indicators to the power-building work over time. For instance, BHC examined whether resident engagement work improved voter turnout, an indicator of an active and engaged community. BHC determined that a $5 per capita investment was associated with a 0.38 percentage point increase in voting participation. Therefore, BHC was able to identify a dose–response relationship in investing in resident engagement and voter turnout.

Such knowledge has multiple applications, including helping TCE to develop and adapt its own strategy. The model’s parameter estimates can be used to map out each community’s strategy and to inform the field about efforts likely to result in desired outcomes. BHC is creating “impact profiles” to help TCE and others anticipate outcomes of a given level of investment or activity. These impact profiles are not performed one outcome at a time, as this work is not a transactional effort. Instead, they are conducted across an ecosystem of connected outcomes. In addition to informing strategy, this builds a case for the value of the work, said Wright.

Better understanding of the role of power building and the mechanisms by which desired outcomes are created bolsters confidence in investment in resident engagement activities. Wright outlined how the learning system can also be used to test each step of BHC’s theory of change. The first step involves examining whether activities supported by BHC activities result in power building, as described in the voter turnout example. Next, the relationship between power building and policy and systems change is explored to determine whether an association exists between improvements in power-building indicators and adoption of key policy changes. Finally, the framework can be used to identify whether policy and systems changes do indeed result in different health

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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outcomes. Wright noted that this is the direction toward which BHC’s work is evolving.

The BHC theory of change represents a major shift from addressing health through programmatic response to power building within communities, said Wright. He contended that it is critical to move beyond assessing whether BHC improved outcomes to developing an understanding of how those improvements were created and who was affected. Such understanding enables the improvements to be sustained and expanded. Wright added that the more BHC can take advantage of the rich variation across BHC communities, the more BHC can serve as a data ecosystem for the field at large. This learning engine will then become a shared asset used by a community of thinkers and researchers who together can advance the state of science to support this work.

COMMUNITY POWER AND HEALTH EQUITY: THE MEMPHIS MODEL’S CARDIAC DISPARITY CASE STUDY

Cutts reviewed a case study in which the Congregational Health Network (CHN), a health system-faith community partnership, was able to decrease sudden cardiac deaths in African Americans within the course of 18 months.1 She noted asymmetrical power dynamics are often present in such partnerships, as health systems typically have more money and resources than partnering organizations, and they are often the largest employers in their communities. Practices to mitigate the asymmetrical power dynamics between a community and collaborating health system can strengthen partnerships.

Partnering to Address Health Disparities in Memphis, Tennessee

Egregious race-related health disparities in terms of diabetes, cancer, suicide and homicide, and infant health are at play in Memphis, Tennessee, said Cutts. The city’s cardiovascular disease mortality rate in 2010 for African Americans was twice that of white people. In 2010, the average white family’s income was approximately double that of the African American family. In 2006, the Methodist Le Bonheur Healthcare (MLH) system formed a partnership with more than 700 religious congregations—86 percent of which were African American organizations. Led by Reverend Bobby Baker, director of faith and community partnerships at MLH, and Gary Gunderson, vice president for faith and health at Wake

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1 More information about the Congregational Health Network is available at https://www.methodisthealth.org/about-us/faith-and-health/congregational-health-network (accessed March 19, 2021).

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

Forest Baptist Medical Center, CHN was created to improve access and health status for the entire community. The network’s efforts are referred to as the Memphis Model.

Cutts stated that CHN’s robust commitment to improved community health is evident in its outcomes (Barnes et al., 2014; Cutts, 2011; Thompson et al., 2018). During the first 25 months of the initiative, medical charges for the CHN patient population were $4 million less in aggregate than for the control group, which was matched for age, sex, and diagnosis related group. The mortality rate was decreased by half for CHN patients. Across the All Patient Refined Diagnosis Related Groups, the period until hospital readmission was 69 days longer for CHN patients. Cutts noted that in spite of distrust in the community, significantly more CHN members navigated to hospice and home health services. The efforts of Wellness Without Walls, a targeted, place-based population health initiative, yielded an 8.9 percent decrease in charity care in one of the poorest zip codes in the country, 38109.

Lessons from the Aligning Forces for Quality Grant

In 2009, MLH received an Aligning Forces for Quality grant from the Robert Wood Johnson Foundation. The health care system launched an effort to standardize racial, ethnic, and language preferences for data collection. The process began with data collection across the hospitals in the MLH system, an activity that had not been performed prior to this effort. In response to patient feedback, MLH added a biracial/multiracial option. Another arm of the study examined ideal measures of cardiac care through racial, ethnic, and language lenses. Cutts stated that Methodist North Hospital, an MLH facility, surpassed ideal measures of cardiac care goals at rates of 96 percent for patients with congestive heart failure and at 100 percent for those with acute myocardial infarction (AMI) who were admitted to the hospital. This level of care was delivered regardless of race, ethnicity, or language, said Cutts. However, a grim disparity emerged from additional data. African Americans inside or in route to the emergency department were dying of sudden cardiac death at twice the rate of their white counterparts. Additionally, readmissions were lower for African Americans than for white patients. Furthermore, in examining the age of the prehospital sudden cardiac deaths, a disparity surfaced with the mean age for African American deaths at 58 years compared to 66.5 years for whites.

Cutts said these findings represented a disconnection between the values, metrics, and leaders of the health system and those of the community. While hospital leadership was pleased with ideal measures of cardiac

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

care goals being surpassed at high rates, CHN members and leaders were horrified at the rate at which African Americans in their community were dying, and they demanded action of the health system, said Cutts. This disconnection highlighted an important lessons: to achieve community health equity, the work must be community led and initiated. Additionally, health systems can become teachable through longstanding, humble relationships with the community. Cutts noted that Gary Shorb, chief executive officer of MLH at that time, allowed transparent sharing of this disparity data with the media. In spite of some pushback from some partners, Shorb maintained that community input was necessary in moving the needle on this health disparity.

Addressing Racial Cardiac Disparities

A series of internal MLH meetings focused on dialogues around race disparities, explicitly discussing topics that previously were not spoken about. The CHN liaison council, a self-organized group of women, allowed MLH access to a broader group of 75 CHN liaisons to share data and receive input on why African Americans were dying at higher rates in route to or inside of the emergency department. This community intelligence revealed that distrust of hospitals is common among African Americans. Cutts referenced the book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, which outlines the source of this distrust (Washington, 2006). Furthermore, lack of health insurance was a barrier to accessing care for many people in the community. Medical fatalism—a hopelessness regarding future health status—was also expressed as a contributing factor.

During an interactive, educational session with community members, CHN shared information about the effect of race on best practice in medication treatment. Research trials are conducted with a majority of white populations, typically beginning with white males and then extending to white females, said Cutts. Only in recent decades have racial and ethnic differences been explored through studies with additional subgroups. During the session, medical professionals shared that calcium channel blockers tend to be more effective than beta blockers in preventing future heart attacks in African Americans. Community members discussed that heart medication side effects, such as erectile dysfunction, affect compliance in taking medication. Cutts recalled that when CHN explained that prodromal and presenting symptoms for AMI differ by race, and that a major symptom for African American and Hispanic women is debilitating fatigue, a collective gasp was heard in the room. Community members shared that many underresourced women work multiple jobs while

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

simultaneously providing care to family members, making fatigue common. The CHN staff members advised the group to encourage any female friends or relatives experiencing fatigue to get prompt medical attention.

The MLH Quality Team shared information with medical staff about best-practice medications for minoritized populations. In collaboration with the community, CHN developed culturally sensitive, low literacy teach back tools on preventing heart failure and AMI to be given to patients during hospital discharge. Other discharge materials were decreased to draw patient attention to the most important health information, bringing the total number of discharge papers from 48 pages to only a few pieces of paper. The CHN Academy co-branded with MLH and incorporated the teach back tools into chronic disease and community health workforce courses. This effort was designed to familiarize people in the community with the acute symptoms that necessitate an immediate trip to the hospital.

Effect and Implications of CHN Efforts

These collective efforts resulted in a 15 percent decrease in the disparity for sudden cardiac death for African Americans from 2010 to 2012. Given the importance of language, Cutts noted that the Systems Bioethics Committee changed its name to the Ethics and Equity Committee. Sunny Anand, an intensivist at MLH Le Bonheur Children’s Hospital, began looking at Hispanic data and discovered that Hispanic children were dying in the neonatal intensive care unit and the pediatric intensive care unit at almost four times the rate of African American and white children (Anand et al., 2015). Anand initiated a 3-year, multilevel community and hospital intervention that decreased this disparity.

Social complexity means that life exists within an interconnected web of systems and relationships that shape social and physical contexts, said Cutts. Like community power, social complexity is difficult to measure, and traditional tools and metrics are inadequate to do so, which calls for creativity and mixed-methods approaches. Additionally, iterative learning cycles and formative evaluation—such as plan-do-study-act cycles—allow metrics to be used expeditiously to refine processes, programs, and policy. Furthermore, measurement must be non-extractive, Cutts maintained. Data belong to the community and should be created, built, measured, analyzed, and continually interpreted with the community. Finally, building trust and integrity within a program are more important than the rigor of the design or metrics. Cutts concluded by emphasizing that “a healthy community is a powerful community.”

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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COMMUNITY EMPOWERMENT AND HEALTH EQUITY: PRACTICING COMMUNITY-BASED PARTICIPATORY RESEARCH IN THE TIME OF COVID-19

Parajón stated that as both a physician and a public health practitioner, her training in these two areas has taught her to see patients as individuals and to see communities. She uses community-based participatory research (CBPR) maps to visualize the work toward equity. CBPR is “a collaborative effort between multisector stakeholders who gather and use research and data to build on the strengths and priorities of the community and use multilevel strategies to improve health and social equity” (Wallerstein et al., 2017). This definition drives the CBPR conceptual model,2 which visualizes connections between four areas: (1) the context of a health outcome; (2) partnership processes; (3) intervention programs, research, and evaluation; and (4) health and social justice outcomes. The model explores factors of each of these areas and the influence the areas have upon one another.3 Parajón noted that this model is based on Paulo Freire’s work, which defined empowerment as “a dialogue process in which passive subjects become participatory actors” (Freire, 1970). She explained CBPR is a plan-do-study-act model that can involve a time investment in building trust. However, once that trust has been created between an organization and community members, the model can using a rapid cycle of listening, dialoguing, and taking action within a community. During the COVID-19 pandemic, using a rapid cycle approach has been helpful in developing effective, time-sensitive services, said Parajón.

Practical Application of Community-Based Participatory Research

Until recently, Parajón served as a physician in a large congregant shelter for people experiencing homelessness. Located outside of Albuquerque, New Mexico, the Heading Home shelter buses residents daily for the 30-minute drive to and from the city.4 The COVID-19 pandemic created high-risk situations both in the bus rides and within the congregant setting, where many residents are housed together in the dormitory. Parajón noted that the shelter also has a number of asylum seekers, and this presents additional challenges to address. A multisector, community

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2 More information about the community-based participatory research model is available at https://cpr.unm.edu/research-projects/cbpr-project/cbpr-model.html (accessed April 15, 2021).

3 More information about this model and additional CBPR tools is available at https://engageforequity.org (accessed March 20, 2021).

4 More information about Heading Home is available at https://headinghome.org (accessed March 20, 2021).

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

coalition–based partnership came together to provide COVID-19 prevention and response efforts for people experiencing homelessness. Dubbing themselves the “Corona Crushers,” the coalition included city and state departments, universities, Medical Reserve Corps, outreach medicine providers, community health workers, and Heading Home shelter staff.

Outcome Identification

Using the CBPR methodologies, the coalition began by identifying outcomes for health equity by speaking with people experiencing homelessness. This community was disproportionately affected by the COVID-19 virus, with many community members expressing fear about feeling unable to keep themselves safe. The overarching health equity outcome identified was reducing the spread of COVID-19 for people experiencing homelessness who do not have homes where they can self-isolate. Parajón outlined desired long-term outcomes, including positive community transformation, improved health by way of decreased COVID-19 infections, and increased access to COVID-19 immunizations. Additionally, desired intermediate outcomes were identified, including power sharing within the multisector coalition and the community, developing a sustained partnership, enacting policy change in universities and in the community to help them find their power, and facilitating individual and agency capacity.

Context of the Health Issue

The coalition then looked at the context of COVID-19 risk for people experiencing homelessness (Kaplan, 2020). Parajón explained that context within the CBPR model involves the following areas: health issue importance, social and structural, political and policy, capacity and readiness, and collaboration trust and mistrust. In this case, the important health issue was the higher rates of illness and comorbidity in the homeless population in comparison to the general population. Social and structural inequities involved the inability to self-isolate within the congregate nature of living in the shelter. The policy and politics contextual aspects included support from a number of departments and agencies. Capacity and readiness involved the capacity of the numerous partners involved in the coalition. The history of trust and collaboration pertained to the year of bimonthly meetings that had taken place.

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

Partnership Processes

Parajón emphasized the importance of various aspects of partnerships, including who the partners are, how they relate to one another, and how the partnership is structured. She stated that partnerships that have deliberate communication, integrate community knowledge, and foster trust tend to have better outcomes. Structures that facilitate powerbuilding practices are also helpful, said Parajón. She noted a partnership practices guide that involves surveys that partnering organizations complete together to identify practices that need to change or be improved upon. Additionally, a partnership data report is generated that highlights indicators shown to improve outcomes, such as the percentage of the budget that is allocated for community spending, final approval, and control of resources.

Program Processes

The Corona Crushers coalition focused on actions that could be completed by communities, eliminating the need to rely on universities, said Parajón. The partners listened to one another, coordinated on a daily basis with partnering organizations and with a medical team of health care providers, and co-developed medical pathways, a volunteer call system, medical coverage, testing sites, and isolation pods. Furthermore, the coalition fostered trust, built community, and facilitated equity and power. As COVID-19 can spread quickly in a shelter, it was important that agencies had clear roles and responsibilities and subscribed to specific organizational practices. Parajón noted that how things are done is as important as what is done. Working alongside shelter staff and community health workers, the coalition established empowering practices to build capacity and integrate local knowledge. COVID-19 screening and testing, isolation, social distancing, early medical care, and partnerships were key elements of the response.

Quarantine areas were developed in collaboration with the community of people experiencing homelessness. In creating quarantine pods, a feedback co-learning process was used in which data from homeless shelter residents was incorporated into the program design. This extended to improving food quality and treating people with kindness. Parajón remarked that after feedback was received that people in quarantine were not being treated nicely, intervention to emphasize the importance of kindness resulted in improved behavior. She noted that helping people quarantine effectively helps slow the spread of COVID-19. Pandemic funding was used for wellness hotel stays that served multiple purposes: the short-term need for isolation and the long-term need for transitional

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

housing. The community expressed confusion about who needed to wear specific types of masks or take other precautions, so the coalition’s medical students and undergrads developed visual guides that were easy to understand.

Power Dynamics in Community-Based Participatory Research

Parajón stated that aspects of power building to focus on in measuring impact include emancipatory power, deliberative communication in partnering practices, valuing community knowledge and co-learning processes, and social justice and equity outcomes (Wallerstein et al., 2019). She outlined some specific effects of the coalition’s efforts. The first was the ability to quickly react to a large COVID-19 outbreak that took place in October 2020 and comprised the majority of New Mexico’s positivity rate that day. The team regrouped and successfully advocated for rapid testing equipment from the Department of Health. As a team and as a community, they reduced COVID-19 infections at the shelter to a rate lower than the community rate. Parajón reported that the risk of COVID-19 infection was currently lower in the shelter than out in the community. The second effect was an alignment of efforts through CBPR and community leadership that involved shared outcomes and collaboration in examining context and developing programs. Third, a new protocol was developed that can now be used in other shelters, congregant settings, and with asylum seekers. Fourth, the coalition worked to build capacity in the students and shelter residents and in resources such as sheltering-in-place beds and supplies. The CBPR pathway—analyzing contexts together, partnering in ways that improve programs, and the resulting social equity outcomes—guides participants in using data through each of these steps. Parajón remarked that CBPR is about “showing up, being who you are, listening intently, believing in social justice, and taking action for social change.”

DISCUSSION

Context and Relational Aspects of Power Building

Yu noted Speer’s emphasis on the role of community dynamics in driving strategic decisions, prioritizing the measuring of community powers, focusing on relational qualities of power building and community change, and examining longitudinal multilevel relationships. She asked the panelists to speak to the connections between one another’s presentations. Speer highlighted the nuance, complexity, and sophisticated practice taking place within community power building. This involves truly listening to people and thinking relationally. Investment by researchers in

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

the deeper methods discussed will enable greater understanding of how power is developed and manifested, said Speer. Yu added that several panelists spoke about context around a health issue, and that this is a challenging component for evaluators and researchers to capture.

Parajón stated that she has worked with the CBPR model in New Mexico and in Nicaragua, and she has found that having a guide and checklists for partners to use facilitates implementation of the model. A checklist is used for each area of the CBPR model: context, partnership, program, and outcome. These include assessing whether staff have cultural humility and whether they are engaging in various partnering practices. Expanding beyond the actual intervention, the list of partnering practices for people to learn and use focuses attention on how staff are interacting with people and building and supporting relationships. She noted that just as memorandums of understanding are used to outline how money and resources will be allocated, checklists for the CBPR components frame how people will relate to one another throughout the processes.

Wright remarked that a contextual aspect of studying community building—which both fascinates and frustrates him—is that community work has been taking place for many years. A current study of community-building work, or a recent initiative like BHC, can give the appearance that this type of work is new. However, an important element of context for researchers in this field to understand is that they are measuring a continuum of work that has been ongoing in communities for a long time, he emphasized. In contrast to a discrete effort that is initiated and results in change that can be measured, power-building initiatives may have amplification effects, but researchers are not creating new work. This is a challenge to address in determining how to study power-building efforts, said Wright.

Cutts added that in her work with CHN in Memphis, she was as an embedded researcher on a medical team integrated into the community group. She attended all community events from the beginning of the initiative, and she helped develop celebratory services and worship events. Cutts noted that congregational leaders emphasized the value of relationships, encouraging team members to “be there for the long run, not just for photo ops.” She said this relational component builds trust and is critical to evaluation efforts. Wright remarked that in the absence of the embedded evaluator role that Cutts described, evaluation can resemble archaeology—that is, a process of piecing together information from an outside perspective. He added that even BHC’s work can sometimes be prone to that dynamic. This type of reconstruction often leads to transactional issues or an incomplete picture of what took place, but this can be avoided by evaluators embedding themselves in the community from the beginning, said Wright.

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

The Evolving Nature of Theory in Power Building

Yu commented on being open to evolving theories of change, noting that BHC did not develop its theory of change until 2013, and that indicators centering power as an end in itself, and not just a means, were not added until 2017. As a foundation, TCE uses an adaptive learning mode that is responsive to community, she added. Yu asked panelists to comment on the process of evaluating interventions or outcomes without being wedded to a specific framework or theory. Martinez stated that this process can be frustrating for consultants and evaluators. Power building is not one distinct intervention with a well-defined program model featuring a beginning and end that can be assessed for fidelity. Rather, it is a process of constant improvement. Realizing that this work around power building, resistance, and survival has been taking place for centuries can be helpful in shifting to that perspective, she noted. While the absence of a linear theory of change and measures can be challenging, it is also powerful to wade into the complexity of the dynamics, striving to improve the ability to capture what is taking place, said Martinez.

Noting the flexibility needed in addressing power in all its various forms, Parajón stated that she appreciates that the CBPR model involves a dialectic process in simultaneously serving as a tool for planning, evaluation, and reflection. With this model, everyone—medical practitioners and people experiencing homelessness alike—learns together through the practice of listening, dialogue, and taking action. The power of this approach was apparent in the COVID-19 environment, in which situations and information evolved rapidly, said Parajón. The people living and working together in the shelter continually used a reflective cycle, and the collaborative act of using this cycle built trust. She added how important collaboration is in defining the community’s priorities, as this leads to clear outcomes that everyone collectively works toward.

Transparency and Confidentiality in Community Data

A participant asked how to approach long-term data efforts that protect communities of color, given that this data can be used by those who oppose your efforts. Yu noted that BHC is giving care to protecting confidentiality in a survey currently being developed. Wright responded that BHC evaluation work involves a large ecosystem of individuals and organizations. To support, build, and weave that network together, BHC surveys community organizations and partners. They discuss the importance of transparency and creating a shared community asset. However, he noted there are risks with transparency, as the data they are collecting could be valuable to someone with ill intentions toward the outcomes

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

BHC’s network strives to achieve. Therefore, BHC tries to anticipate potential unintended consequences in determining whether or not to make data available. Wright said this raises the issue of responsibility in creating a learning system, as the consequences of learning engines can be positive in building power but there is potential for destructive ramifications. Yu said it is critical to develop systems that serve power builders’ strategy capacity but do not tip off the opposition.

Remote Community Engagement

A participant in a modified remote CBPR approach for a place-based intervention asked how to engage with the community without being physically present. Parajón replied that video conferencing is an option if community members have Internet access. In the shelter, residents did not have phones, and physical presence was required. However, when lack of Internet access is not a barrier, video conferencing platforms such as Zoom make remote community-building activities that build trust possible. She has worked on projects using CBPR with health councils via Zoom, and this platform enables progress in the absence of in-person interactions. Additionally, she uses Jamboard, an interactive digital whiteboard, that works well for CBPR model planning and visioning. Yu added that geography and time constraints can make it difficult to be in the community, yet relationship and trust building require it. She said COVID-19 is forcing people to interface in a different way, via video conferencing, and that this requires access issues to be addressed.

Community-Building Learning Engine

A participant asked for additional information about BHC’s emerging platform for open source, collective action learning, such as its design features, important elements of infrastructure, and timeline. Wright replied that rather than creating an evaluation, BHC is working to develop a connected analytic engine and data ecosystem. The concept involves an extensive catalog of practices and their connections to one another. Eventually, TCE will invite partners to this catalog. The universal coding and connecting system developed by BHC will potentially enable a user with a specific question of interest to easily sort through data elements along applicable dimensions. The confidentiality concerns previously discussed come into play in determining a process for extracting information from the data ecosystem, said Wright. He remarked that the goal is to have a repository that thinkers and researchers working to advance the field can take advantage of. Local control in numerous communities has played a strong role in the evolution of BHC, leading it to become a laboratory for

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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innovation. Wright remarked there is much to learn from all that activity, and it is hoped the learning engine will enable lots of minds to come together to learn as much as possible from the data.

Power-Building Efforts in Memphis, Tennessee

A participant interested in the Memphis Model asked about the extent to which power-building efforts have continued in Memphis and about any challenges preventing a wider diffusion of the model. Cutts stated that she now lives in North Carolina, but she is aware that some community-building efforts in Memphis are ongoing. She said CHN has entered a latent period owing to leadership changes, which could send a negative signal to the community regarding community power. However, faith community partnerships have endured for hundreds of years, and will continue to do so in spite of pandemics and leadership changes, she remarked. Leaders approach power differently. Some leaders are open to creating space for horizontal power differentials in which the community’s power, intelligence, agency, and capacity are valued, while other leaders are not invested in that view. Cutts stated that the leaders involved in the Memphis Model intentionally held space open for community members to occupy, but she is unclear as to whether that continues to be the case. Leadership within health systems and within the community greatly affect how power is manifested. She added that the 2007 infant mortality rate for African American babies in Memphis was the same as the rate in Zimbabwe, and that this has since improved.

Summarizing Reflections

Ray Baxter, trustee of Blue Shield of California Foundation, shared several reflections about the workshop:

  • Social determinants drive health but power defines, drives, and shapes those social determinants. The field of community health improvement needs to move from a technocratic approach toward a more democratic approach to health that values people above all.
  • Narratives from communities are more than an additional source of evidence, more than another tool, not just one more input into decisions. They help us confront the dominant narratives that serve power and that have already shaped what questions are even considered. Those dominant narratives can normalize racism, white supremacy, misogyny, selfish individualism, and economic exploitation.
Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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  • There is already a body of knowledge, expertise, and proven practices around community power building. There is a diverse array of practitioners and organizations devoted to doing this and supporting it, and people working in the health field need to connect more fully with it.
  • Relationships are just as important as technical solutions, not just institutional relationships but personal, economic, and cross-cultural relationships.
  • Investing in leaders, particularly positioning youth and residents to lead in their communities and in our institutions is critical.

Baxter’s final observation was that at the present moment, some institutions are failing communities and that “this is a time when transformational change is possible.”

Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×

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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
×
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Suggested Citation:"7 Amplifying the Empirical Base Linking Community Power and Health Equity." National Academies of Sciences, Engineering, and Medicine. 2022. Community Power in Population Health Improvement: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26306.
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Next: Appendix A: References »
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To explore issues related to community-driven power-building efforts to improve population health, the Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine hosted a virtual public workshop, "Community Power in Population Health Improvement", on January 28 and 29, 2021. Participants discussed the different components and dimensions of community-led action around different population health improvement topics such as education, transportation, environmental health, healthy eating, and active living, among others. This Proceedings of a Workshop summarizes the presentations and discussion of the workshop.

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