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Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop (2023)

Chapter: Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation

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Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
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Appendix D

Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation

Erika Blacksher

The National Academy of Science, Engineering, and Medicine’s virtual workshop on civic engagement and health equity concluded with a practical exercise that asked a subset of participants to answer the question, “What are the most important investments in civic infrastructure to advance health equity?” Befitting the workshop’s theme, we created an opportunity for participants to use their civic skills—reasoned discussion; mutual listening and respect; justification on the basis of values, evidence, and lived experience; careful consideration—to weigh in on this collective challenge. We dubbed the exercise a “mini-deliberation” because its design incorporated several features of “democratic deliberation,” a substantive form of public discussion that seeks practical solutions to collective challenges and is itself a civic engagement strategy.1 This appendix briefly describes the core tenets of democratic deliberation, reports on participants’ discussions and priorities, and reflects on the outcomes of the exercise.

There is no consensus definition of democratic deliberation, but when one looks across widely cited definitions, several shared elements surface. They include a commitment to convening diverse people with varied backgrounds and perspectives; framing the issues with nonpartisan questions and factual, balanced information; and creating conditions in which all can engage on equal footing in a circuit of learning and dialogue

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1 S. Burkhalter, J. Gastil, and T. Kelshaw. 2002. A conceptual definition and theoretical model of public deliberation in small face-to-face groups. Communication Theory 12(4):398–422.

Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×

that may use small groups, voting, and polling to capture viewpoints and shifting positions en route to well-informed and well-considered recommendations.2,3 Democratic deliberation is purpose-built for social questions that involve competing values and sensitive or contentious issues and where there may be low trust.4 Its rise in use over the last several decades reflects a broader participatory turn in the U.S. health sector that led the Agency for Healthcare Research and Quality (AHRQ) to fund a randomized controlled trial of deliberative methods and has centered the experiences of patients, research participants, community members, and ordinary citizens in other ways (e.g., community advisory boards, community-based participatory research, and patient-centered outcomes research).5

This workshop’s deliberative exercise was designed in the spirit of democratic deliberation. The exercise divided a subset of workshop participants—approximately 40 people who had signed up in advance to participate in it—into five small groups. They were asked to imagine they were city council members for “Ourlandia” and tasked with deciding together how best to allocate $10 million among four categories of civic infrastructure—government agency coordination, community media, education (K–12, higher ed.), and civil society (nonprofit, for-profit, faith organizations). The workshop’s panels and presentations provided participants with background information about what civic engagement and civic infrastructure are along with examples of various types of it, including the four categories they were tasked with prioritizing. In addition, participants were given information about the population of Ourlandia: a racially and ethnically diverse town of 250,000 people, 10 percent of whom lived at or below the federal poverty, with that subset having disproportionate representation among Black, brown, and indigenous people due to historical and structural racisms and discrimination.

Participants were also instructed (1) to ensure that everyone had the opportunity to speak; (2) to identify areas of agreement and disagreement on priorities and underlying reasons (e.g., values, evidence, beliefs, experiences); and (3) to aim for common ground but to not press for consensus.

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2 S. Chambers. 2003. Deliberative democratic theory. Annual Review of Political Science 6(1):307–326.

3 E. Blacksher, A. Diebel, P. G. Forest, S. D. Goold, and J. Abelson. 2012. What is public deliberation? Hastings Center Report 42(2):14–17.

4 S. Solomon and J. Abelson. 2012. Why and when should we use public deliberation? Hastings Center Report 42(2):17–20.

5 K. L. Carman, M. Maurer, C. Mallery, G. Wang, S. Garfinkel, et al. 2014. A community forum deliberative methods demonstration: Evaluating effectiveness and eliciting public views on use of evidence. AHRQ Publication No. 14(15)-ehc007-EF. Rockville, MD: Agency for Healthcare Research and Quality.

Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×

That last instruction was in part pragmatic, a recognition that the 30 minutes provided for deliberation was barely enough time to register everyone’s views and priorities.6 The groups were also instructed to choose a rapporteur who would describe their group’s allocations, where there was agreement and disagreement, and their underlying justifications to the entire workshop once all of the workshop participants had reconvened.

Education came out on top for all five groups, but only one group created a four-tiered lexical ranking of investments. This group invested $4 million in education, $3 million in civic society, $2 million in government agency coordination, and $1 million in community media. One other group allocated $4 million to education, but then split the remaining $6 million evenly among the remaining three areas of civic infrastructure. Two groups allocated $3 million to education, but also invested that exact dollar amount in one other of area of civic infrastructure (community media and civil society) and split the remaining $4 million evenly between the remaining two areas of civic infrastructure. The remaining group also prioritized education, allocating $4 million, but could not come to agreement on their priorities for the remaining $6 million. One of the most clearly articulated reasons for prioritizing education was that it would help “grow future civic leaders” and “train future citizens.” This “upstream investment” would help “change the culture.”

The deliberations, brief as they were, may have influenced participant priorities and, specifically, their prioritization of education. Polls were taken twice prior to the deliberative exercise, once before the workshop began, as attendees joined the event, and after the end of the workshop but prior to the mini-deliberation [was this second poll just of mini-deliberation participants or did all workshop attendees take the poll, too?]. The poll asked respondents to rank-order civic infrastructure investments in order of importance for advancing health equity. Participants ranked all four forms of infrastructure in the same order of priority in both polls—civic society first, followed by education, followed by government agency coordination, and community media last—with slight variations in degrees of support. Deliberation may have also had an impact on deliberants’ views of community media, because it moved from the bottom position in the first two polls to the first or second position after deliberation.

Several rapporteurs noted that in addition to discussing priorities, their groups also talked about the nature of civic infrastructure. What did “government agency coordination” or “education” really mean, and what

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6 Deliberations typically last longer, often several hours or a full day or several days; however, among the four deliberative methods studied in AHRQ controlled trial, one had a duration of only 2 hours. This type of deliberation is called a brief citizens deliberation.

Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×

should it mean? One rapporteur, for example, noted the group’s emphasis on funding coordination among different levels of government. Another group redefined the nature of the government activity they wanted to invest in, from agency coordination to data generation and sharing, so as to support a range of civil society and education activities. In regard to education, one group emphasized continuing, lifelong education, which they thought was missing from the workshop discussion. Another group expressly stated that their education investment should help people “unlearn” biased histories, behavior, and attitudes. Some rapporteurs noted that while talking about the content of civic infrastructure took time, it was constructive in helping people learn new things and better understand one another’s views and priorities. These discussions also led many to gain insight into the interconnections among different types of civic infrastructure, which might help explain why most groups tended to spread the money somewhat evenly across the categories rather than invest all or the majority of the $10 million in one category, which no group did.

Another reported theme that arose in at least two groups was whether infrastructure investments should be targeted or universal in reach. The small groups were not primed to address this question, but it is not surprising that it arose. It is a longstanding question in population health policy and in ethics because it raises unresolved questions of fairness and any particular policy’s or program’s capacity to reduce health inequities.7 The issue of targeting interventions in health equity efforts also raises questions about how to interpret “diversity” and “disadvantage,” given that targeting usually involves deciding which areas and which groups to invest in. As one rapporteur noted, the sociodemographic description of Ourlandia was insufficient, because in addition to racial and ethnic diversity and poverty, one needs to also understand population differences related to gender identity and expression, immigrant status, religious affiliation, and age.

Although we did not take a post-deliberation survey to assess the quality of the deliberation, several outcomes signaled that it may have met some standard criteria of sound deliberation. The level of engagement was high across all small-group discussions, and there was considerable depth in the reasoning, as described by the rapporteurs. The fact that education moved to a top investment across all groups (from second place in the first two polls) also suggests that deliberation may have had an impact on people’s priorities. Further evidence of the deliberations’ impact was that deliberants appeared to learn from one another, as noted above. There was also evidence of continued learning during

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7 D. Mechanic. 2002. Disadvantage, inequality, and social policy. Health Affairs 21(2):48–59.

Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×

the reports themselves. The most poignant example of this was one rapporteur’s comment that hearing about other groups’ discussions made her realize that she had taken for granted existing institutions, norms, and processes whereas others had designed their investments to challenge dominant histories and cultural perspectives. This reflects a deep form of learning, one in which she became aware of and began to question the unstated assumptions that had informed her reasoning. These are all signs of good deliberation.

One limitation is worth noting. Deliberations aspire to convene people with diverse perspectives. No data about participants was collected, but it can be assumed that participants likely came to the workshop and the mini-deliberation with a commitment to, or at least interest in, health equity, and they likely were college educated. These are common challenges for those who design and organize deliberative and participatory activities. Just how a broader swath of Americans would think about priorities for health equity and civic infrastructure is unknown. But it seems a question worth pursuing given the poor state of the nation’s overall health and the deep inequities that characterize it.

Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×

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Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×
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Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×
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Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×
Page 73
Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×
Page 74
Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×
Page 75
Suggested Citation:"Appendix D: Prioritizing Civic Infrastructure Investments to Advance Health Equity: A Mini-Deliberation." National Academies of Sciences, Engineering, and Medicine. 2023. Civic Engagement and Civic Infrastructure to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26590.
×
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There is increasing evidence that civic participation - from voting to volunteering - is a social driver of health. The National Academies of Sciences, Engineering, and Medicine's Roundtable on Population Health Improvement convened a workshop to explore the links between civics and health; between measures of civic engagement and quantitative and qualitative measures of health equity; and the roles that civic infrastructure, narrative, and media play in shaping civic engagement. Presenters discussed voting along with other important dimensions of civic engagement; others include the ability to set agendas, shape how policies are implemented, communicate information, model civic behavior, and support the involvement and inclusion of other individuals and groups.

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