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Suggested Citation:"2 Key Concepts and Measures." 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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2

Key Concepts and Measures

This chapter summarizes the presentations from two panels and the associated discussions. The first panel provided a succinct grounding for the workshop, outlining the connections between health and civics as well as between health outcomes and the political determinants of health. The subsequent session provided a brief overview of quantitative and qualitative measurement (and data and research) at the interface of health and civic engagement (see chapter highlights below).

The first panel, moderated by Bruce Link of the University of California, Riverside (UCR), included presentations by Daniel Dawes from the Satcher Health Leadership Institute at Morehouse School of Medicine and Karthick Ramakrishnan of UCR and the Center for Social Innovation in the format of a “fireside chat.” Link said that the concept of the social determinants of health has helped the field articulate how people’s location in society “cascades down to influence people’s health.” The fireside chat, which was intended to be conversational, Link said, would examine “the sources of those positional locations and their meaning in our society” by looking “at what produces those hierarchical relationships.”

ON THE POLITICAL DETERMINANTS OF HEALTH

Dawes discussed the “consequences of unrepresentative government and policies” as they are manifested in the striking inequalities seen in American society. He then listed some key effects of inequality: how it gets “under the skin,” leading to premature aging or biological weathering (Geronimus, 1992; Geronimus et al., 2006); increases the prevalence

Suggested Citation:"2 Key Concepts and Measures." 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.
×

of chronic diseases in some populations; and leads to intergenerational trauma over time. Dawes asserted that the nation’s health is not an organic (i.e., natural or chance) outcome and “it is not a coincidence that certain groups of individuals in this country actually experience higher premature death rates and poorer health outcomes than others.” Dawes proceeded to explain how the social, environmental, and behavioral factors that shape health status and outcomes are themselves shaped by political determinants that can no longer be disregarded. “For every social determinant of health,” Dawes said, “there was a preceding legal, regulatory, ordinance, legislative, or other policy decision that resulted in that social determinant of health. Those are the political determinants of health.”

Dawes listed examples of health inequities linked with specific environmental and social factors, from the prevalence of asthma in communities with pollution from highways, bus depots, and railroads, to the long-term and intergenerational health effects of the economic and policy system based on slavery. Over time, explicitly racist policies gave way to policies that appeared neutral on their face but that had the same

Suggested Citation:"2 Key Concepts and Measures." 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.
×

destructive effect when implemented. Examples given by Dawes include the National Housing Act (1934), which displaced more than half a million African Americans and other communities of color, and the Federal Highway Act (1944), which financed the construction of major highways across and through predominantly Black and Brown neighborhoods.1

Dawes then said that prohibitions and restrictions on civic engagement have prevented access for many communities to the political levers that shape the political determinants of health and ultimately affect health and create health inequities. The political determinants of health, according to Dawes, involve three systematic processes that work concurrently and reinforce each other to create or, in the examples below, hinder opportunities for improved health and health equity:

  • Structuring relationships: examples include redlining policies under the Home Owners Loan Corporation Act, anti-miscegenation laws, and immigration laws shaped by racist ideology;
  • Distributing resources: examples include a lack of access to special education and social services; and
  • Administering power: examples include gerrymandering and restricting voting access.

Dawes concluded his remarks by noting that the work to further health equity requires consistency. The work does not end once a policy objective is achieved, he said, but requires monitoring for unintended consequences, including on civic engagement and on health equity. It is good news “that the structural barriers and the resulting inequities are not permanent,” but effecting change requires sustained civic engagement and collective action.

ON THE INTERSECTION OF CIVIC ENGAGEMENT AND HEALTH

Karthick Ramakrishnan began his brief remarks by saying that the focus of his scholarship focuses is at the intersection between civic engagement and public policy. In reflecting on the meaning of a healthy democracy, he said, it is clear that the term can refer both to the health of a democracy and to the ways in which democratic institutions contribute to or detract from promoting health equity. Ramakrishnan showed a figure from the Bay Area Regional Health Inequities Initiative2 depicting a framework that includes civic engagement as one of the social factors that play a role in the pathways leading to health and health equity.

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1 For some background on the two federal policies, see Gross, 2017; Archer, 2021.

2 See https://www.barhii.org/barhii-framework (accessed January 19, 2022) or Appendix E.

Suggested Citation:"2 Key Concepts and Measures." 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.
×

Civic engagement, he added, plays a role in shaping living conditions in communities “through advocacy, through the nonprofit sector and the ways that institutional inequities then produce inequities in living conditions, which then has those downstream effects in terms of health behaviors—injury and mortality.” Ramakrishnan outlined several different ways to think about civic engagement beyond the individual level and the organizational level. Civic engagement or participation is predicted by individual/background attributes, interpersonal influences, and contextual factors (e.g., media, residential, employment). Civic participation can take place through

  • formal political participation (e.g., voting, discussing politics with family and friends, posting on social media);
  • social activism or social movement participation (e.g., petitions, protests); and
  • civic voluntarism (e.g., charitable contributions, volunteer service).

Civic engagement is unequal in the sense that different individuals and groups have different levels of influence and some civic organizations are better resourced and have greater influence on policy makers than others. Finally, Ramakrishnan said, more civic engagement is not necessarily better, because the conditions under which civic engagement occurs are important.

At the level of community organization, civic engagement may be thought of as civic infrastructure, analogous to physical infrastructure such as roads, tunnels, bridges, and broadband internet access. The pillars of civic infrastructure (see Figure 2-1) include government agency coordination; community media; the education sector, which plays a key role in civic education); and civil society, which includes nonprofit organizations, faith-based organizations, business, and others.

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FIGURE 2-1 A depiction of civic infrastructure.
SOURCE: Karthick Ramakrishnan presentation, June 16, 2021.
Suggested Citation:"2 Key Concepts and Measures." 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.
×

DISCUSSION

Ramakrishnan spoke about the common assumption that more civic engagement is better than less civic engagement, noting that civic participation, such as protest behavior, may be pro- or anti-democratic and may advance or harm health equity. Therefore, he said, it bears asking what conditions make civic engagement good for furthering health equity.

Link began to relay audience questions, starting with one about how people engaging in the civic life of their community could navigate conflict with people who think very differently than they do. Is there hope of dialogue, or is conflict inevitable? Ramakrishnan answered that developing better arguments and finding paths to more productive conflicts are among the hallmarks of representative democracy. “The Founders,” he said, “with both their wisdom and their limitations, saw that conflict was an inherent feature of the American republic. The question is how do we make sure that it improves governance and, in our more contemporary context, improves health equity.” Dawes shared his belief that “the forces of division and polarization” must be confronted, and he asserted that health equity-focused policies in this country have generally enjoyed bipartisan support. It is important to use approaches and language that will resonate with people in order to persuade them to support the cause of furthering equity, for example showing how it may “align with a commercial interest and a government investment value.”

A second viewer asked if any communities have operationalized concepts about healthy civic engagement to deliver impact, and Ramakrishnan offered as an example of civic infrastructure the thousands of “complete count” committees and Census coalitions that were formed around the country to assist with the recent U.S. Census. These were diverse groups that brought together people from many different sectors and with many different perspectives, and the census coalitions included community-serving and ethnic media including Spanish language radio and Vietnamese radio. But that civic infrastructure was temporary, Ramakrishnan added, and in ideal circumstances, the American Rescue Plan and other federal investments in localities will provide opportunities to sustain the civic infrastructure that has been built.

Ramakrishnan was asked about the difference between organizing and mobilizing, and he drew on the political science literature to explain that mobilization is short-lived (e.g., as in the case of a political campaign), while organizing is longer lasting and sustained. Organizing often blends different levels of government and policy. Organizing, he added, may include a social movement component that involves “changing social attitudes, norms and preferences” and is therefore a richer, much more robust phenomenon than mobilization.

Suggested Citation:"2 Key Concepts and Measures." 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.
×

Another audience member asked about how Americans seeking a greater level of civic engagement in a diverse and divided nation might find common ground on shared values.

Ramakrishnan ended with a list of five core values that are thought to resonate with people from all walks: innovation, resilience, inclusion, sustainability, and equity, which are referred to collectively as I-RISE. He expressed his hope that social science research would clarify and help measure these values. The notion of values, Dawes commented, is linked with the concept of the moral determinants of health, and although there are areas of agreement on basic concepts of equity and improving minority health, there is a long way yet to arrive at an acknowledgment of the moral determinants of health.

QUANTITATIVE AND QUALITATIVE APPROACHES FOR MEASUREMENT

Ramakrishnan introduced the day’s second set of panelists, who would discuss topics in the measurement of civic engagement and its relationship to health. The panel consisted of Dawn Hunter of the Network for Public Health Law and Healthy Democracy, Healthy People; John Gastil of the University of Pennsylvania; and David Grusky of Stanford University.

Hunter began her remarks by reflecting on her own civic engagement, registering people to vote and using her legal expertise to help restore voting rights to people with felony convictions. “My ancestors did not have the right to vote,” Hunter said, “and so many people who came before me sacrificed so that I could have that right so I feel like it’s important for me to continue to protect the vote and to encourage others to engage.” Hunter described the Healthy Democracy, Healthy People (HDHP) initiative, “a nonpartisan coalition of public health organizations working to advance health equity by ensuring that everyone has access to the ballot.” For people wondering why public health organizations are interested in civic engagement, she explained that voting determines who gets elected and what laws get enacted and that these decisions in turn influence the conditions in which people live, work, play and learn—the social and political determinants of health. She added that the evidence indicates that voting and civic participation, such as volunteering, yield many individual and community health benefits.

The Healthy Democracy, Healthy People initiative set out to create a Health and Democracy scorecard (later referred to as an index) to illustrate the links among civic engagement, voting, and health outcomes. Indicators used as part of the scorecard are based on those measurements

Suggested Citation:"2 Key Concepts and Measures." 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.
×

commonly found in literature. Among measures of health, self-rated health is often studied for its relationship to voting behavior. The voting metrics reviewed include voter registration and voter turnout, along with indices that assess different aspects of elections. The Cost of Voting Index, first published in 2016 as an analysis of the relative cost of voting in presidential election cycles from 1996 to 2016, “measures the relative restrictiveness of each state’s voting or electoral environment,” and it consists of nine issue areas across two key categories, registering to vote and casting a ballot.

For the Health and Democracy scorecard, the team assembled the data for the indicators and then sorted them by the Cost of Voting Index (see Table 2-1). The pattern that emerged, Hunter said, indicates that

on average, states that have the least restrictive electoral environments have, across the board, better individual and community [health] outcomes than the U.S. average. And the reverse is also true, so states with the most restrictive electoral environments have the worst outcomes.

In addition to voter turnout, Hunter said that the scorecard was expected to include voter registration and a range of health measures, as well as community and family safety ranking at a later date.

Hunter reminded the audience that the indicators in the scorecard are averages, so there are outliers. The website, is expected to show data by

TABLE 2-1 Linking “Cost of Voting” and Health Data

Cost of Voting Voter Turnout 2020 General Election Self-Rated Health – % Good or Better Avg. # Poor Mental Health Days in the last 30 days % Adults Receiving Disability Benefits % Uninsured
Top 15 States 71.7% 84.7% 4.15 4.34 10.27
US Average 66.8% 82.7% 4.3 4.7 11
Bottom 15 States 64.0% 80.7% 4.71 5.95 15.04
Cost of Voting Active Physicians per 100K pop Chronic Disease Prevalence Premature Mortality. YPPL per 100K pop Infant Mortality Rate % households below FPL
Top 15 States 305.70 8.85 6588 5.43 10.38
US Average 277.8 9.5 7350 5.67 12.2
Bottom 15 States 238.56 11.49 8901 6.52 13.46

SOURCE: Dawn Hunter presentation, June 14, 2021.

Suggested Citation:"2 Key Concepts and Measures." 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.
×

state and will include data stratified by race, ethnicity, and other factors.3 HDHP partnered with the Center for Civic Design to conduct research to inform its website development, and Hunter solicited feedback from the civic participation and public health experts. Hunter explained that the HDHP website and the Health and Democracy score card are intended to help communities and organizations in their advocacy and data-informed action and added that Jeanne Ayers would speak about the HDHP initiative in a later session.

John Gastil began his remarks by talking about how his parents’ unsuccessful runs for office spurred his interest in the study of democracy and public participation in democracy but his Quaker upbringing also instilled in him an appreciation of consensus-based decision making as part of the democratic process. Seen through these two lenses, the democratic process is not just about winning and losing elections, but also about dialogue and the quality of the dialogue. Gastil then outlined five criteria for democracy (based on the work of Robert Dahl), each of which draws on or has implications for data collection and measurement:

  • Inclusion, and especially inclusion to enable the exercise of power (e.g., who is included or excluded from the voter rolls?);
  • Voting equality, and the fact that some votes have more power than others, as manifested in the electoral college and district boundaries;
  • Agenda control, referring to what is on the agenda and who shapes it, and acknowledging that protest politics can change the conversation;
  • Effective participation, referring to who has and uses opportunities to express their voice; and
  • Deliberation on public issues, which ought to include evidence, reasoned arguments, and consideration of diverse views, empathy, and reason.

For the deliberation criterion, Gastil described examples of governing institutions that engage in deliberation, from juries empowered to make a decision to “conventional government bodies or new deliberative bodies designed specifically to transform democratic practice.” The latter are sometimes called mini-publics, and the Oregon Citizens Initiative Review provides an example (Gastil et al., 2018). A small random sample of the public in Oregon writes the one-page issue analysis provided in the official voter guide, and that illustrates one creative way to make civic engagement more deliberative.

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3 See https://democracyindex.hdhp.us (accessed August 31, 2021).

Suggested Citation:"2 Key Concepts and Measures." 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.
×

David Grusky began by saying that “we don’t have a fully satisfactory set of tools for discovering what is happening on the ground among people with no power and no voice, people who don’t, by virtue of power differentials, have a megaphone permanently strapped to their face.” It is a failure of the social sciences that society lacks an early warning system for civic crises—with the opioid epidemic providing one example of such a crisis, he continued. The reason existing tools fail, Grusky said, is because these old-fashioned tools “amplify the voices and sensibilities of the powerful while leaving others largely voiceless.” The current measurement infrastructure—including, for example, surveys—is limited by the fact that the very questions to be asked by researchers are set by such people as policy makers and social scientists who have the sensibilities of the 1 percent. And even if the correct questions are asked, surveys still yield a narrow reflection of how members of the public think. Analyses of social media are similarly narrow, as they reflect their user base, and journalism also highlights stories that support a journalist’s hunch or theory. Qualitative studies, Grusky asserted, have long been the method of choice for discovery in the social sciences, but they, too, are often based on small, unrepresentative, sometimes proprietary samples, and it is unclear if the results are trustworthy.

What is needed to solve the problem of inadequate data and information about society and civics is the development of “a new form that combines the representativeness and transparency of quantitative research with the immersive richness of qualitative research,” Grusky said. He clarified that this is not a call for greater use of mixed methods but a new way to do research. The American Voices Project4 aims to integrate the strengths of qualitative and quantitative data, i.e., “immersive conversations with a representative sample of Americans” to learn how they are doing and how they are feeling. The project uses semi-structured, long-form conversations with the precise prompts that facilitate discovery, follow-up, and eliciting of authentic and honest conversation. Project data are transcribed, de-identified, and “made available to qualified researchers on secure servers.”

The American Voices Project, Grusky said, captured aspects of the unfolding pandemic-related crisis that conventional surveys and administrative data may overlook—for example, uncovering coping strategies, gaps in the safety net, mental health needs, the heavy toll of the noxious contracts5 that “essential” workers were being asked to engage in, a new racial divide in discourse, and much more. Grusky said that future

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4https://americanvoicesproject.org (accessed March 27, 2022).

5https://inequality.stanford.edu/covid/noxious-contract (accessed March 27, 2022).

Suggested Citation:"2 Key Concepts and Measures." 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.
×

research will also include new measures and new predictive models of poverty, intolerance, and other social issues.

DISCUSSION

Ramakrishnan began the discussion period by asking why measures matter for people “on the ground.” Hunter said that she believes in using storytelling with data to highlight a problem and monitor progress and that people need to have data to use in their advocacy with decision makers to achieve change on their community priorities. Gastil agreed and added that measurement is also important for improvement. Referring to the Citizens Initiative Review in Oregon, he said that the questions that need to be asked about the process include: (1) What is the quality of deliberation that informs the text in the Voters Guide? and (2) Does the statement in the guide influence voter knowledge and ability to be effective participants in the election? The data on these questions are encouraging, such as evidence suggesting that the Voters Guide “can improve the factual accuracy of voters’ beliefs and the coherence of their values considerations related to an issue (Gastil et al., 2017, p. 23). It is important to ascertain both if a civic engagement strategy is effective and the extent to which it makes a difference.

Ramakrishnan asked as a follow-up whether a “deliberation day” about elections and state and local policy issues would be a helpful approach to inform voters before elections. Gastil shared the “Deliberation Day” idea that Bruce Ackerman and Jim Fishkin (2002) have promoted, an idea that could take different forms, i.e., be implemented in different ways. He then underscored two ideas about deliberation: that deliberation is sometimes just intrinsically good and that it also can be designed to be consequential, i.e., connected to real outcomes. Research has shown that deliberative processes have links to health and to health-policy decision making (Degeling et al., 2015; Scherer et al., 2020).

In the next question that he relayed, Ramakrishnan asked if community-based participatory research (CBPR), which refers to research approaches that engage communities as co-researchers and change agents (Minkler and Wallerstein, 2003) could help with the balance of power between researchers and communities. Grusky said he is strongly supportive of CBPR approaches. However, he added that, more generally, the process of data collection in communities can be extractive or dehumanizing in some cases. The immersive interview process used in the American Voices Project differs from surveys because it is controlled by the person who is being interviewed, “and that’s what makes it an engaging, cathartic and less dehumanizing experience,” he said. To make sense of the evidence, it is important to bring community members, social scientists, and policy

Suggested Citation:"2 Key Concepts and Measures." 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.
×

makers into the conversation. Ramakrishnan asked if Grusky would feel comfortable with community members drafting the semi-structured interview instrument. Grusky agreed that this is desirable, while acknowledging that the project is not living up to those aspirations at this time, and he added that both people in the community and social scientists have expertise to contribute to this work. Hunter added other examples of community participation, from citizen scientist programs to community conversation models, and echoed the importance of asking about the value for communities in participating in this work and research. It is imperative to explain to community residents what happens with community feedback after they participate in city council meetings or other events.

Earlier comments referred to the power imbalance between communities and researchers, Ramakrishnan noted, but there are other kinds of power that need to be examined as well. “How can academic knowledge and data” or “measurement and research” be used by people “who have been marginalized or silenced when it comes to having influence over these policy decisions?” he asked. Hunter said that a lack of knowledge and power imbalances are not mutually exclusive. Reflecting on a Carter G. Woodson quote about how controlling people’s thoughts implies also controlling their actions, Hunter discussed how giving people access to data and knowledge is a way to help them build power, saying that it equips people “to be in a position to question and to critically assess the systems that they are in and that shape their lives.” Gastil referred to the third criterion of democracy previously listed—controlling the political agenda. There is evidence about the effective levers of power and on how policy agendas are shaped, and it is critical to use effective methods that can have an impact. Grusky added that “power imbalances are part of that knowledge generation problem” and “the powerful are building the measurement devices.” New methods are needed that will generate information in an authentic, community-based way.

It is challenging that evidence that is conveyed as generalizable or universal evidence is often evidence that comes out of questions that carry a power imbalance, according to Grusky. Civic education, Hunter said, is a key component of what is needed to recalibrate the power balance, so it necessary to consider what is being taught in schools and universities about U.S. history and the development of laws, especially in the contemporary context of efforts made by powerful decision makers to limit what is available to learners.

Ramakrishnan underscored the importance of narrative and shared a simple framework developed by his center, called DNA, for data, narrative and action. All three components are needed for research that produces meaningful change. Narratives need to be supported by data in order to drive strategic action.

Suggested Citation:"2 Key Concepts and Measures." 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.
×

Ramakrishnan posed another audience question related to measuring civic engagement: “how [do] we measure opinions, priorities and interests among groups?” Hunter shared a story about families of children with epileptic seizures who wanted access to medical cannabis and how their advocacy in linking data with their stories proved influential in getting laws changed to permit use of medical cannabis for certain groups as form of treatment for a specific diagnosis. Housing instability and homelessness are another context in which information can be provided to advocates, Hunter said. Information could include data about the linkages between housing issues and health and about policy and regulatory gaps: needed revisions to landlord–tenant laws, ordinances needed for code enforcement, and strategies that could be used at client intake in various settings (a medical–legal partnership, seeing patients in a hospital or health system, etc.). Ramakrishnan emphasized Hunter’s point about needing not just data and research but also an understanding of policy, investment, and program tools so that people who are advocating for change understand the range of levers that are available and their advocacy can be more targeted.

Gastil commented that the distance between thinking about the health of a democracy and thinking about public health is short. For example, in the case of vaccination hesitancy, he said, “if the political systems breeds a kind of sense of learned helplessness and it’s antithetical to robust evidence-enriched deliberation, it is not hard to see how that can result in a lot of people feeling that they can’t trust institutions, governing institutions included.”

Reflecting on COVID-19 vaccination disparities, Ramakrishnan remarked on how the lack of democratic influence and representation, along with disparities in civic engagement, yielded a lack of access to the vaccine for some communities in the early part of the roll-out. How did this come about, he asked? Gastil acknowledged that those who participate in elections exercise more power than those who do not, although the reasons senior citizens, who are known to be a reliable voting constituency, got access to the vaccine first may be more complex. Ramakrishnan reminded the audience about the tension some governors presented between public health and economic considerations. In response, Hunter said that one contributor to that state of affairs was the failure of the public health community in explaining its value in pre-pandemic times so that times of crisis would not see debates about the value or validity of public health strategies. Hunter added that representation matters. For example, she said, “when we see vaccination campaigns or other kinds of public health interventions roll out and they are in locations that only people with cars can get to, clearly somebody designed that who doesn’t understand the transportation needs of the community.”

Suggested Citation:"2 Key Concepts and Measures." 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.
×

Another important topic touched on during the discussion was messaging about racial equity, and Hunter explained that if a specific community is being helped, that

doesn’t mean that anyone is going to lose out. If we put interventions in place that make sure that everyone can be healthy and that the people who are struggling most among us are uplifted, then we are all uplifted. You can still get your vaccine if you are not in a priority population group, but also, all these people who are still at risk and haven’t gotten it yet, we’re going to make sure they get it, too. And so I do think we can be much stronger on that message.

Reflecting on the earlier point about disparities in civic engagement, Grusky said that Americans live in a “disparity-generating world” where, as explained by Dawes in the fireside chat, inequalities and inequities are “baked” into institutions, which become machines for creating disparities. Transformative change is needed to address these baked-in inequities, not the piecemeal plugging of holes in the dam that is far more common and that is done both during crises and more generally, Grusky added. He called for “thinking big,” recognizing the magnitude of the problem, and targeting “the disparity-generating institutions that we have built.”

Referring to the Roundtable’s January 2021 workshop on community power,6 Ramakrishnan asked the panel about the relationship between civic engagement and power-building. Gastil answered that civic engagement is frequently ineffective in the absence of organization, strategy, and message. Power can be latent or effectively exercised, but it, too, requires organization. The Trump Administration’s criminal justice reform bill was made possible by a moment of alignment among powerful sources of influence that surprised many people, Gastil noted. “Public health needs that kind of a moment” to take the “latent, widely distributed power and potentially concentrate it into a political force that could make a real difference” and add up to having “an effective voice in the political system,” he said, adding that the current pandemic could perhaps offer such a moment.

Hunter agreed with the importance of the effectiveness of civic engagement and added that people inherently have power but that they need training and equipping to build their capacity for wielding their power and engaging civically. Power-building enables people to engage effectively and to exercise influence and “shape the electoral environment over time.” An audience member asked what members of the public can do, and Hunter said that people can get involved in their neighborhood associations, write op-eds to the local paper, attend school board meetings, and submit public comments on rules, laws, and ordinances that

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6 The publication is available at https://nap.edu/26306.

Suggested Citation:"2 Key Concepts and Measures." 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.
×

are being considered. Gastil agreed and said that political self-confidence, also called internal efficacy (or “the belief that one is capable of effective political action and self-governance”) is a predictor of success in every model (see Knobloch et al., 2020, p. 428).

Ramakrishnan said that knowing how the system works—or, colloquially speaking, “how the sausage is made”—is another factor in the efficacy of civic engagement. There are both formal and informal rules related to the system, and it seems important to ask to what extent this knowledge needs to be democratized and what might be some unintended consequences (e.g., if people will ill intent become engaged). Ramakrishnan asked, “Is it worth it to just democratize this knowledge regardless of how people may want to wield that influence?” Hunter responded that there currently are people in positions of power who are enacting policies that will not improve the health of people or communities, and democratizing this knowledge is not necessarily a bad thing. Then she added, “[T]here is no better time than now for people to stand up and get involved and get engaged and say this isn’t working for us the way it works for you. It can work for everyone better. And maybe there will be some downsides to that, but maybe some of the upsides are the things that we’re missing now and we need to be willing to take on that risk.” Grusky said he worries that if the informal rules are democratized, those who are in power could readily develop a new set of informal rules to “protect the advantage of those who have power.”

Ramakrishnan shared a question about civic engagement outside of government, i.e., in the nonprofit sector. Gastil said that research has shown that successful democratic social movements have had democratic and deliberative internally and that that has been a key to their success. “When advocacy organizations become a little too interested in the exercise of strategic power without empowering their membership,” Gastil said, “they do tend to drift away from those broader purposes of a democratic social movement.” Ramakrishnan also passed along a question about gun policy reform and the possibility of finding common ground. Reflecting on the questions, Hunter used the example of Florida voters voting for increasing the minimum wage while also voting for Donald Trump and asserted that these seemingly discordant outcomes demonstrate that there was a heterogeneous group of voters all of whom found something resonant in the minimum wage ballot measure. Different people were responding to different messages that appealed about the proposed policy, and the outcome was that a law has gone into effect that has benefits for everyone, including for pay equity and for specific health outcomes such as infant mortality (Komro et al., 2016). This story shows the strength of thinking about common ground and considering the ways a policy appeals to different people’s values.

Suggested Citation:"2 Key Concepts and Measures." 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.
×

Ramakrishnan concluded the discussion period by asking the panel, “Is there hope for a healthy democracy?” and “What gives you at least an informed sense of optimism?” Hunter shared her hope from seeing grassroots work to register people to vote and push back against voting restrictions and from observing partnerships with business and philanthropy to support healthy elections by offering space for vote centers, supporting poll worker recruitment, and offering other assistance. Gastil reflected on the adoption in other countries of a range of democratic innovations that engage people in the political process or elevate democratic deliberation. Broad sections of the electorate can become productively involved in well-designed deliberations that policy makers can find valuable. Grusky said he was hopeful because so many people, organizations, and sectors (nonprofit, academia, philanthropy, etc.) are concerned, becoming active, and committing to finding a way forward.

Suggested Citation:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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 12
Suggested Citation:"2 Key Concepts and Measures." 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:"2 Key Concepts and Measures." 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 14
Suggested Citation:"2 Key Concepts and Measures." 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 15
Suggested Citation:"2 Key Concepts and Measures." 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 16
Suggested Citation:"2 Key Concepts and Measures." 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 17
Suggested Citation:"2 Key Concepts and Measures." 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 18
Suggested Citation:"2 Key Concepts and Measures." 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 19
Suggested Citation:"2 Key Concepts and Measures." 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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