Community Power in Population Health Improvement Proceedings of a Workshop (2022) / Chapter Skim
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7 Amplifying the Empirical Base Linking Community Power and Health Equity
7 Amplifying the Empirical Base Linking Community Power and Health Equity
Pages 93-122
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From page 93... ...
• Power building is not only a means to achieving health equity, it is an end in and of itself. (Martinez)
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From page 94... ...
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.
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From page 95... ...
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.
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From page 96... ...
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.
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From page 97... ...
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.
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From page 98... ...
98 COMMUNITY POWER IN POPULATION HEALTH IMPROVEMENT TABLE 7-1 Diverse Practices for Developing Community Power Dimensions Descriptions/Common Alternatives Source of • Problems arise from deficits of people or lack of skills and/or problems motivation • Problems arise from conditions of environment • Problems arise from systems of exploitation and the powerlessness they produce Change • People solve their own problems rather than looking to strategies 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 • Consensus building, better communication, educate people, social tactics 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 • Collaborators and partners in common goals to power • Employers, sponsors, meritorious elites structure • Actors external to community with divergent interests from residents Boundary • Target geographic area definitions • Target relational communities • Target identity-based alignments (gender, race, ability, class) • Target existing group memberships (school, faith group, workplace)
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From page 99... ...
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
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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.
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From page 101... ...
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)
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From page 102... ...
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.
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From page 103... ...
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.
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From page 104... ...
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.
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From page 105... ...
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.
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From page 106... ...
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.
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From page 107... ...
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.
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From page 108... ...
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.
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From page 109... ...
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.
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From page 110... ...
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.
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From page 111... ...
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.
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From page 112... ...
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.
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From page 113... ...
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.
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From page 114... ...
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.
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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.
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From page 116... ...
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.
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From page 117... ...
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.
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From page 118... ...
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.
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From page 119... ...
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.
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From page 120... ...
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.
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From page 121... ...
AMPLIFYING THE EMPIRICAL BASE 121 • There is already a body of knowledge, expertise, and proven prac tices around community power building. There is a diverse array of practitioners and organizations devoted to doing this and sup porting it, and people working in the health field need to connect more fully with it.
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