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Bridging the Gap Between Transformative Practices and Traditional Public Health Approaches

Egbuonye, Nafissa Cisse PhD, MPH; Sesterhenn, Lisa MBA; Goldman, Bailey MPH; Pikora, Joshua MPH; Parmater, Jared MS

Author Information
Journal of Public Health Management and Practice: July/August 2022 - Volume 28 - Issue 4 - p S151-S158
doi: 10.1097/PHH.0000000000001502

Abstract

In November of 2018, the 24/7 Wall Street publication described Waterloo and Cedar Falls (located in Black Hawk County, Iowa) as the worst cities in the nation for Black Americans to live due to the disproportionate gaps in income, unemployment, and homeownership among racial groups.1 African Americans make up 9.7% of Black Hawk County's 131 228 residents, the highest percentage in the state of Iowa.2 The county is also home to a vastly diverse immigrant and refugee communities from Bosnia, Syria, Burma, Marshall Islands, Liberia, and Congo.3 In 2019, the county's median household income for White individuals ($57 500) was twice as high as Black individuals ($29 164).4 This level of disparity is shared across the Midwest.4 Disparities in the county reflect the consequences, socially and economically, of discriminatory policies, practices, and personal biases.5 Research has proven that people with these disparities residing in low-income neighborhoods are more likely to experience barriers to quality housing, transportation, recreational facilities, and other health-promoting aspects of the built environment.5,6 This, along with the significant wealth gap, contributes to chronic stress, disease, and lower life expectancy in communities of color.7,8

Prior to the report, Black Hawk County Public Health (BHCPH) understood the need to operate beyond the traditional role of public health practice; it needed to deepen collaboration with existing traditional partners and expand efforts with non-traditional ones to implement strategies, initiatives, and policies that explicitly address the social determinants of health.9 Funding from the Kresge Foundation's Emerging Leaders in Public Health offered a unique opportunity to explore innovative approaches that are rarely prioritized in traditional funding streams. BHCPH collaborated with Engaging Inquiry to adopt a systems mapping approach by bringing together existing expertise and resources from across the community. This approach provided a method to examine and discuss the underlying patterns in the system, the ways in which to leverage the system, and how the community can learn and adapt as the system continues to change.10

The recognition that public health challenges require a systemic approach is 1 of the 8 core competencies for public health professionals.11 The challenge for public health is how to implement systems thinking in communities where the sheer diversity of perspectives and values makes sustaining collaboration difficult.12 Deeply divergent views and experiences can create fragmentation and calls for a new set of tools to support the community to see itself as a connected system, have the necessary difficult conversations, and move forward together toward strategic action.

Implementation

When starting a systems change initiative, the first step is to describe the desired future state. This is particularly important when the success of an effort requires engagement and action from a diverse set of stakeholders who may not always see a problem the same way, let alone agree on the steps for addressing it. As such, BHCPH, along with a core group of strategic partners, agreed on the following Guiding Star:

A Black Hawk County where people want to live—and where they will thrive. A place where our citizens see themselves and each other as the beautiful and unique creations we were all meant to be.

With the destination in mind, the next step was to build clarity on the current factors producing the outcomes experienced within the community. In June 2019, BHCPH brought stakeholders together for a workshop to build understanding and alignment around the issue of racial inequity. Seventy-six stakeholders, including representatives from health care, mental health, education, economic development, faith, human services, and government, participated throughout the process. Workshops were designed to minimize power dynamics between individuals by having them stand side-by-side, as equals, to consider different viewpoints and experiences.

Participants were facilitated through an iterative process to collectively grapple with the question: “What accounts for the current level of equity, or inequity, experienced by our communities?” This consisted of:

  1. A force field analysis of the most critical factors either enabling or inhibiting equity (Table 1).
  2. Small group conversation and reflection on the multidimensional factors that caused a specific theme to exist, and the impact that its presence has in the community.
  3. Identification of patterns and the creation of causal feedback loops; a visual demonstration of how key variables are interconnected to maintain and reproduce the outcomes experienced by community members.

TABLE 1 - Force Field Analysis of Critical Inhibitors and Enablers of Equity
Inhibitors Enablers
Racism Quality of education
Policy and politics that maintain inequity Diversity of the community
Entrenched mindsets and resistance to change Presence of coalitions and willingness to work together
Financial exclusion/poverty Strong economy
Rejection of the “other”
History/legacy of exclusion
Access to mental/physical health services
Fear
Lack of support to families and communities

Stakeholders and all BHCPH staff were then invited to attend a session facilitated by Human Impact Partners. During this session, the consultants built on the themes of the initial systems workshop and introduced information and opportunities for discussion designed to build awareness of the historical and systemic drivers of racial inequity, and the impact on the community's overall health and well-being.

The loops generated during the initial systems workshop were carefully synthesized and woven together to create a cohesive and comprehensive map of the system. This draft map was shared widely with additional stakeholders, across sectors, to test the logic of the map and collect grounded examples of how these patterns show up across the community. This evaluation provided refinements and contextual data to the map leading to the next stage: Finding Leverage.

Due to the coronavirus disease-2019 (COVID-19) pandemic, the leverage process took place virtually in October 2020. Participants came together to consider: where are the opportunities to achieve outsized impact on the health of the system? This process included:

  1. Naming the outcomes of the current system in a systemic challenge statement.
  2. Describing the different types of energy present in the system; what we can build on, and what we must work around (Figure 1).
  3. Hypothesizing areas of high change potential, the shifts it would produce in the system, and key areas for monitoring and learning.

F1
FIGURE 1:
Identifying Energy in the System

Participants then reconvened to provide reflection and feedback. The session ended with a call to action: we each hold shared responsibility and shared opportunity for bringing our vision of a healthy system to life.

Evaluation

The systems mapping process applies a developmental evaluation approach to support rapid learning and adaption, and to demonstrate the commitment to responsiveness and listening to stakeholders. Evaluation activities included real-time feedback after every workshop (eg, each participant completing “I like, I wish, I wonder” statements), community feedback of mapping outputs after each workshop (context and leverage), and ongoing consultations with a cross-sectorial advisory committee. In this way, evaluation was an integrated support tool for innovation and impact in a dynamic environment.13

Results

System map

The outcomes of the first mapping workshop were 52 dynamic feedback loops that visualize how diverse forces (structural, attitudinal, and behavioral) are connected into patterns that explain how the broader system works (Figure 2).14 (A high-resolution map is also available as Supplemental Digital Figure 1, available at https://links.lww.com/JPHMP/A920). Additionally, participants engaged with individuals they may not have known before or perceived as in opposition to equity goals. The ability to collectively name and experience inequity as a systemic challenge represented the beginning of essential individual-level work.

F2
FIGURE 2:
Black Hawk County Equity Systems Map

Workshop loops provided the building blocks for a comprehensive and cohesive map visualization of the current system understood by the stakeholders, the “theory of context.” This map holds the dynamics—the patterns underneath the problems—highlighted by the combined stories of workshop participants, along with the focus groups conducted after the workshop to bring voice and context to these loops.

The deep structure is the first sentence of the larger system narrative (Figure 3).14 This loop represents a key pattern that holds together the supporting detail of the map. This is the story it tells:

F3
FIGURE 3:
Systems Map: Deep Structure

When groups of people within a community are separated from each other, either socially or systemically, uninformed narratives and beliefs about the “other” persist. This creates an “us versus them” mentality, which leads to, whether deliberately or unintentionally, the selection of sameness. This increases inequality in the distribution of opportunity and access to resources, undermining the ability of the community as a whole to thrive. When some members of a population are doing well while others struggle, it creates a fear that drives people to either hold on to what they have and maintain the status quo, or mistrust a system that has only caused them harm. This fear serves to further accentuate the divide between groups of people within a community, assuring that they never have the opportunity to build awareness of inherent human connection.

Nineteen loops are interwoven around the deep structure, each with a narrative describing the causal logic and descriptive detail, further describe essential patterns of behavior in the following areas (see the legend of Figure 2):

Community health and cohesion. These loops represent the ways in which the community is able, or unable, to work together to ensure the health and safety of its residents.

Systemic forces. Loops in this section describe patterns upheld by systemic forces (such as policies, laws, institutions, and environmental factors), which drive current inequity in our community.

Stereotyping and bias. This small but powerful section highlights the role of stereotypes, biases, and racism, whether implicit or explicit, in fueling inequality and justifying the systemic disadvantaging of people and groups.

Resource distribution. These loops describe patterns that determine how and where resources or wealth is distributed and/or maintained, and who is included in that decision-making process.

Finding leverage

As a result of the participatory leverage process, stakeholders co-created a diagnosis of the current system, a systemic challenge statement:

This system is perfectly functioning to maintain the status quo—reinforcing existing power and privilege while further harming large groups in our community, bringing forward a history of distrust and hopelessness, and creating an environment of conflict and polarization.

With alignment on the challenge, they defined strategic pathways toward transformation, grounded in the energy and opportunity already present in the system. In systems work, finding “leverage” describes a way of learning from and connecting existing energy so that a relatively small engagement can have an outsized impact, over time, on the overall health of the community. This allows for the development of “leverage hypotheses,” which are systemic theories of change that are mutually reinforcing and provide valuable insight across discipline and level of system (eg, from classroom to school district, health department to police department) (Figure 4).14 (A high-resolution map is also available as Supplemental Digital Figure 2, available at https://links.lww.com/JPHMP/A921.)

  1. Facing fear to reduce segregation, profiling, discrimination. Harnessing media and community outreach platforms to share an accurate, community-voiced narrative will foster understanding and connection, instead of fear. As fear decreases at all levels of the system, it will, over time, create shifts in behavior, the policies and programs that are developed, and how they are implemented.
  2. Passing the mic to build a sense of belonging. Redefining the leadership environment to lift up the power already present in the community will build belonging and shift perceptions from separate to intrinsically intertwined. A more equitable community is possible when people and communities move beyond obligatory inclusion to true co-creation. This will lead to stronger stable social networks, impactful public programs, and greater well-being across social determinants of health.
  3. It takes a village to increase community resources and capacity. Building from community leadership, creating pathways for locally responsive funding will ignite the seeds of resilience loop bringing in the right resources, energy, and ideas. When the community possesses the necessary building blocks of health, education, safety, and economic security, it will produce increased access to opportunity, health and safety, and the ability to lead.

F4
FIGURE 4:
Black Hawk County Equity Leverage Map

Theory to practice

In 2019, BHCPH began its community health improvement cycle using the Mobilizing for Action through Planning and Partnerships (MAPP) framework.15 The systems practice work was integrated into the Forces of Change Assessment to allow systemic factors to be considered in the identification of threats and opportunities in the local public health system. The systems map and leverage hypotheses allowed planning teams to better understand shared experiences and patterns of behavior in the community, the ways the system might “push back” against change efforts, and the opportunities to leverage positive energy that supports health improvement strategies.

With deepened knowledge of the patterns and forces that led to current inequities, BHCPH staff was able to shift the narrative of the local COVID-19 pandemic response to one that considers “what is equitable?” In April 2020, during a significant outbreak at a major meatpacking plant, stories about barriers to testing, fear of job loss, and fears of dying were shared with staff daily. BHCPH was able to advocate with state partners for immediate on-site testing, and work with plant management and union representatives for increased safety measures and paid time off for sick and exposed workers. Throughout the pandemic, existing relationships with community leaders both informed implementation and supported the communication to those most impacted. In this example, this 2-way sharing deepened community trust in the pandemic response because actions were only decided with the direct participation of the groups affected by the action: nothing about us without us.

To develop a stronger, more sustainable culture of health equity practice, BHCPH expanded its health equity training introduced during the 2019 staff session with Human Impact Partners. BHCPH and the Midwestern Public Health Training Center collaborated to develop a 6-session training series for staff. The pilot training curriculum was designed to create a working environment where everyone feels a sense of belonging, advocates for health equity, and establishes the building blocks for a sustainable culture of health equity practice. The trainings challenged the team to look beyond themselves, pay close attention to their areas of unawareness, and to under the historical and ongoing ways in which structural racism impacts our society. Systems mapping was also integrated into the training to build an understanding of the linkages necessary for transformational change. All 56 staff members participated in the trainings.

Discussion and Conclusion

The COVID-19 pandemic, systemic racism, and the inequities in our built environment present challenges for our society and the field of public health. In 2016, Public Health 3.0 called on health departments to go beyond the traditional role of public health practice; it underscored the need for health departments to expand and strengthen collaboration with nontraditional partners to implement strategies, initiatives, and policies that explicitly address the social determinants of health.9 In 2020, the 10 Essential Public Health Services were revised with a strong, centralized focus on equity.16 The National Network of Public Health Institutes most recent report emphasized the importance of infusing equity into all aspects of our work and embracing the challenges and opportunities for strengthening the public health infrastructure.17

In public health we recognize that our societal issues are fluid and complex. While COVID-19 highlighted gaps in the public health system, we learned that implementing innovative strategies to meet the needs of our community was crucial. Thus, it is compulsory that public health work with other sectors to move beyond traditional, and often siloed solutions to ones that impact our policies and practices. This needs to take place within partnerships that are deepened by formalized structures, connections, and trust. The partnerships also need to be broadened to allow for increased shared power providing a voice for those most impacted by the inequities.

In addition, for public health to thrive and assure that everyone has the opportunity to achieve their highest level of health, we will need a workforce that is adaptive. Infusing adaptive strategies into practice will provide a steady but meaningful process of change. The initial evaluation results from BHCPH's work show promise in this approach, as participants reported increased awareness and reflection on the interconnectedness of systemic inequities and deepened connections with other stakeholders. This collective understanding can lead to the alignment in the systematic assessment of policy, program, project, and planning decisions that have a significant impact on population health outcomes.

Strengths, Limitations, and Next Steps

Strengths

While we often focus on the external challenges that we see across our populations, systems work teaches us to attend to multiple levels of the system—both the “in here” and the “out there”—as they are connected and reflected in each other. As an example of how this is applied, the first mapping workshop began with a question to our planning team: “What does it look like, and feel like, when you are hosted well?” The idea of public health as a suitable capable convener of the system is its own transformation. Throughout the systems work, we learned to demonstrate the value we saw in each of our participants, even across differences, and in seeing each person we also see the system.

This process balances concrete tools and methods with adaptability allowing us to meet the unique needs and emergent opportunities of our community. This was particularly important given the context of the pandemic, but also for engaging the power of community voice during the racial equity movements of 2020. Similarly, the ability to apply these tools with flexibility allowed them to be more readily adopted by the workforce beyond the scope of this effort.

By centering this initiative around systems understanding, we noticed a greater willingness of stakeholders to emerge from their silos and look with humility at the way systemic patterns are operating to produce outcomes that create harm. This elevates the capability of public health to fully step into the role of meaningful convener for the community to achieve collective impact.

Limitations

Using a structured evidence-based systems practice tool allowed BHCPH to be the convener of a diverse group of stakeholders. This practice resulted in a better understanding of the patterns, practices, and mental models that support the map, but because the first convening involved local public health system leaders and did not provide interpreters, it may have excluded the voices of populations disproportionately impacted by the level of inequity in the community. To mitigate this, BHCPH shared and socialized the initial systems map to deepen understanding and bring patterns to life with additional insights and stories. This often took place in group settings without time allotted for participants and facilitators to diffuse or debrief and had the potential to retraumatize those sharing their experiences.

Next steps

BHCPH continues to collaborate with the Midwestern Public Health Training Center to formalize the health equity pilot training into a module for future use by Iowa's public health agencies. Applied capacity development workshops, facilitated by Engaging Inquiry, will take place to apply leverage hypotheses within BHCPH programs and identify opportunities for improvement and system strengthening. Following the workshops, a toolkit will be developed to guide others who want to take on a similar program assessment.

A focus for BHCPH is to continue to deepen existing relationships with marginalized communities and expand organizational partnerships that will work together to ensure people in our community have equitable opportunities and resources to lead healthier, more fulfilling, and longer lives. A starting point for the expanded partnership is to develop adaptive strategies based on the leverage hypotheses. Based on early feedback, this will likely include mapping the ever-growing resources related to equity in the community.

Implications for Policy and Practice
  • Public health practitioners have an obligation to be a convener of deepened and broadened partnerships that collectively address complex, dynamic problems and disrupt the systems that cause inequities.
  • Adaptive challenges cannot solely be treated with transactional solutions, as they require embracing and making sense of the complexities within a system. Adaptive strategies, coupled with a system thinking approach, will give the public health workforce a deeper understanding of the dynamic relationships and patterns within the community.
  • Systems practice work must be conducted in conjunction with health equity training to connect the past with the present and link the pervasive and entrenched impact of slavery, violence, and segregation with racism's profound bearing on the health and economic well-being of society.

References

1. 24/7 Wall Street, LLC. The Worst Cities for Black Americans. https://247wallst.com/special-report/2018/11/09/the-worst-cities-for-black-americans-4/4/. Published 2018.
2. US Census Bureau QuickFacts. Education Survey. https://www.census.gov/quickfacts/blackhawkcountyiowa. Published 2019.
3. Iowa PBS. Who Are the New Iowans? https://www.iowapbs.org/iowapathways/mypath/who-are-new-iowans. Accessed September 23, 2021.
4. US Department of Commerce. Median Income in the Past 12 Months. American Community Survey. https://data.census.gov/cedsci/table?t=Income%20%28Households,%20Families,%20Individuals%29&g=0400000US19&tid=ACSST5Y2019.S1903.
5. Gordon C. Race in the Heartland. Washington, DC: Economic Policy Institute; 2019. https://files.epi.org/uploads/Race-in-the-Midwest-FINAL-Interactive-1.pdf.
6. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al, eds. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press (US); 2017. https://www.ncbi.nlm.nih.gov/books/NBK425844/.
7. US Department of Health and Human Services. Healthy People 2020. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion; 2020. https://health.gov/healthypeople/objectives-and-data/social-determinants-health.
8. Urban Land Institute. Intersections: Health and the Build Environment. Washington, DC: Urban Land Institute; 2013. https://uli.org/wp-content/uploads/ULI-Documents/Intersections-Health-and-the-Built-Environment.pdf.
9. US Department of Health and Human Services. A Call to Action to Create a 21st Century Public Health Infrastructure. https://www.healthypeople.gov/sites/default/files/Public-Health-3.0-White-Paper.pdf. Published 2017.
10. The Omidyar Group. Systems Practice Workbook. https://docs.kumu.io/content/Workbook-012617.pdf. Published 2017.
11. Council on Linkages Between Academia and Public Health Practice. Core Competencies for Public Health Professionals. http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf. Published 2014.
12. Conklin J. Wicked Problems & Social Complexity. Chapter 1 of Dialogue Mapping Building Shared Understanding of Wicked Problems. https://cognexus.org/wpf/wickedproblems.pdf. Published 2005.
13. Patton MQ. Developmental Evaluation. Applying Complexity Concepts to Enhance Innovation and Use. New York, NY: Guilford Press; 2010. http://tei.gwu.edu/courses_approaches.htm#developmental_evaluation.
14. Black Hawk County Public Health. Black Hawk County Systems Mapping Presentation and Interactive Map. https://bhcph.kumu.io/black-hawk-county. Published 2019.
15. National Association of County and City Health Officials (NACCHO). Mobilizing for Action through Planning and Partnerships (MAPP). https://www.naccho.org/programs/public-health-infrastructure/performance-improvement/community-health-assessment/mapp. Published 2021.
16. US Department of Health and Human Services. 10 Essential Public Health Services. Washington, DC: US Department of Health and Human Services Center for State, Tribal, Local and Territorial Support; 2021. https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html.
17. National Network of Public Health Institutes. Challenges and Opportunities for Strengthening the US Public Health Infrastructure. https://nnphi.org/resource/challenges-and-opportunities-for-strengthening-the-u-s-public-health-infrastructure-findings-from-the-scan-of-the-literature/. Published 2021.
Keywords:

equity; Public Health 3.0; systems

Supplemental Digital Content

© 2022 The Authors. Published by Wolters Kluwer Health, Inc.