As a public health worker in a world with an ever-growing socioeconomic divide, it becomes more important to not only fight sickness, but also to use a systems approach in identifying the causes behind inequalities in health outcomes. A health disparity is a health outcome as a result or consequence of factors such as (but not limited to) sexual orientation, race or ethnicity, socioeconomic status, gender, disability status, or geographic isolation. Most often, a health disparity is due to a combination of these factors.
The Community Health Training Institute, a part of Health Research in Action, hosted two webinars titled, “Introduction to Equity in Community Building” and “Engaging and Empowering Priority Communities”. These two webinars laid out the steps necessary to achieve health equity and identified common barriers to program planning and community engagement. Health equity is the idea that some populations require more resources or assistance to rise to the level of those with optimal health, due to the same factors that contribute to health disparities. I thought the hosts of the webinar did a great job explaining this concept, and this photo of people standing on different level boxes was especially helpful:
To achieve health equity, we must disaggregate the data, looking not only at health differences between populations, but examining factors such as race and poverty. We then must work upstream to address these systematic and institutionalized factors contributing to poor health in a community.
In the first webinar, four questions were presented to show how systems are multi-layered and involve many stakeholders. These questions are:
- Who benefits?
- Who pays (or who is harmed)?
- Who leads?
- Who decides?
The classic example they lay out to demonstrate this approach is the fight against tobacco use. In regards to tobacco, large tobacco distributors benefit; smokers and their families are harmed; community advocates and health departments lead in the fight against tobacco; and government agencies decide. These questions highlight the need for cross-sector evaluation and collaboration in intervention efforts. I think the most important aspect of this framework is identifying how the beneficiaries are often the ones deciding, while the people being harmed, or paying, lack enough agency to affect change.
Another example the webinar offered was the “Community Health Improvement Program” (CHIP) in Worcester, Massachusetts. This program laid out several strategies to engage community members and to identify leaders, especially among youth members. This local program is truly attempting to recruit input and participation from the population directly affected by policies or interventions.
Barriers in Decision Making
In the second webinar, they identified barriers to cross-sector collaboration and community engagement. The barriers to stakeholder involvement are different than the barriers to community member recruitment, but most issues seem to stem from power differentials. These power differentials often due to the same systematic issues that cause health disparities. In other words, the group with less power is the group that may have been directly affected by years of institutional racism and low socioeconomic status.
Two significant barriers that organizations face in trying to involve stakeholders in program planning are the dangers of paternalism and pathologizing. Paternalism is when people with a lot of power in a relationship act as though they know what is best for the people they are supposedly helping. Blaming individuals for their circumstances also have to do with the idea of paternalism. Pathologizing is similar in the sense that it implies that the people you’re helping are somehow abnormal. The key is to identify these issues and remember that decisions should be made with and by the community. Other barriers to successful planning include (but are not limited to): time management, priority differences, literacy, citizenship, and racism.
Some barriers to recruitment and engagement (which happen after the planning process) are similar to the ones previously mentioned. There are intentional and unintentional barriers to involvement. Intentional barriers are operational or contextual barriers, and can be changeable. They include aspects such as meeting times, language usage, and resource availability. Unintentional barriers are difficult to change. They include cultural barriers and situations when community members may distrust implementors or public health workers due to negative experiences with health interventions.
Strategies for Power Sharing
The most useful aspect of this webinar, in my opinion, were the strategies for power sharing that the host discussed with participants. He stressed the need to engage existing community and civic structures, like cultural groups or religious organizations. He also noted that communication should be easy and meetings should be structured in such a way so everyone involved has the same knowledge, has had time to reflect on it, and is actively participating in a conversation about the program.
Additionally, it is important to be as inclusive as possible when thinking of solutions. To empower a group of people, they must feel as though they have the agency to change some aspect of their own behavior or the behavior of others. In order to achieve inclusion, it is also important to constantly be analyzing influencing factors of race, poverty and power so that everyone is educated on the causes and motivations for the project.
I thought the best tip given by the host was that we need to be willing to be uncomfortable and to be able to gauge the comfort level of the group. In my personal experiences working with homeless populations, I have learned to emphasize the importance of leaving your “comfort zone” and going towards an uncomfortable zone, or “learning zone”. It is here that we learn about ourselves and others and are able gain confidence. However, like the host mentioned, it is important to return to that safe zone once and a while, so that the group or community retains trust in their leaders.
Community Health Training Institute (producer). 2016. Introduction to Equity in Community Building. [Webinar].
Community Health Training Institute (producer). 2016. Engaging and Empowering Priority Communities. [Webinar].