Community Organizing And Community Building For Health And Social Equity 4th Edition

[Graciano Goudreau]

Persistent disparities in health stem from social and structural conditions that disadvantage low-income communities of color and put the most vulnerable at increased risk for poor health outcomes (Larson et al., 2008). Health outcomes that disproportionately impact children of color, include overweight and obesity (Flores, 2010; Guerrero et al., 2016; Ogden et al., 2012), asthma (Flores, 2010), and birth outcomes (Blumenshine et al., 2010). Health disparities among children are particularly concerning as recent data suggest that for some indicators these disparities are widening (Mehta et al., 2013). Poor health in childhood contributes to increased healthcare costs across the lifespan, higher morbidity and mortality, and decreased quality of life (Braveman & Barclay, 2009). Strategies and interventions seeking to reduce childhood health disparities must address the underlying social determinants including poverty, racism, and segregation (Braveman et al., 2011; Braveman & Barclay, 2009; Minkler et al., 2019; Sanders-Phillips et al., 2009).

Community organizing philosophy dovetails with public health frameworks that prioritize root causes, social justice, and systems change (Minkler et al., 2019; Pastor et al., 2018) and a CBPR approach that centers community wisdom (Israel et al., 1998, 2003). A goal of community organizing is to support community empowerment, collective action, and advocacy to change the structures and systems that perpetuate inequity (Christens & Speer, 2015). Community organizers accomplish this by directly engaging local residents most impacted by social injustice, with the aim of building and sustaining community power in order to advocate for systems change (Fisher et al., 2018; Grills et al., 2014; Minkler et al., 2019; Pastor et al., 2018; Wallerstein & Duran, 2010). Organizers understand that social change and the fight for health equity requires a transformational, movement-building approach that transcends individual issues or campaigns (Pastor et al., 2011).

Grassroots social justice organizations, community organizers, and community members are key players in the fight for health equity. Organizers have direct knowledge of and experience with a range of social and structural issues that impact health and a deep understanding of community strengths and needs (Minkler et al., 2019). However, community organizing is decentralized and context-specific, making it difficult, at times, to track promising practices or innovative solutions in the field and share knowledge or resources across communities or content areas. To address these challenges, we sought a community-engaged, participatory research method to learn from community organizers about their work on the ground that would also support a big picture analysis to identify shared struggles and best practices in the field. We adapted a process commonly used in community organizing, referred to as landscape analysis, to understand the landscape of issues related to childhood health disparities that could inform community-driven strategies to address health inequities. Our landscape analysis process documents the social justice work and community organizing strategies used to support childhood health in resource-poor communities across the country. Specifically, the landscape analysis revealed important insights about the social and environmental conditions affecting childhood health and the strategies and practices that were most effective for supporting health equity. In this paper, we describe the CBPR framework and methods used in the landscape analysis process including our sampling strategy, development of tools, data collection, data analysis, and data dissemination. We discuss the benefits, limitations, and implications of this approach.

The process itself varies depending on the purpose and goal of the scan, but methods include interviews with key constituents, surveys, literature and documents reviews, focus groups, visual mapping, or some combination of these methods (Sherry, 2013). Importantly, the information gleaned from the scan is actionable. While field scans and environmental scans are valuable tools for big picture assessment and planning, neither explicitly employs participatory methods, which is central to our work with marginalized communities and community organizers. Therefore, we adapted these approaches for use within a CBPR framework that utilizes participatory methods and a consistent social justice lens to analyze the landscape of health equity community organizing. We define landscape analysis as a participatory data collection and assessment process useful for understanding the broader context, evaluating strengths and challenges, and identifying field trends to inform actionable next steps. We use the term landscape analysis, rather than field scanning, to reflect the preferred terminology among the community organizing practitioners that we work with.

Since its inception in 2009, the Communities Creating Healthy Environments (CCHE) initiative, funded by the Robert Wood Johnson Foundation (RWJF), recognized grassroots social justice organizing as a strategy to address childhood health injustice in marginalized communities using a CBPR framework (Grills et al., 2014). CCHE supports the work of grassroots social justice CBOs to advance environmental change using the art and science of community organizing. Over the past decade, the Praxis Project (Praxis) has served as the national program office and the Psychology Applied Research Center at Loyola Marymount University (PARC@LMU) as the national evaluator for CCHE. During Phases 1 (2009-2013) and 2 (2014-2016) of CCHE, Praxis worked directly with CBOs to build organizational capacity, support policy advocacy campaigns (resulting in 72 policy wins that increased access to nutritious and affordable food and safe places to play), and develop a national network of over 200 grassroots social justice CBOs (Grills et al., 2014). Phase 3 sought to leverage these networks and relationships to gain insights about best practices and emerging strategies used by organizers to advance health equity efforts.

CCHE network members are working on any number of social justice issues including fair housing, environmental justice, and police accountability, all of which ultimately advance health equity. CBOs often operate with limited resources (i.e., small budgets, reliance on part-time staff or volunteers, etc.) and because campaigns and advocacy work often focus on the local context, community organizing work can be isolating. The landscape analysis presented an opportunity to learn from a wide range of organizers, produce knowledge, and share resources that could be distributed across the CCHE network.

Under the leadership of Praxis, we developed a five-step process to analyze the landscape of childhood health inequities. Consistent with our CBPR approach, project partners (described below) were involved at every stage of the process.

Once the project partners agreed to the scope and purpose of the landscape analysis, we were ready to begin developing the methodology and analytic plan. A combined strategy was used to ensure that both rigorous qualitative methods and a community organizing focus guided the instrument development, codebook creation, and data analysis.

To ensure a representative sample of diverse CBOs (in terms of geographic location and ethnic/racial communities served) the key informant groups were stratified by region (Midwest, Northeast, South, Southwest, and West) and ethnic/racial constituency group (African American, Asian and Pacific Islander, Latino, Indian Country, and Mixed Constituency). Our project partners assisted with developing a list of potential key informants on a shared Google spreadsheet, which allowed individuals to add suggestions, pose questions to each other, and edit the list in real time. The initial sampling pool was drawn from existing network members (from CCHE Phases 1 and 2) and CCHE Collaborative contacts (these included organizations that were not part of the CCHE network previously, but that were engaged in community organizing work that impacted children).

Through an iterative process, we dropped and added CBOs from the list depending on the interest and availability of key informants. We exceeded our target of 20 interviews by December 2016, with a total sample of 23 organizations. Snowball sampling was used to generate a second sampling pool with 64 new organizations identified by key informants from the first round of interviews. Again, with input from CCHE Collaborative members, we reduced the list of potential key informants from 64 to 26 groups using the same criteria from the first round of interviews. As a result, 49 groups were dropped from the initial list and 11 groups were added for a target goal of 26 interviews. Four groups were not available to complete the interview before the end date in September 2017, resulting in a total sample of 22 interviews. The final sample across two rounds of interviews included 45 key informants representing grassroots CBOs across the country. See Table 1 for ethnic/racial constituency and geographic representation breakdown for both rounds of interviews.

We designed the key informant phone interview protocol in May 2016 with input from project partners. The interview protocol included a statement about confidentiality and the purpose of the landscape analysis, a brief quantitative assessment of organizational capacity needs and strengths (five minutes), and a semi-structured interview (45 to 60 minutes). We found that interviewees were more likely to respond to the organizational capacity survey while we had them on the phone for the interview, rather than try to get them to complete it on their own before or after the phone call. The interviewer read the brief survey questions aloud and recorded their answers in Qualtrics (online survey tool) on behalf of the respondent, and then transitioned to the semi-structured interview questions. The call was recorded on Zoom and the interviewer was trained to take written notes of high-level themes and key words or phrases. In total, the phone call took about one hour and covered the following topics: 1) Social Conditions, Barriers, and Impacts: features of the social and physical environment that inhibit healthy living and impact childhood health; 2) Current Work of the Organization: successful campaigns, efforts and programs to improve health, wellness, or safety in the community; and 3) Best Practices: strategies used by the organization to make a change that matters.

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