What Do We Know About the Drivers of Health and Equity? A Narrative Review of Graphic Representations.

Purpose: Frameworks can be influential tools for advancing health and equity, guiding population health researchers and practitioners. We reviewed frameworks with graphic representations that address the drivers of both health and equity. Our purpose was to summarize and discuss graphic representations of population health and equity and their implications for research and practice. Methods: We identified publicly available frameworks that were scholarly or practice oriented and met defined inclusion and exclusion criteria. The identified frameworks were then described and coded based on their primary area of focus, key elements included, and drivers of health and equity specified. Results: The variation in purpose, concepts, drivers, underlying theory or scholarly evidence, and accompanying measures was highlighted. Graphic representations developed over the last 20 years exhibited some consistency in the drivers of health; however, there has been little uniformity in depicting the drivers of equity, disparities or interplay among the determinants of health, or transparency in underlying theories of change. Conclusion: We found that current tools do not offer consistency or conceptual clarity on what shapes health and equity. Some variation is expected as it is difficult for any framework to be all things to all people. However, keeping in mind the importance of audience and purpose, the field of population health research and practice should work toward greater clarity on the drivers of health and equity to better guide critical analysis, narrative development, and strategic actions needed to address structural and systemic issues perpetuating health inequities.

From Roots to Results: A Qualitative Case Study of the Evolution of a Public Health Leadership Institute Building Capacity in Collaborating for Equity and Justice.

Policy, systems, and environmental change are now widely accepted as critical to sustaining improvements in community health. Evidence suggests that such systems-level change is most effective when driven by community-based partnerships. Yet, after more than three decades of building community-based partnership work, health inequities have continued to deepen. To address health inequities, current and historical distributions of power are increasingly recognized as important considerations in efforts to ensure all individuals have the opportunity to attain their full health potential (i.e., achieving health equity). Building on social determinants of health literature, social injustice and powerlessness are put forth as fundamental causes of health inequities. Focusing on power as a root cause of health and health equity through application of Wolff and colleagues' six principles requires substantial changes in contemporary public health practice. This case study uses document analysis of a single case, the Community Teams Program, to assess the evolution of a statewide public health leadership program's efforts to build the capacity of coalition-based teams to catalyze community change in line with Wolff and colleagues' principles. Deductive, selective coding of the materials surface four themes in the program adaptations: (1) the need to focus on power as a root cause, (2) shifting power through relationship building, (3) storytelling as a way to shift narrative, and (4) building mechanisms into the curriculum that hold coalitions accountable for applying and sustaining learned skills. The themes demonstrate philosophical, pedagogical, and organizational changes to center power building approaches in health promotion. Findings are triangulated by reflections from the program director and recorded reflections of participants captured in existing evaluation data.

Advancing Coalition Health Equity Capacity Using a Three-Dimensional Framework.

Purpose: We examined coalition health equity capacity using a three-dimensional conceptual framework in a 3-year study (2011-2014) of 28 local coalitions engaged in health promotion. Methods: Coalition health equity capacity was defined according to (1) conceptual foundations, (2) collective action and impact, and (3) civic orientation. This framework was used to qualitatively assess progress in capacity building efforts at two time points. Coalition materials and archival documents were analyzed qualitatively for indications of each dimension of coalition health equity capacity. Results: The overall cohort of coalitions was initially determined to be near mid-range in conceptual foundations, above mid-range on collective impact, and below mid-range on civic orientation. As part of ongoing training and technical assistance, coalitions were offered examples of high coalition health equity capacity in each dimension. At time point two, growth in health equity capacity was observed in a majority of coalitions. Conclusions: These findings indicate that a multidimensional approach to coalition health equity capacity can be useful for both analysis and practical purposes of community capacity building, which may, in turn, produce long-term gains in health equity.

Community-Led Collaborative Action to Prevent Obesity.

At the population level, turning the tide on obesity requires not only health education and promotion programs, but also systemic changes in our society. However, few of these changes can be implemented by single agencies or organizations acting in isolation. Broader community-driven efforts are needed to advance and maintain systematic changes across multiple settings. We introduce 2 promising approaches for local action to achieve changes: coalition action and community organizing. Understanding differences between the two approaches makes it clear that while each has distinct advantages, there are also possibilities for synergies between them. We also clarify how community-driven efforts can be catalyzed and supported, and describe our efforts as part of the Wisconsin Obesity Prevention Initiative to identify and implement best practices for building and sustaining the necessary local community capacity to carry out systematic changes. We are working with communities to launch initiatives in which residents are engaged through grassroots organizing, and local agencies, businesses, and other institutions are engaged in pursuit of collective impact on obesity prevention. This will allow us not only to compare the effectiveness of the 2 types of initiatives for driving local changes, but also to explore the potential for the two to work together in pursuit of systemic changes for preventing obesity.

Lessons From a Pilot Community-Driven Approach for Obesity Prevention.

INTRODUCTION: The Wisconsin Obesity Prevention Initiative has piloted a novel approach for community action for obesity prevention that incorporates both coalition and community organizing efforts in 2 counties. This article describes lessons learned to date from this experience. METHODS: A description of the progress made in these communities and the support provided by Initiative staff and other partners are drawn from process evaluation of the pilot from November 2014 through December 2015, as well as the reflections of community partners. RESULTS: In Marathon County, building towards coalition action required thoughtful re-engagement and restructuring of an existing obesity-focused coalition. Community organizing surfaced local concerns related to the root causes of obesity, including poverty and transit. In Menominee County, coalition and community organizing efforts both have drawn attention to cultural assets for health promotion, such as traditional food practices, as well as the links between cultural loss and obesity. CONCLUSIONS: Building coalition action and community organizing varies across community contexts and requires addressing various steps and challenges. Both approaches require critical local examination of existing community action and stakeholders, attention to relationship building, and support from outside partners. In coalition action, backbone staff provide important infrastructure, including member recruitment and facilitating group processes towards collaboration. Community organizing involves broad resident engagement to identify shared interests and concerns and build new leadership. A community-driven systems change model offers potential to increase community action for obesity prevention.

Channeling power across ecological systems: social regularities in community organizing.

Relational and social network perspectives provide opportunities for more holistic conceptualizations of phenomena of interest in community psychology, including power and empowerment. In this article, we apply these tools to build on multilevel frameworks of empowerment by proposing that networks of relationships between individuals constitute the connective spaces between ecological systems. Drawing on an example of a model for grassroots community organizing practiced by WISDOM­a statewide federation supporting local community organizing initiatives in Wisconsin­we identify social regularities (i.e., relational and temporal patterns) that promote empowerment and the development and exercise of social power through building and altering relational ties. Through an emphasis on listening-focused one-to-one meetings, reflection, and social analysis, WISDOM organizing initiatives construct and reinforce social regularities that develop social power in the organizing initiatives and advance psychological empowerment among participant leaders in organizing. These patterns are established by organizationally driven brokerage and mobilization of interpersonal ties, some of which span ecological systems.Hence, elements of these power-focused social regularities can be conceptualized as cross-system channels through which micro-level empowerment processes feed into macro-level exercise of social power, and vice versa. We describe examples of these channels in action, and offer recommendations for theory and design of future action research [corrected] .