Narrative change for health equity in grassroots community organizing: A study of initiatives in Michigan and Ohio.

To achieve health equity, there is a need to act on the social determinants of health. This reality is now understood more widely, and in greater detail, than ever. Amid this movement toward health equity, there has been a natural gravitation to community organizing, which has long worked to produce more equitable systems and policies. Community organizing builds power through cycles of listening, participatory research, collective action, and reflection. One manifestation of this power is that organizing initiatives can often influence which issues are up for public debate, and the terms of those debates. This dimension of community power is often described by practitioners as narrative change work, and involves intervening on, complicating, and resisting dominant societal narratives that hinder action on the systems that perpetuate inequity. This article reports results from a study of organizing initiatives in Detroit, MI and Cincinnati, OH which both engaged in intentional narrative change work around health and health equity. We analyzed data from interviews with 35 key leaders across both cities. Results describe the organizational processes and activities taking place in both sites, with an emphasis on one issue in each city: educational equity in Cincinnati and water equity in Detroit. We then use coded interview data to examine how narrative change work took place in organizing around these issues during the COVID-19 pandemic, a challenging time for organizing initiatives. Results provide insights into adaptations taking place in community organizing during this time, as well as various approaches to narrative change work as part of holistic efforts to build and exercise community power to alter social determinants of health.

Stories of self, us, and now: narrative and power for health equity in grassroots community organizing.

Introduction: Community organizing initiatives, which build power through cycles of listening, participatory research, collective action, and reflection, have demonstrated the capacity to intervene on, complicate, and resist dominant societal narratives while promoting alternative public narratives focused on shared values and hope for a better future. Methods: To explore processes of public narrative change and their relationship to community and organizational empowerment, we interviewed 35 key leaders in community organizing initiatives in Detroit, MI and Cincinnati, OH about how narrative change takes place within community organizing practices. Results: Leaders' perspectives revealed crucial roles for narrative and storytelling in guiding individual and collective behavior, supporting the development of relationships of trust and accountability, and linking personal and collective experiences to pressing social issues. Discussion: Findings from this study indicate that systemic change is a labor-intensive process and one that requires the development of leaders (stories of self) and the cultivation of collective structures (stories of us) capable of enacting power to effect change with urgency (stories of now). We conclude by discussing implications of these findings for public narrative interventions and related health equity promotion efforts.

Community organizing: Studying the development and exercise of grassroots power.

There is now wide recognition that grassroots community organizing is a uniquely necessary approach for contending with the persistent and escalating socioeconomic inequities that manifest as disparities across many societal domains, including housing, safety, education, and mental and physical health. The articles in this special issue report findings from studies designed to increase understanding of community organizing processes and produce actionable knowledge that can enhance these and other similar efforts to create more equitable and just cities and regions. These studies examine a variety of community organizing campaigns, initiatives, and networks in North America, as well as one in Bulgaria, and one in South Africa. These groups are building social power and demanding economic, racial, educational, and environmental justice. In this introductory article, we highlight some of the themes that emerge from this set of studies and make recommendations for future roles that research can play in advancing collective understanding and the practical objectives of grassroots organizing initiatives.

Participation in community organizing: Cross-sectional and longitudinal analyses of impacts on sociopolitical development.

This article reports cross-sectional (Study 1) and longitudinal (Study 2) results from analyses of civic behaviors and attitudes among two groups: participants in grassroots community organizing in five US cities and a geographically balanced sample of their neighbors, many of whom were participating with other types of voluntary organizations (e.g., neighborhood-based or school-based groups). This analytic approach allowed for tests of differences between groups, differences within groups over time, and interactions between groups and time on indicators of sociopolitical development including civic behaviors, psychological sense of community, and the emotional and cognitive components of psychological empowerment. Results showed that community organizing, as a particular type of mediating institution, cultivates sociopolitical development by elevating psychological empowerment and civic engagement over time.

Transformation to leadership: Learning about self, the community, the organization, and the system.

Leadership development is an important practice in community organizing. Although this importance is often acknowledged, relatively little scholarship details how leadership development is actually executed, or how concepts of leadership development are applied in organizing practice. This study reports on a thesis conducted by a community organizer utilizing a critical reflexive methodology. Eight active leaders from a community organizing effort in New Orleans, LA were interviewed about their interpretations of their own development as leaders. Leadership development as experienced by leaders is supplemented with observations from the organizer working with these leaders, providing triangulation on developmental processes in practice. Findings demonstrate the potential for transformation among community residents as they work to build collective power for social change.

Youth Cognitive Empowerment: Development and Evaluation of an Instrument.

Psychological empowerment (PE) is a multicomponent construct that involves the mechanisms through which people and groups gain control over their lives and environments. Psychological empowerment has previously been operationalized using measures of sociopolitical control among young people, with findings indicating links between PE and other positive developmental outcomes. Sociopolitical control, however, is only an indicator for the emotional component of PE. Research has largely neglected the cognitive component of PE, particularly in studies of younger people. In fact, few studies to date have presented and empirically tested measurement instruments for the cognitive component of PE among youth. In this study, we adapted a measure, which previously had been validated and used among adults, for use among young people and tested it in a sample of high school students (53% female, 75% Hispanic) in an urban school in the northeastern U.S. Confirmatory factor analyses were used to assess the hypothesized three-factor structure of cognitive empowerment, and the measure was examined for association with the construct of social justice orientation. Results indicate an adequate fit for the second-order factor, and an expected relationship with the related construct.

Assessing Community Participation: Comparing Self-Reported Participation Data with Organizational Attendance Records.

How well do self-reported levels of community and organizational participation align with recorded acts of community and organizational participation? This study explores this question among participants in social action community organizing initiatives by comparing responses on a community participation scale designed to retrospectively assess community participation (T1, n = 482; T2, n = 220) with individual participants' attendance records in various social action organizing activities over two 1-year periods. By testing the self-reported measure's overall and item-by-item association with documented participation in various types of organizing activities, we find that the self-report measure is positively, but weakly correlated with actual participation levels in community organizing activities. Moreover, associations between self-report and recorded acts of participation differ by types of activity. Examining this unique source of data raises important questions about how community participation is conceptualized and measured in our field. Implications are explored for theory and measurement of participation in community and organizational contexts.

Large-for-Gestational-Age Ultrasound Diagnosis and Risk for Cesarean Delivery in Women With Gestational Diabetes Mellitus.

OBJECTIVE: To assess the accuracy of a large-for-gestational-age (LGA) ultrasound diagnosis and the subsequent risk for cesarean delivery associated with ultrasound diagnosis of LGA among women with gestational diabetes mellitus. METHODS: This was a retrospective cohort study of 903 women with GDM who delivered after 36 weeks of gestation with an ultrasound-estimated fetal weight within 31 days of delivery. Delivery outcomes were compared between women with an ultrasound diagnosis of LGA and a non-LGA ultrasound diagnosis. RESULTS: Based on ultrasound assessments, we identified 248 women with an LGA fetus and 655 women with a non-LGA fetus. Among women with an LGA ultrasound diagnosis, 56 of 248 (22.6%) delivered an LGA neonate, whereas, of women with a non-LGA ultrasound diagnosis, 18 of 655 (2.8%) delivered an LGA neonate. Ultrasound diagnosis of LGA was associated with increased risk for cesarean delivery (adjusted odds ratio [OR] 3.13, 95% confidence interval [CI] 2.10-4.67, P<.001) after adjusting for relevant covariates. Stratified analyses demonstrated that ultrasound diagnosis of LGA was associated with an increased risk for cesarean delivery whether the birth weight was between 2,500 and 3,499 g (OR 2.82, 95% CI 1.62-4.84, P<.001) or between 3,500 and 4,500 g (OR 3.47, 95% CI 2.06-5.88, P<.001). CONCLUSION: Ultrasonography significantly overestimates the prevalence of LGA in women with gestational diabetes mellitus, and an ultrasound diagnosis of LGA is associated with an increased risk for cesarean delivery independent of birth weight. LEVEL OF EVIDENCE: II.

Organization-level predictors of sustained social movement participation.

Long-term sustained participation represents one of the most important resources available to community organizations and social movement organizations (SMOs). The participatory literature on community and SMOs has identified a host of individual-level factors that influence participation beyond initial engagement, and has more recently identified contextual factors that influence participation. This study builds upon current understandings of participation in SMOs by examining how sustained participation in movement activities is affected by two qualities of SMO settings: repertoire of organizational activity, and equality of staff contact with organization members to cultivate and facilitate individual participation. To this end, we employ multi-level regression techniques to examine longitudinal data on participation within 50 local chapters of a national congregation-based community organizing federation. We find that the conduct of organizational activities previously shown to increase levels of participation among individual persons does not necessarily lead to increases in aggregate or organization-level participation. Further, we find that conditions of unequal staff contact among organization members represent a notable drag on organization-level participation over time. Our findings suggest that organizers and organizational leaders may well see greater levels of participation in their organizations by simply re-distributing resources and opportunities more equitably within their organizations.

Novel Mutation in the PKHD1 Gene Diagnosed Prenatally in a Fetus with Autosomal Recessive Polycystic Kidney Disease.

We report a 29-year-old gravida 2, para 0100, who presented at 19 weeks and 4 days of gestation for ultrasound to assess fetal anatomy. Routine midtrimester fetal anatomy ultrasound revealed enlarged, hyperechoic fetal kidneys and normal amniotic fluid index. Follow-up ultrasound at 23 weeks and 5 days revealed persistently enlarged, hyperechoic fetal kidneys. Progressive oligohydramnios was not evident until 29 weeks of gestation, with anhydramnios noted by 35 weeks of gestation. Amniocentesis was performed for karyotype and to search for mutations in the PKHD1 for the presumptive diagnosis of autosomal recessive polycystic kidney disease (ARPKD). In our patient, a maternally inherited, previously reported pathogenic missense mutation in the PKHD1 gene, c.10444C>T, was identified. A second, previously unreported de novo mutation, c.5909-2delA, was also identified. This mutation affects the canonical splice site and is most likely pathogenic. Our case highlights PKHD1 allelic heterogeneity and the importance of genetic testing in the prenatal setting where many other genetic etiologies can phenocopy ARPKD.

Prenatal midtrimester fetal long bone measurements and the prediction of small-for-gestational-age fetuses at term.

OBJECTIVE: To determine if the length of fetal long bones (LB) at mid-trimester ultrasound is predictive of small-for-gestational-age (SGA) newborns at term delivery. METHODS: Retrospective evaluation of 6,781 women between 18 and 24 weeks' gestation at Magee-Womens Hospital (MWH). Gestational age (GA) was confirmed by first- or second-trimester ultrasound and patient's last menstrual period. Data were accrued from the institutional database at MWH. LB measurements were normalized to GA at the time of the ultrasound. The ratio was correlated with the probability of delivering an SGA newborn at term. RESULTS: In all, 583 women were identified with an SGA newborn (8.6%). LB-to-GA ratios were associated with the probability of delivering an SGA newborn at term (p < 0.001). There was no single LB that proved to be superior in predicting an SGA newborn. CONCLUSION: There is a significant association between LB-to-GA ratio at midtrimester and the probability of SGA at term.

Community organizing practices in a globalizing era: building power for health equity at the community level.

In the postindustrial era, global economic processes have constrained the ability of local agencies, service providers, and civic groups to respond to systemic challenges in public health. Community health psychology can benefit by focusing on interventions through mediating structures that develop innovative methods of leveraging power in the context of globalizing economic forces. Promising methods include careful analysis of power within targeted policy domains and developing strategic alliances with others, so as to exercise social power to affect policy change. The case of ISAIAH, an organizing group based in Minnesota, illustrates innovative avenues for intervention in the context of globalization.

The influence of participation, gender and organizational sense of community on psychological empowerment: the moderating effects of income.

This study explored the influence of participation, gender and organizational sense of community (SOC) on both the intrapersonal and interactional components of psychological empowerment (PE). Participants were residents (n = 562) involved in community organizing efforts in five U.S. communities. Measures of participation and SOC were tailored to community organization contexts. SOC assessed three dimensions: (1) connection of members to the organization; (2) perceptions about the organization as a bridge to other groups and organizations in the broader community; and (3) bond or attachment to the community at large. Income (low, middle and high-income) was tested as a moderator of these relationships. Results showed significant moderating effects of income on the relationship between participation, gender and SOC on both components of PE. Participation was positively related with intrapersonal empowerment across income levels, but positively related with interactional empowerment only for low-income individuals. Gender was only associated with intrapersonal empowerment, and only for low-income individuals. SOC, as expressed through bridging to the broader community, was positively related with interactional PE for all income levels, but with intrapersonal PE for only low and middle-income individuals. In contrast, member connection to the organization was not related to interactional empowerment and significantly related to intrapersonal empowerment only for individuals with higher income. The importance of participation, gender and SOC for different types of empowerment and the impact of income on the SOC-empowerment relationship are discussed.

Risk of morbid perinatal outcomes in small-for-gestational-age pregnancies: customized compared with conventional standards of fetal growth.

OBJECTIVE: To estimate and compare the risk of morbid perinatal outcomes in pregnancies identified as small for gestational age (SGA) with customized compared with conventional standards of fetal growth. METHODS: Ultrasound-derived estimates of fetal weight were used to generate a fetal growth trajectory (N=7,510). The gestational age at delivery and pathologic and physiologic variables from 5,072 pregnancies were used to calculate a customized threshold for SGA. In a separate analysis of 32,070 pregnancies, rates of morbid outcomes were compared in participants classified as SGA according to a population-based birth weight standard only (SGApop only), a customized standard only (SGAcust only), and both methods (SGAboth). RESULTS: Eight-hundred seventy-five (2.7%) participants were SGApop only, 1,970 (6.1%) participants were SGAboth, and 609 (1.9%) participants were SGAcust only. The odds ratios of neonatal death in SGApop only and SGAcust only pregnancies were 1.78 (95% confidence interval [CI] 0.2-13.1) and 54.6 (95% CI 29.0-102.8), respectively. Rates of prematurity in the SGApop only and SGAcust only cohorts were 4.8% and 64.5%, respectively. After adjustment for the effect of prematurity, odds ratios of neonatal death in the SGApop only and SGAcust only cohorts were 4.8 (95% CI 0.6-37.0) and 2.9 (95% CI 1.4-6.1), respectively. CONCLUSION: After adjustment for confounding stemming from premature delivery, there is little difference in the risk of adverse outcomes between SGAcust only and SGApop only participants. Adoption of customized fetal growth standards into clinical practice may not improve the ability to identify pregnancies with increased risk of perinatal morbidity.

Ecological contexts in the development of coalitions for youth violence prevention: an organizational network analysis.

Community coalitions are a recognized strategy for addressing pressing public health problems. Despite the promise of coalitions as an effective prevention strategy, results linking coalition efforts to positive community outcomes are mixed. To date, research has primarily focused on determining organizational attributes related to successful internal coalition functioning. The authors' research complements and adds to this literature by offering a network conceptualization of coalition formation in which coalition participation is studied within the broader context of local organizational networks both within and beyond a coalition. The authors examine participation in the first year of a youth violence prevention coalition exploring both differences between participating and nonparticipating organizations and levels of participation. Each network variable, reflecting prior collaboration and being viewed by other organizations as a local leader, approximately doubled the explained variance in coalition participation beyond the predictive power of all available organizational attributes combined. Results suggest that initial coalition participation emerged out of a preexisting network of interorganizational relations and provide an alternative perspective on coalition formation that goes beyond conceptual orientations that treat coalitions as bounded organizational entities that exist apart from the communities in which they are embedded.

A customized standard of large size for gestational age to predict intrapartum morbidity.

OBJECTIVE: The purpose of this study was to determine whether a customized standard of large-for-gestational age (LGA) identifies pregnancies with increased perinatal risk. STUDY DESIGN: We evaluated 7510 estimates of fetal weight to generate a fetal growth curve. Next, we analyzed the gestational age at delivery, physiologic and pathological variables from 5072 pregnancies to predict birthweight, and calculated a customized ideal birthweight and cutoff for LGA. In a separate analysis of 32,271 pregnancies, rates of macrosomia-related adverse outcomes were compared in pregnancies that had been identified as LGA by a customized standard (LGA(cust)) and those pregnancies that had been identified as LGA or macrosomic by conventional standards. RESULTS: LGA(cust) pregnancies carried increased risk of shoulder dystocia, third- or fourth-degree laceration, and cephalopelvic disproportion. LGA(cust) pregnancies that did not meet conventional criteria for LGA/macrosomia were at increased risk of all measured outcomes. CONCLUSION: A customized standard of LGA identifies a previously unrecognized population that is at increased risk of perinatal morbidity.

Community participation and psychological empowerment: testing reciprocal causality using a cross-lagged panel design and latent constructs.

Empowerment theory provides both a value orientation for community-based research and practice, and a conceptual framework for understanding and evaluating interventions. One critical question in empowerment theory involves whether a reciprocal (bidirectional) relationship exists between community participation (CP) and psychological empowerment (PE). This study applied structural equation modeling (SEM) with two waves of survey data from a cross-lagged panel design to test reciprocal and unidirectional causal relations between latent variables representing CP and PE. Participants (n = 474) were randomly selected neighborhood residents and organizational members from the United States. Four models were tested using SEM: (a) a baseline model with autoregressive paths, (b) a model with autoregressive effects and CP predicting future PE, (c) a model with autoregressive effects and PE predicting future CP, and (d) a fully cross-lagged model. Results indicated that CP influenced future PE; however, reciprocal causality was not found to occur between the variables. Implications of the study for empowerment theory and community-based practice are described, and directions for future research discussed.

Contextual influences on participation in community organizing: a multilevel longitudinal study.

This article reports results from a study of contextual influences on participation among people involved in congregation-based community organizing. Data are drawn from 11,538 individual participants in 115 congregations taking part in one of five local organizing initiatives in different cities over a five-year period. Analyses used 3-level longitudinal models with binary indicators of participation/non-participation in group meetings each successive year as the criterion. Time-varying predictors at level-1 included prior participation in group meetings as a control, the types of group meetings that participants attended, the number of face-to-face meetings held between each participant and organizing staff of the local organizing initiatives, and a measure of the involvement of participants' affiliation networks. At level-2, demographic information was collected for a subset of participants (N = 461) and was included in a separate model. Neighborhood compositional characteristics were examined at level-3, including median income, economic heterogeneity, and residential stability. Study results found that characteristics of organizational settings (i.e., types of group meetings attended and frequency of face-to-face contact) predicted future participation in group meetings but that individual and neighborhood-level demographic characteristics were generally not predictive of future participation in community organizing activities.

Elevated asymmetric dimethylarginine concentrations precede clinical preeclampsia, but not pregnancies with small-for-gestational-age infants.

OBJECTIVE: The purpose of this study was to investigate maternal plasma concentrations of asymmetric dimethylarginine (ADMA) in mid pregnancy and at the time of disease in women who experience preeclampsia, compared with women with uncomplicated pregnancies and women with small-for-gestational-age infants. STUDY DESIGN: Plasma samples were collected at mid-pregnancy and at the time of delivery from 31 women with uncomplicated pregnancies, from 12 women with small-for-gestational-age infants, and from 15 women with preeclampsia. ADMA and L-arginine concentrations were measured using high-pressure liquid chromatography. RESULTS: Maternal ADMA concentrations were elevated at mid pregnancy and remained elevated at delivery in women who later experienced preeclampsia (0.45 +/- 0.09 micromol/L) compared with women with uncomplicated pregnancies (0.34 +/- 0.08 micromol/L; P < .01) and with women with small-for-gestational-age infants (0.33 +/- 0.06 micromol/L; P < .01). CONCLUSION: Maternal ADMA concentrations are higher in mid pregnancy in women who experience preeclampsia, compared with women with uncomplicated pregnancies and small-for-gestational-age infants. Elevated ADMA concentration before clinical onset of preeclampsia suggests a role of this nitric oxide synthase inhibitor in the pathophysiologic condition of preeclampsia.