Community participation and leadership is critical for advancing equity, addressing upstream determinants, and practicing public health generally. Assuring and supporting such participation is now and will continue to be a core capacity for LPH. But for many agencies, it is one of the most challenging elements of public health practice. As we are immersed in system transformation, these challenges raise a key question: is there a part of local government infrastructure that can promote sustained, equitable, and effective community participation and leadership?
This challenge is not only one of sound public health practice and equitable governance, it also relates to larger public health threats posed by a lack of community connectedness, social capital, and the decline of American civic life. This is a massively complex upstream determinant with impacts on other determinants as well as individual health behaviors. A sobering report from the National Conference on Citizenship shines a light on what they call “civic deserts,” framing it as a health problem. The report details how the decline of many socially-active institutions, such as places of worship and unions, are contributing to the erosion of shared values and accepted facts, trust of neighbors, and belief in the possibility of positive collective change.
While we are engaged in structural transitions, it is timely to think about how local government structure can promote or inhibit community participation. On its own, public health is clearly transitioning to models that have the potential to ameliorate the situation, though not always explicitly. To answer the question posed above, it may help to start recognizing that public health community and partnership engagement is in itself an intervention to improve equity and health, not just a way to support other interventions. If we apply the same upstream-ecological program design methods we increasingly use for other health interventions to community engagement, we may start seeing ways of making community participation more sustained and meaningful through systemic changes in government.
A recently adopted Health Equity in All Policies (HEiAP) resolution in Genesee County, Michigan (home of Flint) offers one example: an “interdepartmental body with representation from all sectors of community life” who receive training and technical assistance in considering equity and upstream determinants. This body serves their board of commissioners by
“1) considering any new governmental policy for which the likely health impacts are not clear; 2) considering current governmental policy whose negative health impacts have been called into question by the public; 3) analyzing the health impacts of any such policy; 4) providing recommendations to the governing body on any changes in these policies that would reduce negative health impacts.”
This appears to be an adaptation of a HiAP model resolution from Changelab Solutions, that included a similar body made of only government staff. There are not yet many details available on how this type of structure is initiated, its feasibility, or its impacts. And one wonders if just an advisory role is enough, or would such a body need specific authority to be effective.
There are also clear chicken and egg challenges with this approach. If a community lacks the social capital to engage in collective improvement efforts, how is it supposed to get enough citizens to serve on such a body? It would also need a structure that permitted members of all education levels and languages to participate and be able to accommodate those with limited time and transportation options. Some communities may have to consider preliminary social capital interventions before attempting to form a permanent and quasi-professional community advisory body.
Other models aim to use the existing interactions between government and community members to engage on issues that are related to the interaction topic but are broader and systemic in scope. An example might be asking survey questions about a community’s overall food systems while on a restaurant inspection. This may be a more practical stepping-stone to a formal advisory body, but such activities would require significant training and probably additional staff. It would also require a redesign of how certain services are provided, including new process workflows, updated forms, and investing in relational databases and assessment capacities that can tie all the information together.
I’ll be following this topic over the next year and hope to explore some more specific examples of how LPHAs and their governments can foster civic engagement. In the meantime, check out a recent research report from New America that tested some of the assumptions we make about the potential benefits of increased civic engagement and the tactics used to get there.