Community-level System Research Articles

COPEWELL all-hazards resilience model predicts COVID-19 outcomes

The COVID-19 pandemic has presented an unprecedented challenge to public health and other community level systems throughout the United States since 2020. Investigating county-level factors (covariates in a statistical sense) closely related to COVID mortality is an important research objective, as it can provide insight for improving pandemic preparedness and response. Community resilience, which signifies the capability and capacity of communities to withstand and recover from adverse events, is a crucial component of pandemic preparedness. In this study, researchers employed Pearson's correlation coefficient and mediation analysis to explore the community resilience predicted by the Composite of Post-Event Well-Being (COPEWELL) model as a potential covariate that could be used to predict COVID-19 fatalities and further examine the generalizability and validity of the COPEWELL Model to the pandemic. Our findings indicate that the resilience predicted by the COPEWELL model is more strongly associated with COVID-19 health oucomes than county-level vaccination rates, although vaccination rate partially mediates the relationship between community resilience and COVID-19 fatalities per capita. This article underscores the effectiveness of implementing comprehensive all-hazards preparation strategies in the context of a pandemic and demonstrates that the COPEWELL model can serve as a valuable tool for identifying investments that can enhance community resilience.

Structural Violence and Stress Experiences of Young Pregnant Black People.

Approximately 10-20% of individuals suffer from mental health concerns during the prenatal period due to their vulnerability and emotional responses to stressful events. Mental health disorders are more likely to be disabling and persistent for people of color, and they are less likely to seek treatment due to stigma. Young pregnant Black people report experiencing stress due to isolation, feelings of conflict, lack of material and emotional resources, and support from significant others. Although many studies have reported the types of stressors experienced, personal resources, emotional stress responses on pregnancy, and mental health outcomes, there is limited data on young Black women's perceptions of these factors. This study utilizes the Health Disparities Research Framework to conceptualize drivers of stress related to maternal health outcomes for young Black women. We conducted a thematic analysis to identify stressors for young Black women. Findings revealed the following overarching themes: Societal stress of being young, Black, and pregnant; Community level systems that perpetuate stress and structural violence; Interpersonal level stressors; Individual level effects of stress on mom and baby; and Coping with stress. Acknowledging and naming structural violence and addressing structures that create and fuel stress for young pregnant Black people are important first steps to interrogating systems that allow for nuanced power dynamics and for recognizing the full humanity of young pregnant Black people.

Building blocks of community positive health: the contribution of Kenyan communities

BackgroundBeyond the health system, people draw on a complex system of everyday community resources to strengthen human and environmental health. These resources, and the community members who use them, are often overlooked by traditional approaches to planetary health. We aimed to apply a resourcefulness approach to define community positive health and the systems of resources that support this, and to define ways in which communities can pursue and sustain health agendas driven by local priorities. MethodsThrough a multi-site, mixed-methods research project, we worked with different groups of community members across three diverse field sites in Kenya, in the Baringo, Siaya, and Nakuru counties. We used a mixture of qualitative (78 focus discussion groups), participatory (67 activities, such as cognitive mapping, community timelines and mapping, tree diagrams, patient journeys, and walking interviews), and data-driven approaches to understand community concepts of positive health and collaboratively define the building blocks that shape community positive health. FindingsPreliminary research findings indicated that community positive health was defined by building blocks that included nutrition, clean water, education, and adequate local infrastructure. Crucially, these building blocks were underpinned by intangible community resources, such as culture, knowledge, and social cohesion. With cognitive mapping, we understood how communities leveraged these building blocks into a functioning community-level system. However, one of the greatest challenges felt by each community was the detrimental effects of climate change, contributing alongside human action and inaction to droughts, floods, and natural resource degradation. InterpretationThis initial stage of research defined community positive health and uncovered systems of local resources. Findings will be refined in a further stage of research to co-produce a pilot-tested, validated toolkit to enable resourcefulness-based approaches to community positive health. This output will be supported by an inclusive knowledge-building process that will set the stage to support communities to make more effective decisions about the use of local resources. FundingBelmont Forum by the UK Natural Environment Research Council.

Personal data ordering in context: the interaction of meso-level data governance regimes with macro frameworks

The technological infrastructures enabling the collection, processing, and trading of data have fuelled a rapid innovation of data governance models. We differentiate between macro, meso, and micro level models, which correspond to major political blocks; societal-, industry-, or community level systems, and individual approaches, respectively. We focus on meso-level models, which coalesce around: (1) organisations prioritising their own interests over interests of other stakeholders; (2) organisations offering technological and legal tools aiming to empower individuals; (3) community-based data intermediaries fostering collective rights and interests. In this article we assess these meso-level models, and discuss their interaction with the macro-level legal frameworks that have evolved in the US, the EU, and China. The legal landscape has largely remained inconsistent and fragmented, with enforcement struggling to keep up with the latest developments. We argue, first, that the success of meso-logics is largely defined by global economic competition, and, second, that these meso-logics may potentially put the EU's macro-level framework with its mixed internal market and fundamental rights-oriented model under pressure. We conclude that, given the relative absence of a strong macro level-framework and an intensive competition of governance models at meso-level, it may be challenging to avoid compromises to the European macro framework.

Community Resilience: A New Theme in Modernizing Community-Level Governance System and Capability in China

Community Resilience: A New Theme in Modernizing Community-Level Governance System and Capability in China

Governance networks around grasslands with contrasting management history

Romanian grasslands have high nature value, being among the most important biodiversity hotspots at the European level. The European Union Common Agricultural Policy (CAP) contradicts the Biodiversity Strategy to 2020 objectives by hindering coordinated grassland governance and collaboration among the involved actors. At the European level, few attempts have been made in creating conceptual strategies for implementing conservation measures in a multi-actor and multi-scale governance setting. Our paper focuses on a comparative network analysis of grassland governance of three Romanian regions (Iron Gates Natural Park – SW; Sighisoara - Tarnava Mare – center; and Dobrogea - SE), representatives for grassland management in mountain and lowland landscapes. We investigated the structural characteristics of one-mode directed governance networks in the three protected areas (standard cohesion and reciprocity metrics, exponential random graph models), the position of actors participating in networks (node-level centrality metrics), and the perception of CAP influence on grassland governance by farmers benefiting of CAP agri-environmental payments. In Sighisoara, grassland governance has been centralized but biodiversity-friendly, while in Iron Gates, grasslands were traditionally managed through a decentralized, community-level system, and this type of governance continues to date. In Dobrogea, grassland governance was performed in an intensive, centralized state-run management regime during the communist time and by large landowners after the transition period ended. Our findings illustrate the structure of the three governance networks and dissimilar patterns of collaboration, indicating distinct particularities to be considered when exploring barriers to and options for successful governance in traditionally managed grasslands in the context of CAP measures-driven management.

Braiding and Layering Funding: Doing More With What We Have

Braiding and Layering Funding: Doing More With What We Have

Suggestions on Effective Organization, Mobilization and Management of Non-Governmental Voluntary Organizations from the Practice of the Prevention and Control of the Pandemic

Voluntary service plays an important part in the united fight against the pandemic, which is an essential symbol reflecting the progress of social civilization. Since the reform and opening-up, more freedom has been given in the development of economy, culture and other social resources, and the government’s function is changing from “government-based” to “individual-based”. Citizens are more aware of their role in the society, and the community-level governance system is steadily improved. However, a large number of public affairs and social problems have arisen, which are difficult to be addressed by the government alone. New social strengths apart from the government are urgently needed to effectively to give support and assistance. They fundamentally provide conditions for the development of non-governmental volunteer organizations.

HARNESSING THE POWER OF NETWORKS: PARTNERSHIPS TO PROMOTE HEALTH AND WELL-BEING FOR FAMILY CAREGIVERS

This paper will address social and professional networks that support family caregivers who are providing care to older adults. Family caregiving is commonly a long-term commitment that can include functional, health care, social, financial and emotional support. This role can have a major impact on the health, well-being and economic security of the family caregiver, particularly for those who are socially isolated. This paper will highlight the nature of caregiving demands on individuals and families, particularly those providing intense and complex care, with a focus on cultural diversity. Health care professionals encounter family caregivers during routine care and at times of crisis and have an opportunity to enhance support and preparation. This paper will discuss effective community-level and health system partnerships and strategies that promote health and well-being for family caregivers, examine the potential for scaling these approaches, and suggest priorities for education, practice and future research.

Pioneering Health Care for Children with Disabilities: Untold Legacy of the 1916 Polio Epidemic in the United States

ABSTRACTIn 1916, the United States experienced its first polio epidemic, resulting in 6,000 deaths and 21,000 injured individuals. Medical practices were ill prepared to stop the disease and treat survivors. Historians have documented the creation of the polio vaccine during the 20th century, but less is written about efforts to provide rehabilitation services to children afflicted with polio. This research looked at Polio After-Care Committees, a new form of community practice that provided care to children with disabilities. The Committees worked to change community-level systems of care while providing medical care, demonstrating that new forms of community-based service organization could reach children.

Healthy together Victoria and childhood obesity-a methodology for measuring changes in childhood obesity in response to a community-based, whole of system cluster randomized control trial.

BackgroundHealthy Together Victoria (HTV) - a complex ‘whole of system’ intervention, including an embedded cluster randomized control trial, to reduce chronic disease by addressing risk factors (physical inactivity, poor diet quality, smoking and harmful alcohol use) among children and adults in selected communities in Victoria, Australia (Healthy Together Communities).ObjectivesTo describe the methodology for: 1) assessing changes in the prevalence of measured childhood obesity and associated risks between primary and secondary school students in HTV communities, compared with comparison communities; and 2) assessing community-level system changes that influence childhood obesity in HTC and comparison communities.MethodsTwenty-four geographically bounded areas were randomized to either prevention or comparison (2012). A repeat cross-sectional study utilising opt-out consent will collect objectively measured height, weight, waist and self-reported behavioral data among primary [Grade 4 (aged 9-10y) and Grade 6 (aged 11-12y)] and secondary [Grade 8 (aged 13-14y) and Grade 10 (aged 15-16y)] school students (2014 to 2018). Relationships between measured childhood obesity and system causes, as defined in the Foresight obesity systems map, will be assessed using a range of routine and customised data.ConclusionThis research methodology describes the beginnings of a state-wide childhood obesity monitoring system that can evolve to regularly inform progress on reducing obesity, and situate these changes in the context of broader community-level system change.

Snap shots from a photo competition: what does it reveal about close-to-community providers, gender and power in health systems?

In this commentary, we discuss a photography competition, launched during the summer of 2014, to explore the everyday stories of how gender plays out within health systems around the world. While no submission fees were charged nor financial awards involved, the winning entries were exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. Anyone who had an experience of, or interest in, gender and health systems was invited to participate. Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement and in venues where their perspectives are often missing. The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. In total, 54 photos were submitted by 29 participants from 15 different nationalities and country locations. We unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. Three themes emerged: women active on the frontlines of service delivery and as primary unpaid carers, the visibility of men in gender and health systems and the inter-sectoral nature and intra-household dynamics of community health that embed close-to-community health providers. The question of who has the right to take and display images, under what contexts and for what purpose also permeated the photo competition. We reflect on how photos can be valuable representations of the worlds that we, health workers and health systems are embedded in. Photographs broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways but also reflect the politics, values and subjectivities of the photographer. They represent stereotypes, but also showcase alternate realities of people and health systems, and thereby can engender further reflection and change. We conclude with thoughts about the place of photography in health systems research and practice in highlighting and potentially transforming how we look at and address close-to-community providers.

Taking a community-based participatory research approach in the development of methods to measure a community health worker community advocacy intervention.

Public health advocacy is by necessity responsive to shifting sociopolitical climates, and thus a challenge of advocacy research is that the intervention must by definition be adaptive. Moving beyond the classification of advocacy efforts to measurable indicators and outcomes of policy, therefore, requires a dynamic research approach. The purposes of this article are to (1) describe use of the CBPR approach in the development and measurement of a community health worker (CHW) intervention designed to engage community members in public health advocacy and (2) provide a model for application of this approach in advocacy interventions addressing community-level systems and environmental change. The Kingdon three streams model of policy change provided a theoretical framework for the intervention. Research and community partners collaboratively identified and documented intervention data. We describe five research methods used to monitor and measure CHW advocacy activities that both emerged from and influenced intervention activities. Encounter forms provided a longitudinal perspective of how CHWs engaged in advocacy activities in the three streams. Strategy maps defined desired advocacy outcomes and health benefits. Technical assistance notes identified and documented intermediate outcomes. Focus group and interview data reflected CHW efforts to engage community members in advocacy and the development of community leaders. APPLICATION OF LESSONS LEARNED: We provide a model for application of key principles of CPBR that are vital to effectively capturing the overarching and nuanced aspects of public health advocacy work in dynamic political and organizational environments.

Evaluation of Diverse Community Asthma Interventions: Balancing Health Outcomes with Developing Community Capacity for Evidence-Based Program Measurement

The challenge of evaluating community asthma management programs is complicated by balancing the emphasis on health outcomes with the need to build community process capacity for conducting and monitoring evidence-based programs. The evaluation of a Georgia Childhood Asthma Management Program, a Healthcare Georgia Foundation-supported initiative for multiple diverse programs and settings, provides an example of an approach and the results that address this challenge. A "developmental evaluation" approach was applied, using mixed methods of quantitative and qualitative data collection and analysis, to assess the progress of community asthma prevention programs in building community within the context of: where the community is starting, community-level systems changes, and the community's progress toward becoming more outcome measurement oriented and evidence based. Initial evaluation efforts revealed extensive mobilization of community assets to manage childhood asthma. However, there were minimal planned efforts to assess health outcomes and systems changes, and the lack of a logic model-based program design linking evidence-based practices to outcomes. Following developmental technical assistance within evaluation efforts, all programs developed logic models, linking practices to outcomes with data collection processes to assess progress toward achieving the selected outcomes. This developmental approach across diverse projects and communities, along with a quality improvement benchmarking approach to outcomes, created a focus on health status outcome improvement. Specifically, this approach complemented an emphasis on an improved community process capacity to identify, implement, and monitor evidence-based asthma practices that could be used within each community setting.

Planners Coming to the Table

Planners Coming to the Table

Evaluating the Legacy of Community Health Initiatives

Community health initiatives typically involve time-limited funding from foundation or government grants to support their initial activities. But if there are to be lasting improvements in health outcomes, initiative activities must be sustained over a relatively long period of time. Despite the importance of sustaining work begun under health initiatives, there have been few attempts to track sustainability after the period of funding has ended. This article provides a framework for evaluating the legacy of community health initiatives and illustrates its use with the legacy evaluation from The California Wellness Foundation’s Health Improvement Initiative (HII). The HII was largely successful in sustaining its core elements of collaborative partnerships, community-level systems changes, direct services, and population health measurement. The authors discuss differences in evaluation design and data collection between the funded-period and legacy evaluations; these differences may justify a distinct methodological approach.

The California Wellness Foundation's Health Improvement Initiative: Evaluation Findings and Lessons Learned

To evaluate the effect of the Health Improvement Initiative (HII), a 5-year grantmaking initiative funded by The California Wellness Foundation designed to identify the critical factors needed to bring about population health improvements through community-level systems change. The evaluation of the HII used a case-study, logic-model approach to make inferences about the effect of each community coalition (Health Partnership) on its target community. The primary outcome measure was the creation of significant and sustainable community-level systems change. The HII included nine communities in California that received funding to create broad-based Health Partnerships. Primary data were collected from a variety of Initiative stakeholders by key informant interviews, closed-ended surveys, and participant observation. The HII provided funding over 5 years to nine Health Partnerships that were intended to be a driving force in implementing community-level systems change. The ultimate objective of the systems change process was to improve "population health, " broadly defined to include social economic, and cultural determinants of health, in addition to traditional health status indicators. Both qualitative and quantitative techniques were used to assess the effect of the HII on key community systems. The primary outcomes were qualitative descriptions of community-level changes. At the end of the 5 years of HII funding, six of the nine Partnerships had played a critical role in implementing sustainable systems changes that would likely have a significant effect in their target communities. The HII was successful in promoting community-level systems change in the majority of funded communities, although the evidence was mixed regarding the role of the Partnerships in bringing about these changes.

Evaluating the California Wellness Foundation’s Health Improvement Initiative: A Logic Model Approach

The difficulties of conducting randomized trials to evaluate community-based initiatives have led some researchers to argue in favor of a case study "logic model" approach to evaluation. This article describes a case study logic approach adopted for the evaluation of one community initiative, the Health Improvement Initiative (HII) funded by the California Wellness Foundation (TCWF). The HII is a comprehensive, community-based initiative designed to improve population health by implementing and sustaining community-level systems changes. Nine communities received funding to create broad-based community coalitions (Health Partnerships) that were charged with developing and implementing action plans around systems change. The HII is being evaluated using a case-study logic-model approach that uses quantitative and qualitative data to construct indicators of coalition functioning, systems changes, and population health. By examining the relationship between these indicators over time, it should be possible to determine if any changes in intermediate or long-term outcomes are associated with Health Partnership activities.

A participatory evaluation model for Healthier Communities: developing indicators for New Mexico.

Participatory evaluation models that invite community coalitions to take an active role in developing evaluations of their programs are a natural fit with Healthy Communities initiatives. The author describes the development of a participatory evaluation model for New Mexico's Healthier Communities program. She describes evaluation principles, research questions, and baseline findings. The evaluation model shows the links between process, community-level system impacts, and population health changes.

Indicators of chronic health conditions: monitoring community-level delivery systems

As the creation and implementation of health policy become increasingly managed at the community level, ways must be found to ensure the proper measurement and monitoring of health program efficiency. 'Indicators of Chronic Health Conditions' explores the current understanding of selected chronic conditions and the capacity of community-level health services and delivery systems to address the health care needs for persons with the various illnesses. Beginning with a history of health indicators and community-level management of health services, this book goes further to examine the care needs and service delivery systems affecting different populations. These subpopulations include children, persons with mental retardation, persons with chronic mental illness, adults with physical disabilities, adults with chronic medical conditions, chronic substance abusers, and elderly persons. The volume concludes with ideas for monitoring community-level systems for persons with chronic health conditions. Professionals and students in the fields of health policy, public health, health care for persons with chronic illness, and public policy will benefit from the information provided.