35 research outputs found
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Can Creative Placemaking Be a Tool for Building Community Resilience?
No full textAcross the nation, heat waves, droughts and floods are becoming more frequent and severe, increasing risks to individuals and infrastructure. Simultaneously, amplified and rapid urbanization continue to increase pressure on the environment and local governments managing the confluence of these trends. The threat of these stressors on vulnerable populations, who have consistently experienced trauma, disinvestment, and discrimination, can present significant health implications. Economically constrained, communities of color, immigrant, elderly, and homeless populations are at greater risk and often have limited access to the resources necessary for responding to these conditions. When we think of resilience as a privilege unequally supported across different communities, it changes the responsibility of stakeholders in providing interventions. In the face of “market” and natural forces, it is up to organizational allies to support community residents in advocating for community informed investment. This starts by creating environments for collaboration, lifting resident’s voices, and building social cohesion and capital. Communities most resilient to disaster are not only structurally sound but also socially empowered and connected. The Climate and Cultural Resilience (C&CR) Program funded five community-based organizations across the country to use creative placemaking towards community resilience outcomes, testing the theory that building cultural resilience- the capacity to maintain and develop cultural identity and critical cultural knowledge and practices (107)” advances communities overall resilience. This study develops a qualitative case study to investigate how climate resilience, cultural resilience and creative placemaking are understood among different stakeholders engaged in community development, the role of creative placemaking in advancing climate and cultural resilience, and the role that intermediaries are best suited to influence these strategies. It found that creative placemaking is a tool for building community resilience with limitations, and that communities understand resilience in different ways on the ground that is more expansive than the program parameters. Ultimately, intermediaries hold a powerful role in supporting creative placemaking for community resilience but have to fully incorporate cultural resilience, and be more interdisciplinary, participatory and disruptive in order to be most impactful.climate resilience; cultural resilience; community resilience; creative placemakin
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My Ambitionz Az a ‘Rida’: Leading for Equity & Social Justice in the Atlanta Public Schools
No full textThe Atlanta Public Schools is among the 100 largest school districts in the country. Its 51,600 students attend 87 schools spread throughout the city: 40 elementary schools, 9 middle, 11 high schools, 2 multi-grade alternative schools, and 25 charter schools. The student breakdown includes: 75% African American, 15% white, 7% Latino, and .2% Native American. In addition, 3% of the students are English Language Learners.
There are deep seeded inequities that exist amongst all student groups. A 2014 audit revealed substantial variations across schools in all areas where equity was examined. Most notable were the differences between facilities and funding in the more affluent, predominantly white schools in the north of the district and the poorer, predominantly Black schools in the south. The district has since taken steps to address these inequities. However, inequities continue in teacher quality, academic programming, student achievement, and discipline. As a result, in 2019, the Board of Education passed the district’s first equity policy and the administration developed a five-year strategic plan outlining eleven equity commitments that will guide the district’s efforts from 2020-2025.
As a resident, I worked with the Superintendent and senior leaders to support the implementation of the Board’s equity policy and district strategic plan. This included supporting the development of the district’s first equity office, which will be charged with leading the district’s efforts to disrupt the reproduction of racialized outcomes My strategic project entailed developing the plans and structures necessary to build the office, as well as assessing the opportunities and challenges inherent in cultivating the internal conditions necessary for the office to tackle the inequities that exist within the system, uncover their root causes, and address barriers to progress.
This Capstone examines this work and discusses the steps I took to build the organizational capacity needed to implement the district’s equity policy and strategic plan in a systemic and sustainable manner. It concludes with recommendations for systems leaders on how to successfully develop an organizational equity change strategy that is coherent and ensures all organizational elements—culture, systems, structures, resources, and stakeholders—are being used to enact a theory of change that is grounded in equity and aligned to a robust vision of excellent and culturally-responsive teaching
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How to Scale-Down: Adapting a National Primary Health Care Measurement Tool to Subnational Governments
No full textNearly half of the world’s population lacks access to essential primary health care, a problem that has negative cascading effects on population health. This is further exacerbated by a lack of adequate data that both describes countries’ health systems and is required for effective health care reform. Access to clear, actionable data allows policymakers to better understand gaps in the system and make targeted improvements.
In light of this problem, in 2015, the Bill & Melinda Gates Foundation, World Bank, WHO, Ariadne Labs, and Results for Development founded the Primary Health Care Performance Initiative as a multi- year, multi-million-dollar investment in improving primary health care provision and measurement. One component of this initiative, and the focus of this research, is Ariadne Labs’ Progression Model. The Model is a mixed methods tool for low-and-middle-income national governments that measures health governance, system inputs, and population health. The Progression Model has been utilized by 11 countries and is proving valuable in summarizing previously uncollected data and prompting conversations on primary health care reform. Yet, many large countries with diverse populations find that nationally aggregated data lacks the utility and granularity required to develop effective policies for the subnational level. Furthermore, little is known about subnational governments’ authority over primary care provision and their ability to effect changes. These countries require an adapted version of the Progression Model based upon subnational data.
This DrPH dissertation attempts to address these gaps by:
1) Developing a subnational classification structure to understand which layers of government have authority over certain indicators.
2) Providing recommendations for improving the Progression Model at the subnational level.
This work was conducted remotely from Boston, Massachusetts, with stakeholders in 10 countries who implemented the Progression Model. I drew from qualitative research methods and realist evaluations to develop recommendations for adapting this work to the subnational level. I conducted Health System Assessments to understand authority dynamics in each country and created subnational classification structures. The two most significant subnational categories were classified as Consulted and Directed, terms that indicate the varying degrees of control that subnational governments exert over primary health care.Public Healt
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Public Health in the Predictable City
No full textCities are vital units of analysis for public health problems, both in the United States and globally. City-dwellers, who account for more than half the world’s population, face a characteristic set of health risks. Many of these risks are closely related to housing, transportation, sanitation and other social determinants of health for which local governments are responsible. For better or worse, therefore, local government performance produces health outcomes.
This DELTA doctoral thesis examines three novel methods intended to improve local government service delivery and prevent adverse health outcomes. Each uses machine learning algorithms and publicly available datasets to generate actionable predictions. (1) In Portland, Oregon, we used a random forest model and city property records to rank over 200,000 properties according to fire risk. In a statistically simulated field trial, we found that following these rankings could improve the efficiency of fire safety inspections by 1.5 times and home safety visits by up to 9.0 times. (2) In Fortaleza, Brazil, we combined convolutional neural networks and ridge regression to predict dengue case incidence based on block-level satellite imagery. In five-fold cross-validation, our model explained 73% of variance in log-normalized case counts. (3) Using Google Street view images and city records from Detroit, Michigan, I trained a convolutional neural network to identify physically distressed properties. In a balanced testing set of 400 images, the model correctly classified 87% of images as either distressed or normal condition, with an area under the curve statistic of 0.94.
Each of these methods is novel, meets appropriate standards for accuracy, and aligns with accepted preventive interventions for important public health problems. Nonetheless, it does not automatically follow that the proposed public health benefits will outweigh potential societal costs. The final section of this document reviews additional factors, such as equity, ethics and staff motivation, that local governments must consider prior to adopting predictive strategies.Urban health; machine learning; fire prevention; dengue; housing; neighborhood effect
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Convening with Purpose: An Impact Analysis of Malaria Related Advocacy in the Asia-Pacific
No full textThe Asia-Pacific Leaders Malaria Alliance (APLMA) hosts their annual convening, Malaria Week, and the Senior Officials Meeting (SOM), annually. It was originated to be a space where leaders pledge to agreements presented throughout the week, hold one another accountable for regional progress, and identify bottlenecks in malaria elimination. Over the last five years, Malaria Week and the SOM have focused on several regional elimination goals. However, the APLMA leadership team has not assessed the impact the Malaria Week and SOM sessions have had on national malaria elimination efforts. Using a mixed-methods, cross-sectional study survey I assessed the primary outcomes of interest, how participants felt the recommendations presented at Malaria Week and the Senior Officials Meeting influenced programmatic or policy actions taken at the national level. Our target population was high-level government officials and senior members of the NGO, academic, and private sectors. Roughly half of the study participants suggested that there was a perceived influence, but the majority could not clarify why, when asked specifically. In the qualitative responses, some participants suggested a need for stronger accountability and follow-up, country-level technical support, and help with resource mobilization
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Shopping for Healthcare: A Retailer's Foray Into Healthcare Service Delivery in the United States
No full textThe healthcare system in the United States (US) is broken for consumers. It is built on a complex web of relationships between powerful entities that often exclude the consumer. This can translate into a poor – and at times disheartening – experience for consumers. Three problems underpin the brokenness of the healthcare system for consumers: (1) healthcare costs are high and rising; (2) access and convenience to basic healthcare services are lacking; and (3) the quality of healthcare services is often poor and variable.
Walmart, the major American retailer, is interested in changing the delivery of healthcare in the US. In September 2019, Walmart opened its first Walmart Health Center in Dallas, Georgia. It offers several basic healthcare services under one roof – primary care, dental, audiology, vision, behavioral health, and others – at transparent and affordable prices. The Walmart Health Center accepts insurance and provides reasonable cash prices for consumers who may be uninsured. It operates with extended hours and is led by a team of medical professionals from the local community.
With a desire to test, learn, iterate, and eventually expand, Walmart was interested in understanding the integration and optimization of primary care services at its Walmart Health Center. Integration of basic healthcare services could allow the company to reduce healthcare costs, provide an accessible and convenient healthcare experience, and offer high-quality healthcare to consumers. The project had two aims: (1) to understand existing models of primary care that integrate several services under one roof; and (2) to determine how Walmart Health could better integrate the healthcare services at its Walmart Health Center.
Based on a series of qualitative interviews, this project established two major conclusions. The first is that the current landscape of primary care models is influenced by several contextual characteristics that determine the extent of integration. The second is that the Walmart Health Center has the foundational structures, operations, and workflows to support the effective integration of primary care services. Given the early stages of Walmart Health’s operational life, several recommendations are offered to provide a roadmap for effective integration of basic healthcare services.Public Healt
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Advancing Health Equity Through Multi-Sector Collaboration
No full textThis doctoral thesis, Advancing Health Equity Through Multi-Sector Collaboration, highlights the need for multi-sector collaboration to address current health inequities. It is focused on three separate projects based in three distinct sectors, which included: local government, a primary care association, and a collaborative focused on creating partnerships and elevating data, policies and practices that promote health equity. The methods employed to better understand the difficulty of facilitating a cohesive multi-sector collaboration and achieving successful outcomes included a survey, a set of interviews, and an assessment of the literature on the effectiveness of policies and programs to improve health opportunity. Although the project goals for each organization differed, collectively they provided insights into the challenges presented when building a multi-sector collaboration, and allowed for the identification of the necessary elements that enable the success of multi-sector collaboration to advance health equity. This doctoral thesis highlights current knowledge on multi-sector collaboration in policy and in public health, delineates the goals, methods and findings based on the three projects and concludes with considerations towards achieving multi-sector collaboration to advance health equity.Public Healt
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Further Inspection: Leveraging Housing Inspectors and City Data to Improve Public Health in Chelsea, MA
No full textSubstandard housing represents an important and growing public health problem. It is associated with higher rates of mental illness, chronic and infectious disease, and other negative outcomes. Housing inspectors, by nature of their work inside homes and close contact with residents, are some of the only public officials to witness these risks. Early intervention can reduce public health risks and reduce costs to governments and society. However, current housing inspection focuses on technical enforcement of housing codes rather than broader socioeconomic or health impacts that the codes were originally designed to address. Further, the potential for early intervention is limited because 1) cities are not aware of problems soon enough, as inspection is often reactive or relies on tacit knowledge, and 2) housing inspectors lack systems to respond to the range of public health risks they encounter. In response to these problems, the objective of my DrPH dissertation was to:
1) Develop and implement a social-service referral innovation within a city’s inspectional services department that leverages the unique role of housing inspectors to link at-risk residents with social services, and
2) Develop an approach to using city data to identify and prioritize the response to prevalent housing-related health threats.
I carried out this work in Chelsea, Massachusetts, in collaboration with Chelsea City Hall and other City agencies. The goal is that the complex public health risks related to substandard housing are reduced because the City is aware of problems sooner and housing inspectors respond with both enforcement and service provision interventions.
I drew from action research methods, a process of systematic inquiry that is collaborative, reflective, and participatory. The result was a sub-contract between City Hall and a local social-service agency to respond to referrals from housing inspectors and intervene early on problems that cannot be resolved through code enforcement alone. Further, through aggregating and analyzing City data, I identified housing-related public health problems and ways to improve efficiency, effectiveness, and equity of code enforcement. In this dissertation, I capture the lessons learned, describe the impact achieved, and lay a conceptual foundation for future inquiry and public health change.Public Healt
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An Applied Political Analysis of the Targeted Free Care Reform in Mali
No full textIntroduction - Health financing through out-of-pocket payments is deeply inequitable and imposes barriers and risks for patients. After decades of charging patients for healthcare in Mali, an ambitious primary health care reform was announced in February 2019 that would exempt target populations from payment - “targeted free care” (TFC).
This thesis is an in-depth case study of the policymaking process of introducing TFC in Mali. It aims to apply the methodological toolkit of political analysis and adaptive change to understand where things stand 32 months later (September 2021).
Methods - A literature review traces the history of user fees in Sub-Saharan Africa, distills 14 best practices for removing them, and identifies features of the Malian health care system relevant to TFC. Next, a documentary review, 21 months of participant observation and 19 stakeholder interviews provide the data for a reconstructed narrative of the reform’s development and announcement, as well as a political analysis using three frameworks: the 14 best practices for TFC, stakeholder analysis, and Kingdon’s Multiple Streams framework.
Results - Several features of the Malian context make implementing TFC difficult: small and contracting health budget, weak state capability demonstrated by existing programs, sector-wide strategic fragmentation and poor coordination, and highly autonomous primary healthcare centers dependent on user fees. These are heightened by the political and security crisis.
Issues with the reform’s development, content, and announcement reduced buy-in from key stakeholders. It witnessed a loss of high-level support due to ministerial turnover and two coups’ d’ tats - inconsistent leadership made consensual policy development, coordination, and network building difficult. Stakeholders closest to the operational level with the most discretion around TFC implementation are also the most against it. The reform window for a national TFC policy has closed, and it is moving forward on a pilot-scale with uncertain ministerial support.
Conclusion - The multi-dimensional costs to families of user fees are well known and the need to repeal them urgent. However, Mali’s worsening security and political crises appear to be a more pressing priority for those in power. This could provide time to work out the policy’s design and build consensus
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The Influence of ‘Context’ and ‘Nature of Challenges’ on Leadership and Leadership Development: Perspectives From Senior Health Systems Leaders in Sub-Saharan Africa
No full textThere has been a growing recognition to make Africa an equal player in the global health community and to strengthen leadership capacity building for health systems in the region. Leadership is widely acknowledged as vital to effective health systems functioning as well as positive population health outcomes. However, there is little empirical research on health leadership and leadership development in sub-Saharan Africa. Additionally, most of the research has focused on identifying individual competence characteristics of influential leaders, and while these are vital, they are not sufficient without consideration of context. From the perspectives of senior health system leaders in sub-Saharan Africa, this research analyzes how ‘context’ and ‘nature of challenges’ influence leadership and leadership development in the region.
A qualitative study was conducted using interviews with strategic African leaders (n=15) who had in-depth knowledge and experience working to transform healthcare systems in sub-Saharan Africa. Purposive sampling was used to ensure a diversity of perspectives. Male and female leaders, originally from 13 different African countries and working from around the globe at national or international levels, were interviewed. The interviews were conducted virtually and were audiotaped and transcribed. For data analysis, thematic analysis was used, applying both inductive and deductive approaches and facilitated by Nvivo. A case study of leadership lessons in a health crisis was also conducted to identify key leadership behaviors and actions that can be applied to the current Covid-19 pandemic.
Research findings show that senior health systems leaders in Africa have a similar conceptualization of leadership as leaders in the West. However, ‘humility’ was identified as a representative leadership value amongst African leaders. Secondly, there were several social, economic, political as well as organizational contextual factors that influence leaders’ abilities to cope the nature of challenges strategic -level leaders face. Thirdly, societal constructs of leadership were more connected to women’s opportunities for leadership positions rather than their abilities as leaders.
This research provides evidence of the contextual factors influencing individual leadership within health systems in sub-Saharan Africa. The findings will inform leadership development for senior health leaders in the region.Public Healt
