Moving the needle on health inequities: principles and tactics for effective cross-sector population health networks.

PURPOSE OF REVIEW: To summarize elements of cross-sector population health networks to support systems and policy change to achieve equitable access to health services and healthy development opportunities for young children and families, allowing everyone to have a fair and just opportunity to be as healthy as possible. RECENT
FINDINGS: The principles and tactics of Equity and Inclusion, Readiness, Joint Planning, Governance, and Data can guide cross-sector networks in effectively supporting communities in addressing health inequities. These principles are not linear or siloed, but rather, they overlap and reinforce each other. The principles require equity and the participation of community members to be central in all aspects of cross-sector network work.
SUMMARY: By building strong relationships among community partners, cross-sector population health networks can ensure the network is not a short-term, transactional one-time project, but rather, a sustained collaboration through enduring processes and infrastructure. Networks can gain a fuller understanding of the needs and assets of a community through engagement and leadership by community members than they could gather from data and surveys alone. This approach to serving a community by making members equal partners in the effort helps to place equity at the center of a network's focus, as does embedding equity-related decision-making tools and processes into daily operations of the network. If cross-sector networks build resilient, inclusive structures and procedures, they can utilize them to quickly pivot and adjust to emerging needs or respond to crisis.

INTRODUCTION

Communities and regions across the country face serious population health challenges and significant inequities in health outcomes by race and ethnicity as a result of longstanding structural racism in the United States [1,2,3▪▪]. Addressing disparities is important from both a social justice standpoint and for improving overall population health. Many healthcare providers, public agencies, and service- and community-based organizations across sectors are committed to helping communities reduce health disparities that stem from widespread inequality. However, they cannot effectively promote population health and reduce health inequities without aligning and coordinating with stakeholders outside their own sector [4,5]. Pediatric healthcare providers have historically been limited to using clinical interventions to influence the health of individual children [6]. It is difficult for pediatric providers to address the nonclinical causes of poor health outcomes for their patients and other children in a community. Pediatric providers can expand their impact on child health by engaging in networks comprised of organizations from different sectors that are collaborating to address local population health concerns. When organizations across multiple sectors form networks to work in service to communities to pursue a population health goal, they can enhance their individual work and leverage multiple areas of expertise to address the root causes of health inequities whereas changing systems to help populations achieve their full health potential. Cross-sector population health networks can strengthen their efforts by centering equity within their population health strategies [7].

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The collective impact model is an approach for addressing complex social challenges that cannot be solved by just one sector or organization and entails forming a cross-sector collaborative, or network of organizations, to act in concert to solve a common problem [8]. The body of research on collective action and multisector networks is expanding as the number of cross-sector networks grow. Cross-sector networks need to start with a strong understanding of the problem (e.g., obesity among young children, lack of access to care) they are striving to solve in order to identify and engage stakeholders to effectively engage in collective action [9]. A key step is developing a common understanding of terms and barriers to aligning the different systems across sectors impacting population health [10]. Networks should create a governance or supportive infrastructure to align partners and support the creation of common goals and metrics (e.g., a portfolio of short- and long-term goals with measures and accountability) [9]. Research found it effective for partners within cross-sector networks to share accountability for ‘integrative activities,’ the governance, oversight, and administrative functions that enable cross-sector networks to implement strategies related to the network's shared population health goals [11▪▪]. This includes activities such as creating decision-making processes, developing data-sharing agreements between partners, creating mechanisms for measuring progress and identifying policies to make the network more effective.

Cross-sector networks utilizing collective action principles to address health challenges achieve successes in improving population health. A survey of population health cross-sector networks found that about a quarter reported improved community outcomes related to increased consumption of healthy foods, increased physical activity, reduced body mass index, reduced utilization of emergency healthcare, and improved self-reported health [12]. Other cross-sector networks have achieved broader systems changes that improved outcomes for the prioritized community [13]. However, the intensity of their impact is affected by the degree of alignment within the networks and inclusion of an explicit focus on equity [13].

PRINCIPLES AND TACTICS FOR EFFECTIVE CROSS-SECTOR NETWORKS

The following principles and tactics can guide cross-sector networks in supporting communities in addressing health inequities. These principles are not linear or siloed, but overlap and reinforce each other [14▪▪]. The principles require equity and the participation of community members to be central in all cross-sector network work.

Equity and inclusion

For cross-sector networks to improve population health and reduce health inequities, the network must ensure that equity is central to all its goals. A shared understanding of the root causes of the health and social needs of a community, coupled with concrete skills and tools, enables networks to address the policies, systems, and environmental factors that perpetuate inequity [15]. These root causes exist not just in the health sector in the form of barriers to accessing quality healthcare services, but also in other sectors presenting as a lack of access to jobs with livable wages, neighborhoods exposed to high levels of pollutants, violence, lack of critical infrastructure, or toxic stress caused by exposure to racism [16]. To gain a full understanding of a community's needs and the factors that shape them, cross-sector networks must engage the community to understand their ‘lived experience’ [17,18▪▪]. When multiple individuals are engaged, lived experience is the firsthand knowledge of the conditions, strengths, and needs of a community, and insight into the systems that impact them. Effective cross-sector networks working in service to a community should engage the community to build trust and foster relationships [19]. Cross-sector networks that cultivate intentional and trusting relationships with community members can recruit community members to participate in network decision making and leadership, ensuring their lived experience informs and directs goal setting, data collection, and activity planning efforts [20,21]. For example, a Florida early childhood cross-sector network brought parents into compensated advisory board positions and other leadership roles so that they could inform systems change efforts in the state [22]. Compensation for community members and leaders participating in networks is an acknowledgement of the value of their expertise and time, role as consultants and role in implementation [23].

Readiness

To maximize the impact of a cross-sector network, partners must assess their individual organizational readiness and ability to participate in the network and its activities [24]. In considering readiness, network partners should cultivate support and commitment within their organizations for changes that will facilitate the network's work, such as securing funding for staff to devote time to participating in the network, creating changes to workflows to carry out or support the networks activities, and/or incorporating changes to organizational policies to align and reinforce the work of the network [25]. This effort can institutionalize policies that prioritize engagement in network activities and goals that outlive leadership and staff transitions, ensuring that participation in the network does not fade when organizations undergo personnel changes. The skills and expertise needed for effective leadership in a network are not static and will depend on the network goals and organizational strengths across partners [26▪▪]. A school readiness coalition in Oklahoma struggled to effectively engage tribal communities until it spent time building the foundation for long-term relationships with tribes and communicated the value that collaborating with the coalition could bring in terms of resources and access to data [27]. These steps helped cross-sector networks deeply engage in network activities and advance group decisions. When partners have the necessary interest, capacity, and staff engaged in the network, the people at the table are empowered to make necessary commitments to the network and its goals.

Joint planning

Networks engagement in joint planning on goals to reduce health disparities and promote health equity, partner accountability, and timelines fosters coordination and accountability among partners. This entails assessing how each individual organization's goals align, identifying the unique strengths and expertise of each partner, and deciding what resources (such as staff time, funding, or data sharing infrastructure) they will each contribute to the network initiatives and activities [28,29]. Differences across partners are identified early on to avoid miscommunication. Although working collaboratively to develop short-term network goals, a maternal mental health coalition in Flathead County, Montana determined that members with lived experience would be better suited to lead the network and successfully executed a leadership transition to advance the work [30]. A traditional project work breakdown structure, or other project management structures, can track and communicate these roles and commitments in as much detail as is needed.

Governance

Integrating the work and goals of multiple organizations into a cross-sector network requires agreements and structures about how network partners and community experts work together and make decisions, as well as how costs and benefits will accrue to individual organizations and the network [31▪▪]. To facilitate buy-in from multiple partners and give voice to all of those around the table, the leadership function must be distributed in a fair, inclusive and equitable way and ensure members lead in areas of their expertise [32]. Effective governance agreements may range from informal (e.g., sign-ons) to formal (e.g., memoranda of agreement) and provide guidance for all involved. For example, a population health collaborative in Washington, DC re-committed its membership and network leadership by planning and conducting a retreat to develop a ‘values document’ summarizing core activities and impact on member organizations and partnerships and crafting a strategy to improve alignment with community partners [30].

Many leaders agree that it will take an entire community to address the social determinants of health that contribute to negative and disparate health outcomes for residents. However, there is no standard way to create shared accountability among cross-sector network partners [33]. Partners in networks must establish a leadership table that distributes accountability for achieving network goals [34]. Configurations that have a range of sub-committees and broad representation (as opposed to a single ‘lead’ or ‘anchor’ organization whose role is to convene partners and take the lead on establishing goals and tracking progress) can create the buy-in necessary for members to stay committed to the network and systems change work over the long-term [35▪▪]. This creates clarity about roles and responsibilities and unifies competitors and unfamiliar collaborators by allowing each group to do what they do best [36].

Data

Joint sense-making of data shared between network partners and community members can be effective in helping networks identify community needs, measure the impact of network activities, and foster accountability [37]. Sharing and integrating the data collected by network partners across sectors, augmented by engagement of community members with lived experiences, aids networks in developing a full understanding of a community's health and needs to guide the development of their goals and strategies [38]. Aggregated data on the causes of a population health challenge can help a network make a compelling case for system or policy change [39]. As the work deepens and becomes more embedded in the fabric of the community, the network's data sharing efforts may require a more robust infrastructure to integrate data from multiple sectors and analyze its impact on the community as a whole and to measure the impact on equitable outcomes. Disaggregated data allows the network to identify sub-populations in need of targeted resources and specialized strategies to address inequities [40].

Promoting equity through data disaggregation

Analyzing improvements in health outcomes at too high a level (e.g., a whole community or entire patient population) can obscure inequities in access to healthcare and healthcare outcomes related to race, ethnicity, and other demographic characteristics [40,41,42]. In order to explore health inequities across its patient population, Nemours Children's Health developed a patient equity index to disaggregate patient data by demographics (race, ethnicity, and language spoken in patient home). Although research on health disparities is extensive, the literature on health system development and utilization of patient equity indexes or dashboards, especially in pediatrics, is nascent [43,44]. Nemours’ patient equity index tracks outcomes around prevention, access, and clinical outcomes across patient subpopulations. Patients and families representing varied populations may face different barriers to accessing care including structural (limited transportation, time off work), interpersonal (limited English proficiency or health literacy), and systemic (mistrust of health system recommendations based on historical patterns of institutional discrimination). The goal of the equity index is to provide a platform for deep dives into these areas to understand what impactable factors might drive inequities and can inform the work of networks to address them.

After exploring various clinical measures related to inequitable pediatric health outcomes, three initial pediatric healthcare access and clinical measures were identified:

Access to Care (Primary Care patients seen at least once in the previous 365 days).

Arrival Rate (Percentage of patients who showed up for an appointment as expected).

Flu Vaccination Rate (Percentage of patients receiving one vaccine dose during the flu season annually).

Analysis of health disparities within the Nemours patient population is a step toward achieving health equity among patients and in the community. The patient equity index can be applied to all areas of the pediatric health system. Nemours will share data from its patient equity index within its networks to support the development of shared interventions that address the barriers to equitable healthcare access and disparate health outcomes. The patient equity index advances health system e accountability to both its patients and communities in making measurable progress toward eliminating health inequities. It will also help Nemours and its partners better assess where the expertise and experience of the health system can best be brought to bear and where it makes sense to provide support for other community leads [45▪▪].

CONCLUSION

Cross-sector networks can enhance their impact and improve the sustainability of their efforts by integrating the above principles into their structures and work. By building strong relationships among partners, cross-sector population health networks can ensure the network is not a short-term, one-time project, but a sustained collaboration through enduring processes and infrastructure. Networks can gain a fuller understanding of the needs and assets of a community through engagement and leadership by community members than they could gather from data and surveys alone. This approach to serving a community by making members equal partners in the effort helps to place equity at the center of a network's focus, as does embedding equity-related decision-making tools and processes into operations of the network. If cross-sector networks build resilient, inclusive structures and procedures, they can utilize them to pivot and adjust to emerging needs or respond to crisis.

It is more imperative than ever that population health networks address the causes, not just the symptoms, of health inequities. There are clear behavioral attributes that contribute to the success of cross-sector networks in tackling root causes of inequity. Those that have cultures of learning and embrace opportunities to change and evolve are most successful in working in service to their communities to promote health and wellbeing. As state and local governments, healthcare providers, and community service organizations grapple with reducing inequities and disparities in child health and wellbeing outcomes that span multiple sectors, it is imperative for stakeholders to form networks with equity embedded in their structures and community-driven goals. Leveraging the work of groups that came before them can allow the current partnerships to succeed where others have stalled or failed. The principles and tactics explored above can accelerate and enhance the impact of communities – recognizing that an organized community is an asset that can quickly and effectively respond to new opportunities as they arise.

Acknowledgements

The authors gratefully acknowledge the assistance of Trevor Lee of Nemours Children's Health in gathering information for this article as well as Lavisha Pelaez of Nemours Children's Health in co-developing the Nemours patient equity index. Additionally, the authors want to acknowledge the following partners in informing the content of this article:

Bridgeport Prospers

DC Heath Matters Collaborative

First 1,000 Days Sarasota

Florida Association of Healthy Start Coalitions

Ready for School, Ready for Life (also previously known as Get Ready Guilford Initiative)

Institute for Public Health Innovation

Maternal Mental Health Coalition of Flathead County

New Jersey Interdepartmental Planning Group

Financial support and sponsorship

This article is informed by findings from projects funded by the Robert Wood Johnson Foundation and the Kresge Foundation.

Conflicts of interest

There are no conflicts of interest.