The Building Blocks Collaborative: Advancing a Life Course Approach to Health Equity Through Multi-Sector Collaboration
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- Shrimali, B.P., Luginbuhl, J., Malin, C. et al. Matern Child Health J (2014) 18: 373. doi:10.1007/s10995-013-1278-x
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Too many children are born into poverty, often living in disinvested communities without adequate opportunities to be healthy and thrive. Two complementary frameworks—health equity and life course—propose new approaches to these challenges. Health equity strategies seek to improve community conditions that influence health. The life course perspective focuses on key developmental periods that can shift a person’s trajectory over the life course, and highlights the importance of ensuring that children have supports in place that set them up for long-term success and health. Applying these frameworks, the Alameda County Public Health Department launched the Building Blocks Collaborative (BBC), a countywide multi-sector initiative to engage community partners in improving neighborhood conditions in low-income communities, with a focus on young children. A broad cross-section of stakeholders, called to action by the state of racial and economic inequities in children’s health, came together to launch the BBC and develop a Bill of Rights that highlights the diverse factors that contribute to children’s health. BBC partners then began working together to improve community conditions by learning and sharing ideas and strategies, and incubating new collaborative projects. Supportive health department leadership; dedicated staff; shared vision and ownership; a flexible partnership structure; and broad collective goals that build on partners’ strengths and priorities have been critical to the growth of the BBC. Next steps include institutionalizing BBC projects into existing infrastructure, ongoing partner engagement, and continued project innovation—to achieve a common vision that all babies have the best start in life.
KeywordsLife course perspectiveHealth equitySocial determinants of healthLocal health departmentCommunity collaborative
Supportive community environments—access to healthy food, safe and appealing parks, high quality housing and education, job opportunities, clean air and water, resources to save and build financial assets, and other community factors—are key to good health. Policies and practices influence the creation of these healthy environments and the ability of all people, regardless of race or socioeconomic status, to live in them. Alameda County faces disparities in health by income, race/ethnicity, and place, and the Alameda County Public Health Department (ACPHD) is working to address these disparities and advance health equity by partnering with local leaders to improve community conditions and support good health . The life course perspective brings a critical additional lens to this work, highlighting the importance of ensuring that babies and children live in supportive community environments that will foster optimal health, development, and well-being over the course of their lives [2–4].
In 2009, ACPHD launched its life course initiative, Building Blocks for Health Equity, and its Building Blocks Collaborative (BBC), to help advance health equity. BBC is mobilizing partnerships, incubating projects, and redesigning services—toward a vision that all children in Alameda County—no matter where they live, how much money their families have, or the color of their skin—have the best start in life. Since its inception, BBC has been critical in laying a foundation for health equity by building broad community support for maternal and child health concerns; providing the space for diverse representatives from non-health related agencies to be advocates for health; launching cross-sector collaborative projects in key strategy areas; and serving as a catalyst for the re-design of services and systems within ACPHD that are rooted in the life course perspective.
Call to Action
Perinatal data trends in Alameda County are similar to those across the nation, with little change in low birthweight rates over the last two decades and significant disparities in perinatal, infant, child, and adult health outcomes between African-Americans and Whites. For example, compared to a White child in the affluent Oakland hills, an African-American child born in West Oakland is 1.5 times more likely to be born premature or low birthweight; 7 times more likely to be born into poverty; 1.5 times more likely to be behind in immunizations; 4 times less likely to read at grade level; and 5.6 times more likely to drop out of school—culminating in a 15 year difference in life expectancy .
In 2008, a group of ACPHD leadership and program managers working with families during the perinatal period came together to establish a learning community to study the life course perspective, review local population data, and discuss promising interventions. A brief client survey was also conducted to better understand the experiences of current participants in ACPHD’s home visiting and other perinatal programs. These experiences were considered in the context of concentrated neighborhood poverty, racism, and disinvestment, to identify possibilities to support local residents in building on community assets to transform community conditions.
The group began to recognize that although current health interventions during pregnancy, infancy and early childhood can lay the groundwork for a lifetime of good health, ensuring healthy community conditions is necessary to address inequities in perinatal and child health. This could not be done by a health organization in isolation, but instead needed to happen through a broad coalition of multi-sector partners.
Responding to the Call: Implementation
In September 2009, ACPHD hosted a symposium called “Building Blocks for Healthy Babies, Healthy Families, Healthy Communities,” which was organized around a theme of building cross-sector partnerships and included national health equity and life course leaders .
Building Blocks Collaborative key partners
Allen Temple Health and Social Services
Alameda County Child Care Planning Council
Alameda County Community Food Bank
Alameda County Deputy Sheriffs’ Activities League
Alameda County Public Health Department
Alameda County Sheriff’s Office
Alameda County Social Services Agency
Alameda Health Consortium
American Diabetes Association
Ashland Cherryland Garden and Arts Network
Attitudinal Healing Connection
Berkeley Food and Housing Project
Centering Parenting at West Berkeley Family Practice
Centering Pregnancy at LifeLong Medical Care
City of Berkeley Black Infant Health Program
City of Fremont Human Services Department
City Slicker Farms
Community Child Care Coordinating Council
Dig Deep Farms and Produce
East Bay Asian Local Development Corporation
East Bay Regional Park District
First 5 Alameda County
Food/Transportation Resource Connection
Fremont Family Resource Center
Girls Incorporated of Alameda County
Kaiser Permanente, Community Benefit East Bay
Kaiser Permanente, Community Benefit, Greater Southern Alameda Area
Lifelong Medical Care, Heart 2 Heart Program
New Haven Unified School District
Oakland Unified School District
Tiburcio Vasquez Health Center
University of California, San Francisco
UC Berkeley-UC San Francisco Joint Medical Program
Urban Strategies Council (Alameda County Community Asset Network)
West Oakland Health Council
Following its launch, BBC engaged in three phases to advance the vision for health equity put forward at the symposium: 1. Building a strong, multi-sector collaborative based on trust and shared vision, 2. Learning, sharing and orienting to shift the paradigm from a narrow focus on services to a broader focus that includes improving community conditions that influence health, and 3. Incubating new projects to advance healthy environments for babies and children.
Phase 1: The Launch
Building Blocks Collaborative bill of rights
All children in Alameda county have a right to be born healthy, and to
1. Be believed in
2. Live, play and grow in a clean, safe place
3. Receive a quality education
4. Be loved by a caring adult
5. Eat healthy food
6. Explore nature
7. Enjoy economic opportunity and financial security
8. Access health care that promotes well-being
9. Be free from discrimination and violence
10. Be included and valued by a supportive community
Six months after the collaborative came together, a multi-sector steering committee—composed of ACPHD staff and representatives from BBC’s community-based organizations—was created to oversee both the work of the external BBC and the internal life-course driven work underway at ACPHD. BBC recently celebrated its 3 year anniversary, with a diverse mix of partners continuing to meet, now on a bimonthly basis to connect and collaborate on shared priorities.
Phase 2: Learning, Sharing, Orienting for a Paradigm Shift
Launching BBC required promoting a culture of learning and inquiry. ACPHD staff engaged BBC partners in thinking differently and sharing their unique expertise and knowledge of their sectors. This sharing allows partners to develop new ideas and partnerships, and fosters collaborative efforts to advance healthy communities and greater health equity, as evidenced by one partner’s testimonial: “Over the past year, East Bay Asian Local Development Corporation has begun the conversation about how our work would shift if we considered ourselves health providers and not just affordable housing developers and managers.”
Regular meetings provide informal and formal opportunities for learning and dialogue. ACPHD and partners have shared local data and discussed best practices related to the Bill of Rights, drawing on diverse partners’ knowledge and expertise. Addressing the role of race, power, and privilege is an important part of these conversations in recognition that solutions should be rooted in an understanding of race-based and class-based historical and political contexts that have shaped community environments. Community residents are critical partners to transform these dynamics. Local institutions and the individuals within them must not perpetuate these racial and economic injustices, and must work with residents toward a more equitable future.
ACPHD staff link participants to opportunities outside the meetings to learn more about the life course perspective and health equity—including symposiums, trainings, and workshops—and to share BBC successes and challenges. BBC’s online learning community is a virtual hub for learning about BBC approaches, partners and their resources, and what BBC is doing to further health equity . Grants from Kaiser Permanente local community benefits programs have supported communication and other efforts.
Phase 3: Incubating Projects
With a foundation of trust, shared ownership, and a space for thinking differently, BBC serves as a project incubator. Although BBC partners are countywide, ACPHD encourages BBC projects to focus in the communities of greatest need, as supported by data showing disproportionate burden of poor health outcomes. ACPHD staff pursue fund development opportunities to promote collaborative project development, and provide mini-grants to support innovative projects.
Building Blocks Collaborative project guiding principles
BBC projects must
1. Have a clear link(s) to the bill of rights
2. Be sustainable and build capacity
3. Work toward systems change
4. Provide opportunity for broad buy-in and involvement for community and BBC (driven by community need; building on BBC partner strengths), and
5. Be achievable, with greatest likelihood of demonstrating success
BBC encourages sharing of resources between partners to create new projects and foster connections. Every meeting has a partner spotlight (where the partner hosting the meeting presents on their work and other attendees complete a form to suggest areas for collaboration and support) and structured networking. BBC staff also conducted an asset-mapping survey to assess resources that can be shared and leveraged in this work, ranging from conference rooms and kitchen space to facilitation and grant writing.
BBC has engaged many partners in the movement toward health equity, with over 100 partners from over 50 organizations representing a diverse mix of sectors and expertise. There are 25–30 attendees at each meeting, now six times a year, and BBC’s website has had over 12,000 views since its launch in September 2009.
BBC supports rich dialogue that bridges individual/family needs with changing/broader community conditions.
Cross-Sector Maternal and Child Health Projects that Advance Health Equity
Together ACPHD and BBC partners have launched three projects that advance health equity.
Food to Families is a project in West Oakland and Ashland-Cherryland that provides “prescriptions” for fresh food to pregnant women receiving health services at local health centers that are then “filled” at local food businesses where community youth are employed. This Kresge Foundation funded project engages two BBC partners focused on developing food enterprises and employing local youth: Mandela Marketplace and the Deputy Sheriffs’ Activities League; and two community health centers: West Oakland Health Council and Tiburcio Vasquez Health Center. The neighborhoods were chosen based on their disproportionate burden of poor outcomes. Input from residents in both communities about the need to have access to fresh produce in their neighborhoods, to increase youth employment opportunities, and to improve local economic development helped shape the design of the project.
The BBC, in partnership with ACPHD’s Place Matters initiative and the Urban Strategies Council’s Alameda County Community Asset Network, developed the Alameda County Prosperity Project to improve health by supporting financial well-being. Increasing income and wealth allows people to access health care services, purchase healthy food, and afford high quality housing, and can help mediate stresses. This project, supported by the Robert Wood Johnson and Walter & Elise Haas Foundations, helps residents navigate predatory financial landscapes and identify lower-cost alternatives through the development of a “Savvy Consumer Toolkit.” Information from the toolkit, other financial tools, and strategies for policy engagement are being incorporated into ACPHD’s perinatal home visiting programs to support families during this critical period in the life course. To improve community environments, this project is also working to advance policy changes that will increase local access to non-predatory financial services.
In 2012, BBC became part of a new W.K. Kellogg funded project led by the University of California, Berkeley called the Best Babies Zone Initiative (BBZ). This place-based project, focused on a 7 by 12 block area of East Oakland, will develop solutions to neighborhood issues and foster new county collaborations, with the goal of achieving community transformation to ensure a healthy future for the neighborhood’s children. Strategies to reach BBZ’s goals include supporting resident leadership development and capitalizing on BBC partners’ strengths in both the services and systems-change arenas. With support provided by the California Wellness Foundation, ACPHD is building capacity to use human-centered design thinking in the zone to uncover new insights and generate early wins. Design thinking is a problem-solving methodology that focuses on in-depth understanding, rapid idea generation, and prototyping to generate innovative solutions to complex challenges [9, 10]. ACPHD will include residents in the planning of new programs and services, and will develop universal approaches to maternal and child health that not only help families in crisis but also address community change priorities and engage both residents and public agencies in their solutions.
Shifting a paradigm is slow, and BBC’s investment in learning, creating space for inspiration and possibility, building new relationships and partnerships, and testing new approaches lays the groundwork for lasting change. In the development of a new paradigm both ACPHD and BBC have had to embrace the ambiguity needed to develop new approaches, and welcome the contradictions inherent in challenging the status quo.
Several core elements have made BBC possible and successful: strong leadership; dedicated staff; shared vision and ownership; flexible partnership structure; support for building BBC partners’ capacity; broad collective goals that build on partners’ strengths and priorities; and funds to promote learning, sharing, creating, and launching projects.
As trusted institutions, local health departments are logical conveners of broad-based community initiatives to address health equity. Committed leaders within ACPHD, such as the Department Director whose support was critical to the BBC’s founding, and several Division Directors, have been key contributors to the success of BBC. Despite the ACPHD Director’s retirement last year, department leadership has continued to support the BBC’s work. Department leaders are voices for change; take risks to support new and untested approaches; use their influence to invite crucial partners to the table; provide guidance to staff on this challenging and evolving work; dedicate resources, such as staff time and funding for meetings and training; and ensure connection to others in the department to support collaborative multi-sector work.
ACPHD has dedicated staff to support BBC. Guided and supported by the Family Health Services Director and the Department’s Deputy Director for Policy, Planning, and Health Equity, staff plan and co-facilitate bimonthly meetings with partners, maintain communication (email, blog, and website), coordinate trainings, convene the steering committee and other workgroups, recruit new partners, facilitate connections between partners, seek collective funding opportunities, and manage funded projects incubated by BBC.
Shared Vision and Ownership
In launching and sustaining BBC, staff strive for transparency and shared ownership, building a culture of trust and collective vision. Staff engage in consensus driven-facilitation, and are responsive to the interests and needs of the collaborative. The vision, mission, products, and direction of the collaborative are developed collectively, with an intention of promoting cross-sector learning essential for innovation.
Community partners are encouraged to host meetings at their organizations, co-plan meetings, co-facilitate agendas, recruit new partners, and participate in workgroups. BBC partners rotate planning and facilitation duties to engage new people and encourage shared ownership of BBC’s direction. Staff hold a breakfast orientation for new partners before each meeting to ensure continued engagement of new participants.
Flexible Partnership Structures
Two years after the launch of BBC, a two-tiered engagement structure consisting of members and supporters was instituted to allow different levels of participation, acknowledging the constraints of organizations with limited staff and resources. BBC members sign a partnership commitment form and participate by attending meetings and trainings; contributing to workgroups; facilitating bi-directional communication between their organization and the BBC; and leveraging resources, partnerships, and networks to advance health equity through a life course orientation. BBC supporters attend meetings less regularly and receive regular email updates.
ACPHD provides limited funds to spur partnership and innovation, as well as fund development support. BBC mini-grant projects have included a range of activities including stress-management classes, the creation of a “learning” garden at a partner health center, financial education classes, and a youth employed and administered exercise program.
ACPHD grant writers have conducted a grant writing training and served as a resource to aid in future grant development for BBC partners. Scholarships have also been provided for BBC partners to attend health equity and life course symposiums and trainings.
Broad Collective Goals
In working with a diverse group of community partners, ACPHD intentionally did not select one health outcome in order to maintain broad participation, which often is at odds with funding priorities and long-standing public health operations. The suggestion to focus on one specific health outcome was rejected from the outset as a BBC partner from the East Bay Regional Park District reminded the group “I can’t go back to my organization and say I’m working on infant mortality.” The Bill of Rights was created a way for organizations that are not engaged in health to be able to justify their partnership. It also reflects BBC’s commitment to open-endedness to cultivate authentic sharing and learning. As the lead, ACPHD did not come in with answers or a hidden agenda, but rather embraced the possibilities and a commitment to the life course perspective and health equity. This open-ended approach allowed ACPHD to build on partners’ strengths, as well as existing priorities and momentum in our communities that could be expanded for even greater impact.
In addition, BBC has demonstrated the possibilities for improved health by implementing change strategies at both the service delivery and systems levels. BBC projects meet immediate needs through traditional health service provision, while also addressing the larger context in which people live . The necessity of this type of approach is reinforced by evidence showing that environmental and behavioral change may need to occur in tandem to see results . For example, the Prosperity Project incorporates financial education into home visiting services, while also working to address policy changes that can increase access to non-predatory financial services.
ACPHD is working to institutionalize BBC projects into its existing infrastructure, thereby ensuring their sustainability. The experience with BBC has inspired ACPHD to create a home visiting/family support system of care that links its one-on-one work with families to efforts that are transforming the communities in which they live. Training home visiting staff to provide financial education to clients; incorporating an explicit awareness of race, power and privilege in the design of the a new system of care; and linking clients and community residents to policy change opportunities are a few of the strategies being proposed to accomplish this transformation.
BBC was not organized around any one grant or project—the stakeholders committed their time and expertise to building capacity and orienting their work to a collective movement for health equity. This has been an asset, but funding is needed to test new approaches, build collaboration, and invest differently in communities. BBC has required significant staff time to keep the collaborative strong and ensure continued engagement of its members. Funds from foundations supplement financial support provided by ACPHD, but are time-bound and often limited to specific projects. Public health practitioners should advocate for more flexible health funding streams to that can be used to address creative, cross-sector approaches. These approaches can improve health and ultimately reduce the need for health services by supporting health-promoting conditions in communities.
BBC has laid the foundation for systems change efforts to improve maternal and child health, in ways that help eliminate health inequities in Alameda County. This work takes time, and cannot be done in isolation. The Building Blocks Collaborative helps fuel inspiration, innovation, and transformation within Alameda County Public Health Department and among traditional and non-traditional partners, toward ensuring that all babies have the best start in life.
Thanks to the many Alameda County Public Health Department staff, community partners, residents, project advisors, and funders who have inspired and contributed to the Building Blocks for Health Equity initiative.