Alameda County Public Health Department serves 13 of Alameda County’s cities (all except the City of Berkeley, which has its own health department), a population of 1.5 million residents. Each year in Alameda County, 7000 children start life in poverty. Scientific consensus is emerging that the origins of adult disease are often found in adverse experiences during pregnancy and early life, and cumulative impacts of stressors over the life course. Moreover, an extensive body of evidence exists linking intrauterine and early life experience with a wide array of health impairments, including obesity, chronic pulmonary disease, cancer, alcoholism, depression, drug abuse and mental health problems, and cardiovascular risk factors. Reducing disadvantage early in life may be a powerful strategy for reducing the disparities in later chronic conditions.
Alameda County Public Health Department
Building Blocks Collaborative / Alameda County Life Course Initiative
Alameda County Public Health Department serves 13 of Alameda County’s cities (all except the City of Berkeley, which has its own health department), a population of 1.5 million residents. Each year in Alameda County, 7000 children start life in poverty. Scientific consensus is emerging that the origins of adult disease are often found in adverse experiences during pregnancy and early life, and cumulative impacts of stressors over the life course. Moreover, an extensive body of evidence exists linking intrauterine and early life experience with a wide array of health impairments, including obesity, chronic pulmonary disease, cancer, alcoholism, depression, drug abuse and mental health problems, and cardiovascular risk factors. Reducing disadvantage early in life may be a powerful strategy for reducing the disparities in later chronic conditions. In Alameda County, unfair disadvantage is evident, starting as early as birth, and structural conditions of inequality have concentrated resources and opportunities for health in certain places. In certain disproportionately impacted neighborhoods, over 40% of newborn babies are born into poverty. In addition, African American infants are nearly twice as likely to be born low birth weight compared to White infants, putting their lifelong health at risk from the earliest moments of life. Women giving birth in poverty in Alameda County have likely faced adverse circumstances mounting over their life course. The concentration of these factors results in a life expectancy in certain neighborhoods of Alameda County of up to 10 years less than other areas of the county. Recognizing that no one entity can effectively address the social inequities that affect health in isolation, ACPHD hosted a symposium in September 2009 to educate and engage partners in seeing their role in advancing a Life Course Perspective (LCP) to addressing health and social inequities in Alameda County.
The symposium, called “Building Blocks for Healthy Babies, Healthy Families, Healthy Communities” was organized around a theme to build cross-sector partnerships. Emerging from the symposium was the Building Blocks Collaborative (BBC), a countywide initiative to engage community partners in improving social, economic and environmental conditions for children born in Alameda County. BBC members are from diverse arenas, including local economic development agencies, food access projects, city and county government, community clinics, housing, parks and education. BBC represents a mobilized and motivated group of stakeholders committed to community transformation throughout Alameda County. BBC intends to change the way Alameda County organizations work, as individually and collectively, to create equitable community conditions to support well-being starting from the earliest stages of life, for all children—regardless of where they are born, their race, or how much money their families have. With guidance and support from ACPHD, BBC has engaged in capacity building to participate in policy, environmental, programmatic and infrastructure change, using the LCP as a guiding framework. Concurrently, ACPHD staff engaged in departmental capacity to further the integration of the LCP into the health department’s work with communities. BBC has built capacity for addressing social and health inequities by building a learning community, fostering new cross-sector partnerships, incubating and funding innovative projects, and spreading the word locally and nationally to influence systems change.
In working with a diverse group of community partners, BBC has intentionally NOT selected a health outcome to maintain broad community participation. Over the past two years, the BBC has developed and adopted a shared vision statement -- Bill of Rights – participated in training to provide LCP presentations to stakeholders, launched a web-based learning community, and planned and funded collaborative projects. Internally, ACPHD has been engaged in simultaneous systems change: organizing a home visiting system within a larger context of services for families and developing a curriculum to help ACPHD staff integrate LCP principles into scopes of work. BBC has been awarded several grants to advance health equity projects, including a planning and implementation grant from the Kresge Foundation for a three-year “Food to Families” project in early 2010, a 6-month “Healthy Eating Active Living” project from Kaiser Permanente, and a two year “Collaboration for Income and Asset Protection” project from Robert Wood Johnson Foundation. If they are trusted community-oriented institutions, Public Health Departments are logical conveners of community collaborations that address health equity. Transparency, shared ownership, and consensus-driven facilitation have contributed to a culture of trust and mutuality within the BBC. Internal capacity-building, in tandem with building community partnerships, has laid the foundation for long-standing, sustainable, systems change efforts to improve community health and eliminate health inequities in Alameda County.
There is limited evidence to show that isolated programs and initiatives are enough to address complex and interdependent social issues. The BBC builds local capacity to address the social determinants of health on a structural (rather than individual) level, thereby addressing a number of local health problems. In 2008, ACPHD published a landmark report titled "Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County." This report examined the impact on health in Alameda County of: segregation; income and employment; education; housing; transportation; air quality; food access and liquor stores; physical activity and neighborhood conditions; criminal justice; access to health care; and social relationships and community capacity. Through presentation of local data, research findings, and a series of recommendations, this comprehensive report, has elevated local (and national) awareness of the social and environmental causes driving disparities resulting in intense community wide commitment to addressing health disparities in Alameda County. At the 2009 Building Blocks Symposium, we mobilized partners to organize their resources and efforts around addressing social determinants of health by sharing this local data, as well as information on the Life Course Perspective, in theory and practice.
BBC has maintained a clear commitment to addressing stated community need. Starting in 2007, ACPHD collected data from 300 adults and youth residents, community based organizations, staff, elected officials, and other stakeholders through surveys, community forums, interviews, and dialogues on the impact of structural racism and privilege on the health of our communities. The result informs the broad-based action of BBC, recognizing that poor health concentrates at the intersection of poverty, place, and race that restricts opportunities of our most vulnerable populations to live in health-promoting environments and make healthy choices. In addition, BBC’s planning framework dictates that BBC projects must form at the intersection of expressed community need, existing community projects demonstrating momentum to address this need, and BBC partner and collective expertise. Several local surveys have informed the identification of BBC’s strategic priority areas: Healthy Food, Healthy Economy, and Healthy Youth and Families. These surveys include period door-to-door surveys in the West and East Oakland Communities, a youth survey in West Oakland, and an Ashland-Cherryland Youth Photovoice Project. An iterative design process has been employed to inform BBC projects by gathering concrete resident input to inform projects.
BBC has built capacity for addressing social and health inequities through building a culture of trust and learning, arming partners to spread the word locally and nationally – in health and other sectors, fostering new cross-sector partnerships, and incubating and funding innovative projects. In order to build a culture of trust, collective vision, and mutual learning, BBC has maintained commitment to transparency, shared ownership, and consensus-driven facilitation. The vision, mission, products, and direction of the collaborative have been decided by its members. Over the past two years, the BBC has developed and adopted a shared vision statement – the Bill of Rights – participated in training to provide LCP presentations to stakeholders, launched a web-based learning community, planned collaborative projects, and is developing a methodology for shared outcome measurement. LSDC has completed an evaluation of ACPHD home visiting programs to help organize a home visiting system within a larger context of services for families across the lifespan and is developing a curriculum to help ACPHD staff integrate LCP principles into scopes of work. In early 2010, the Kresge Foundation awarded a planning grant to the BBC and subsequently, additional funding to support the three year “Food to Families” project which was proposed and is being implemented by BBC members. In fall 2011, Kaiser Permanente provided funding for a “BBC HEAL” (Healthy Eating Active Living) project. In addition, in fall 2011 the Robert Wood Johnson Foundation funded a policy and systems change initiative to protect Alameda County residents assets and build wealth--a partnership between ACPHD’s Place Matters Local Policy Initiative, BBC, and BBC member Alameda County Community Asset Network. In addition to these funded projects administered by ACPHD, many collaborative projects have ensued as a result of the relationships and connections made through BBC, including: hundreds of children who rarely leave their neighborhood attending East Bay Regional Parks District parks, use of neighborhood community room facilities for leadership trainings, First 5 kindergarten bootcamp at Oakland Housing Authority, and more.
BBC has used the Life Course Perspective (LCP) as a tool to mobilize a group of stakeholders to each see their role in creating equitable conditions in Alameda County and ensuring all children have the best start in life. ACPHD brought together stakeholders from different sectors and asked each to consider their role in creating healthy communities. The LCP helps each partner elucidate that we each play some role in the creation of health through the experience of negative or positive factors during critical periods of development. The MCH Life Course Toolbox, developed by CityMatCH and Contra Costa Health Services is in the NACCHO Toolbox. BBC’s approach is unique and innovative because it goes beyond the typical use of LCP within Maternal and Child Health by including ACPHD staff throughout the department, and also builds relationships in new sectors. BBC is built on ACPHD’s history of strong community partnerships and a commitment to health equity. To our knowledge, few public health departments have used the LCP to mobilize multi-sector collaborations. Another unique feature that reflects ACPHD’s strong commitment to community partnerships is our multi-stakeholder steering committee. This steering committee provides guidance not only to the BBC but also to the internal systems change work within ACPHD that is working to reorganize systems and services to be in line with the LCP. It is rare in a government system to display this level of transparency and commitment to shared ownership.
ACPHD staff strive to maintain connections to other LCP-oriented work taking place nationally. Based on our knowledge derived from these connections, BBC is an inventive use of the LCP tool. As an illustration, the MCH Life Course Toolbox, hosted by CityMatCH at http://www.citymatch.org/lifecoursetoolbox catalogs Life Course related resources and projects throughout the country. CityMatCH is in a unique position to do so as they represent the voice of Urban Maternal and Child Health. In the area of practice, BBC is listed among only a handful of local practice examples, each unique in their approach of translating LCP into practice.
Based on our knowledge, BBC is the only partnership of its kind that brings together multi-sector stakeholders to advance health equity on a local level through a Life Course lens. While other LCP projects work within public health systems or work to expand service delivery offerings, BBC is working on multiple levels to expand capacity to address health equity through individual service delivery as well as through policy and upstream intervention.
BBC stakeholders represent broad-based involvement and participation from government; residents; academia; and community-based organizations representing healthcare, community, physical and economic environment, and education. BBC member organizations include local economic development agencies, food access projects, city and county government, community clinics, housing, parks and education. In addition, we are working to cultivate partnerships in the private business community to leverage the resources and connections that may be available in those networks.
Role of Stakeholders/Partners
BBC partners provide the legs for this work. Each organization is asked to consider their role in creating equitable conditions for Alameda County’s children and participates in capacity building activities, such as trainings, dialogues, and project incubation. Through this work, several organizations have created new and innovative connections to expand their organization’s work, or have expanded the definition of their organization’s work to include health as an outcome of their work. For example, Urban Strategies Council, which convenes a group of community oriented financial providers called the Alameda County Community Asset Network has expanded its asset and wealth-building work to include a focus on health impacts of economic issues. This has resulted in new dialogues and policy – products from this include a 2010 Health-Wealth Symposium as well as the Collaborative for Income and Asset Protection - a newly funded project from the Robert Wood Johnson Foundation focused on improving access to healthy financial products (instead of the payday lender or check casher) through policy and systems change. Another example is that of East Bay Asian Local Development Corporation, a local housing development organization – as a result of their partnership with ACPHD, they have expanded their organization to include a health equity unit. A third and final example is East Bay Regional Parks District, which through various partnerships developed from BBC has been able to take hundreds of children to experience wilderness programming.
ACPHD is the LHD that serves as a backbone organization for BBC. In this role, ACPHD staff ensure open communication (through monthly meetings, email lists, blog, website, facebook and now twitter), plan and facilitate meetings and trainings, convene the steering committee and other workgroups, help make connections between partners, and seek out funding opportunities on behalf of BBC. ACPHD has shown itself to be a trusted partner in this role. For example, BBC partner Aeeshah Clottey from Attitudinal Healing Connection (a grass roots community based organization in West Oakland dedicated to building healthy communities by breaking the cycle of violence by providing a platform for creative expression and communication for children, youth, adults and families) states, “I came to my first meeting apprehensive, guarded and reluctant to participate in a collaborative of organizations that was spearheaded by a governmental organization. However, I was impressed with the first meeting, which began with the Roadshow presentation that focused on Alameda County’s commitment to improve the condition of the 7000 infants that are born in poverty annually in Alameda County. In addition to this commitment the staff that is the glue of the Building Blocks Collaborative was personable, exhibited competence in the areas of diversity, community and culture. They also were creative and welcoming.”
ACPHD uses several techniques to promote shared ownership of BBC. First, ACPHD has seated a multi-sector steering committee – populated half by ACPHD staff and half by BBC members from community-based organizations. The steering committee holds open meetings monthly and posts notes on the BBC website. Second, ACPHD staff encourage BBC members to participate in planning monthly BBC meetings and facilitating sections of the agenda. Every six months, an agenda-planning sign-up sheet is circulated and everyone is encouraged to do their duty by signing up to help plan and facilitate. Finally, BBC partners are encouraged to host meetings at their site – in this way, the host partner can share a little about their organization and we can learn about the resources available in Alameda County. In addition to promoting shared ownership, ACPHD fosters collaboration through project incubation and implementation. For example, two BBC partners – Mandela Marketplace and West Oakland Health Center are literally down the street from one another but have only cursorily worked together. Through the Food to Families project, pregnant clients receiving prenatal care at West Oakland Health Center are given prescriptions and vouchers to support Mandela Foods local grocery store – thereby helping improve the local food landscape. BBC’s other projects similarly provide opportunities to build strong concrete collaboration. By providing networking opportunities during monthly meetings and trainings, new partnerships and collaborations have occurred and continue to do so.
Tackling health inequity is daunting, and organizations with limited resources may not perceive it as a priority. Significant investment is required to operate or even participate in a large community collaborative, especially one with a long-term Life Course approach to building community health. It is difficult to find common goals across diverse, sometimes competing, sectors. In addition, maintaining transparency can be difficult as things move quickly and when decisions around funding need to be made. Finally, many organizations and funders seek short-term solutions and are reluctant to support infrastructure for long-term systems change.
As described above, in order to achieve objective 1, BBC partners collaboratively developed products essential to its identity – mission, vision (Bill of Rights), website, and Roadshow presentation. In addition, processes were developed to encourage transparency and shared ownership: a multi-stakeholder steering committee, rotating sites, and shared agenda planning and facilitation. BBC members were engaged into various timebound or longstanding subcommittees such as Meeting Planning and Facilitation, Roadshow, Shared Outcomes, Project Planning, others. As described above, to achieve objective 2, various trainings and convenings have been held to build the capacity for partners to engage in dialogue and learning about LCP, health equity, social determinants of health. In addition, partners have been encouraged to strengthen their role in creating equitable community conditions in which all Alameda County children can thrive, leveraging their organization and its resources. Trainings have included the Building Blocks Symposium, Health-Wealth Symposium, Unnatural Causes film Screenings, a Kresge Foundation meeting, Collaboration Matters Conference, Social Media for Health Equity Training, Community Development Financial Institutions convening, In addition to formal trainings and meetings, BBC meetings also provide an opportunity for learning and sharing. At BBC meetings, we have shared local data, resident voice, provided a case for upstream work, and discussed new and best practices related to our Bill of Rights, drawing from the knowledge of the diverse partners represented. In addition, BBC has launched Food to Families, BBC Healthy Eating Active Living, and Collaboration for Income and Asset Development – three on-the-ground projects aimed at connecting clients receiving individual services to a broader understanding of how community resources (or lack of them) shape health. As stated above, to achieve objective 3, BBC has developed an online learning community which houses our roadshow presentation, Bill of Rights video, information about partner organizations, and monthly meeting updates. The Roadshow presentation was originally developed to engage new members into BBC. However, over time presentations and site visits have been hosted by BBC to spread the word --that we must change the way we think about health to include a host of broad community stakeholders and consider how community conditions affect health.
Process & Outcome
Objective 1: Develop a culture of trust and learning to engage collaborators from cross-sector organizations who may have competing priorities and agency agendas To evaluate the success of BBC is achieving this objective, we looked at monthly attendance, the BBC roster, and the development of BBC products that are essential to our identity as a collaborative. In addition we reviewed testimonials from members about their participation, asking them what BBC “seeds” had “taken root” for them. Monthly attendance records indicate about 25 attendees at each monthly meeting, and the BBC email roster lists over 100 members from 52 organizations throughout Alameda County, indicating a lot of interest and momentum. In addition, the development of the Bill of Rights, Mission, Roadshow communication tools, and projects--all of which have been created collaboratively—reflects a culture of shared ownership, trust and mutuality.
A few testimonials from members indicate a deep engagement as they share what has taken root for them:
“Observing deep and amazing connections and collaborations within a multitude of agencies.”
“Enjoyed the process of developing the bill of rights which is the heart of the collaborative’s work.”
“Rich dialogue that bridges individual/family needs with changing/broader community conditions.”
“Growing relationships. The BBC has given me the opportunity to meet and come to know so many people representing so many opportunities to enrich and set the right course for our children, their families, and the community.”
“New Partnerships.” These results indicate that BBC has been able to successfully engage many partners into the movement toward health equity. Partners have indicated that they feel included in shaping the direction of BBC and have benefited from the growing relationships that have arisen from it.
Objective 2: Provide technical assistance and resources to increase local capacity to address health inequities To evaluate this objective, we looked at trainings offered to BBC partners, BBC fostered innovative demonstration projects that address the root causes of health, and testimonies from BBC partners. Launching BBC, about 200 people attended the Building Blocks symposium in September 2009. Following that, we have held various trainings and meetings in which have provided opportunities to learn and share about BBC, LCP and health equity. In summer 2010, BBC members were involved in a Health-Wealth Symposium with about 150 attendees and 50 the night before for an Unnatural Causes film Screening. In summer 2011, 6 BBC partners from Food to Families attended a Kresge Foundation meeting in Chicago, ACPHD provided scholarships for 12 BBC representatives to attend a Collaboration Matters Conference at UC Berkeley, about 40 people attended a Social Media for Health Equity Training in summer 2011, and 5 selected partners attended a convening with Community Development Financial Institutions (CDFIs) to build stronger ties between Public Health and CDFIs.
In addition to formal trainings, BBC meetings also provide an opportunity for learning and sharing. At BBC meetings, we have shared local data, resident voice, provided a case for upstream work, and discussed new and best practices related to our Bill of Rights, drawing from the knowledge of the diverse partners represented. Evaluation records from each training and meetings indicate the trainings have been overwhelmingly positively received. BBC has a strong track record in launching new innovative projects. Over the past two years, BBC has launched three funded projects: Food to Families, BBC Healthy Eating Active Living, and Collaboration for Income and Asset Development. In addition, ACPHD staff have started engaging BBC partners in the redesign of ACPHD perinatal services in a project called Welcome Baby Network. These projects have all been launched within the last year and will be evaluated as they unfold. As indicated in the comments below, partners have also been offered opportunities to network and generate ideas for new collaborative projects.
Testimonials about what has taken root include the following:
“Purchased Unnatural Causes to give a staff training and create greater awareness of health disparities and impact of housing on health."
“Gained knowledge and better understanding of the Life Course Perspective.”
“Organized, well attended, and excellent presentations and collaborations at September 2009 symposium.”
“Including Life course perspective in our work at the Public Health Department.”
“Opportunity to learn about the Life Course Perspective and share it with families in West Oakland.”- Attitudinal Healing connection
“Beginning to work with Oakland Children’s Hospital Early Childhood Mental Health for on-site play therapy groups.”
“Began to incorporate other activities into health program (convincing management that art, financial education, etc. are part of health).”
“Brighter Beginnings and Lotus Bloom financial education programming and staff development.”
“Over the past year, EBALDC has begun the conversation how the shape of our work as a community development corporation would shift if we considered ourselves healthcare providers and not just affordable housing developers and managers.”
Results of this evaluation indicate that partners have expanded their perspective as a result of trainings and resources related to health equity, and several partners have been able to expand their organizations and projects through the work of BBC.
Objective 3: Spread the word about LCP to influence systems change, locally and nationally To evaluate this objective, we looked at opportunities to present our work locally and beyond to make the case that innovative upstream approaches are needed to achieve health equity. Our online learning community (http://buildingblocksalamedacounty.wordpress.com) is a virtual hub for learning about the LCP and what BBC is doing to create health equity. It houses BBC’s roadshow presentation, Bill of Rights video (made by youth from Youth Uprising in East Oakland), blog and monthly meeting updates. It has had nearly 10,000 views (9,629) since its launch in September 2009, and currently has 49 subscribers – a mix of local followers and others from around the country. ACPHD staff and BBC partners have had many opportunities to present on BBC – locally, at the state of California, and nationally. Diverse audiences have been in attendance – from residents to doctors, to students, health service providers, economic service providers, elected officials, prenatal clinic staff, and conference attendees.
Presentations include: California State Maternal and Child Health Bureau, Perinatal Homeless Conference, California State Maternal and Child Health Directors Meeting, Board of Supervisors Health Committee, Eden Area Liveability Initiative, Maternal and Child Epidemiology Conference, Fremont Family Resource Center, Interagency Children’s Policy Council, Comprehensive Prenatal Service Program, Life Course Beyond the Basics Conference, California Maternal Quality Care Collaborative, Teen Pregnancy Prevention Conference, Alameda County Youth Collaborative, Maternal and Child Health Bureau Partnership Meeting in DC, CityMAtCH Conference and many many more.
In addition to presenting at conferences and other organizations, many funders and national organizations have come to visit us, including: Kresge Foundation, Kellogg Foundation, NACCHO MCH division, HRSA Maternal and Child Health Bureau, the San Francisco Federal Reserve, and filmmaker Larry Edelman who is working on a film (similar to Unnatural Causes) called American Birthright. Evaluations and feedback from presentations and visits has been generally positive. Many attendees have been interested in fostering similar work in their areas or in joining BBC as a result of hearing about BBC’s work. Feedback on presentations has been used to constantly retool and tailor BBC’s roadshow presentation, and to train BBC members to give the presentation.
BBC has maintained momentum over the past two years. Each monthly meeting is attended by about 25-30 members, and many others who cannot actively attend monthly BBC meetings participate by staying abreast of updates and minutes posted to the BBC website, or via email. ACPHD staff supporting BBC and BBC members themselves continue to receive regular requests to present at various conference and organizations, indicating outside interest.
One strength of the BBC is that it never organized around the promise of money - the stakeholders involved have committed their time and expertise to building capacity and orienting their work to a collective movement for health equity. ACPHD has committed to providing backbone support to the collaborative which ensures communication flow, appropriate governance, project administration, as well as the pursuit of resources to support BBC’s work. These factors contribute to the ongoing sustainability of BBC. That said, BBC has applied for and received funds to support specific projects. These funds (from the Kresge Foundation, the Robert Wood Johnson Foundation, and Kaiser Community Benefit) supplement financial support also provided from ACPHD.
Plans are underway for ACPHD to build relationships and pursue funding from several foundations to support BBC backbone and projects. In addition, the Steering Committee intends to build relationships with the private sector in order to develop new possibilities for BBC project support.