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Volume
2: Special Issue, November 2005
EDITORIAL
Transforming Public Health Through Community Partnerships
Neil E. Hann, MPH, CHES
Suggested citation for this article: Hann NE. Transforming public health
through community partnerships. Prev Chronic Dis [serial online] 2005 Nov
[date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2005/
nov/05_0072.htm.
This special issue of Preventing Chronic Disease highlights health
education as a core function of public health. Health education is “an
innate aspect of public health practice” as described by Lynne Wilcox in her
editorial (1), and seven key areas of responsibilities for health
educators serve as their fundamental competency base. These seven core areas
include the following (2):
- Assessing individual and community needs for health education
- Planning effective health education programs
- Implementing health education programs
- Evaluating the effectiveness of health education programs
- Coordinating the provision of health education services
- Acting as a resource person in health education
- Communicating health and health education needs, concerns and resources
(2)
How these seven areas of responsibility are implemented by health educators
to achieve lasting behavior change or sustained community health improvement
varies tremendously according to individual, family, and community needs.
However, in recent years, it has become increasingly clear that the seven
areas of health educator responsibilities are often effectively achieved
through collaborative, community-partnership settings. This editorial describes
the experience in transforming public health in Oklahoma and achieving
successful health education and health promotion initiatives through community
partnerships.
From poor health outcomes to community partnerships
Oklahoma has had the unfortunate distinction of consistently ranking toward
the bottom of national health rankings (3). Despite efforts to reverse these
trends during the mid-1980s and through the 1990s, health status indicators
in Oklahoma failed to move in a significantly positive direction. In fact,
Oklahoma has been the only state since 1988 in which age-adjusted death rates
have actually increased (4).
Clearly, this caused a great deal of concern among Oklahoma’s health
leaders, and innovative solutions were sought to reverse these negative
trends. In 1997, an opportunity became available from The Robert Wood Johnson
Foundation and the W. K. Kellogg Foundation. Called Turning Point, the program
issued a request for proposals that encouraged local and state applicants to
rethink the delivery of public health, placing emphasis on state and local
collaborative partnerships and eliciting ideas on intervention priorities from
community partners. Although implementation of these new approaches would
represent a radical change in how public health would be delivered in
Oklahoma, the state health commissioner at the time, Dr. Jerry R. Nida,
decided to move forward with the Turning Point application because he
understood the urgency of needing to change and restructure how public health
was delivered in Oklahoma. The application, submitted by the Oklahoma State
Department of Health (OSDH) and three community partnerships in Cherokee,
Texas, and Tulsa counties in July 1997, included the following opening
paragraph:
“Healthy Communities” is our vision for Oklahoma in the 21st
century. In order to achieve this vision, work must begin now to change the
health culture in Oklahoma through state and local partnerships. . . . [W]e
must find innovative ways of working together, taking risks, in order to
achieve our shared vision of healthy communities. These risks include
questioning the business of health in Oklahoma as well as losing the comfort
of predictability. . . . [W]e begin a new working dialogue in Oklahoma, in
which community partners engage in a stronger leadership role and state
partners assume a stronger technical resource position (5).
In January 1998, the OSDH was awarded a 2-year Turning Point planning grant of
$300,000, and the three community partnerships were awarded $60,000 each for
3 years. During that period, models for transforming public health through
community partnerships were developed in the three pilot sites, and the
philosophy of the state partnering with communities for health improvement
needs began to take shape. Each model proved successful in assessing local
needs, establishing priorities, and implementing interventions tailored to
the unique characteristics of the community. In January 2000, Oklahoma was
awarded a 4-year grant of $950,000 to implement the Oklahoma Turning Point
models on a statewide basis.Historical perspective
To understand the significance of Turning Point for Oklahoma, one must look
at the history of public health infrastructure in Oklahoma and the
transformations that are beginning to occur. Public health in Oklahoma has
evolved into a centralized system, largely as a result of historical actions
of the state legislature and categorical funding through federal sources. The
central office of the OSDH, located in
Oklahoma City, has traditionally directed public health decisions for
Oklahoma. Although the centralized system has resulted in some positive
outcomes, including a comprehensive bricks-and-mortar infrastructure with
county health departments in 69 of 77 counties in Oklahoma, significant
improvements in health status indicators have not been realized.
The lack of improvement in health, despite a good physical public health
infrastructure and a well-trained workforce, has been an area of tremendous
concern for the state board of health and others in the health field. When
we examined the possible reasons for the lack of improvement in health, we saw clearly that the missing element was direct involvement of communities in
public health decisions. Before Turning Point, decisions about public health
were made at the central office and delivered in a cookie-cutter fashion for
each county. Such a delivery system resulted in little progress toward local
health improvement — each community has its own unique challenges, and the
same approaches will not necessarily work in every area of the state. Unless
communities are actively engaged in determining their own public health needs
and developing and implementing solutions, improvement in community health
will not be realized.
The key objective for the Oklahoma Turning Point initiative was to expand
community health improvement partnerships into each county in Oklahoma using
models developed in three original pilot Turning Point partnerships in
Cherokee, Texas, and Tulsa counties.
Key challenges and lessons learned
The key challenge for the Oklahoma Turning Point initiative has been
providing enough skilled health department staff support to the community partnerships to ensure
their success. Skilled staff support is even more important than having funds
directly available for the partnerships. Regional health department field consultants have
provided technical assistance in such areas as identifying priorities through
data analysis, planning and implementing interventions based on priorities,
and evaluating success. In addition, health department field consultants have provided
assistance in such basic areas as developing partnership bylaws, conducting
efficient and productive meetings, developing meeting agendas, recording
partnership decisions through minutes, and communicating partnership
activities through the local news media. Regional Turning Point health
department field
consultants are critical for each of these areas, and partnerships in Oklahoma
have been successful because of the support provided by field consultants.
Other challenges that were encountered early but dealt with effectively
were challenges common to most partnerships — turf and control issues. The
willingness of OSDH to relinquish control and concern about who got credit for
accomplishing health improvement efforts quickly nullified turf and control
issues and allowed the Turning Point collaborative philosophy to flourish.
Through the Turning Point initiative, three key lessons on community health
improvement partnerships were learned:
Collaboration works
Without question, collaborative efforts to
improve health are essential. Working together, sharing resources, and combining
talents enhance the opportunities and likelihood for achieving positive health
outcomes. Because of the complexity and cost of today’s health environment,
public health agencies and others involved in prevention efforts cannot afford
to work in isolation. Collaboration results in positive outcomes that are
superior to outcomes that result from agencies and organizations working
separately on parallel paths.
Giving up control and concern about who gets credit contributes to the
success of partnerships
For collaboration to be successful, partners have
to agree to give up complete control. Although one agency or organization in a
collaborative effort may take a leadership position, all partners are equal,
and it is the partnership that gets credit for success, not any one
organization. Once all partners understand this concept, the partnership will
thrive.
Dedicated staff for partnership development is essential
As
described earlier, regional skilled health department field consultants, who provided
technical assistance and support, were key to
the success of Turning Point in Oklahoma. All of the volunteers in the
Oklahoma Turning Point partnerships have full-time jobs and
responsibilities. Even when volunteer partners are completely dedicated and believe in
the partnership philosophy to improve health outcomes, it is still difficult
for a partnership to thrive without dedicated, paid staff support from a
health department or another participating agency.
System changes
The success in establishing partnerships across the state — and just as
important, the success in ensuring the sustainability of the partnerships —
has been better than the most hopeful expectations. There are now 50
partnerships based on the three original models in Cherokee, Texas, and Tulsa
counties. The partnerships are in
varying stages of development, with several new partnerships in the planning
stages. Regional Turning Point field consultants are assisting partnerships in
identifying local health improvement priorities, implementing local
interventions, and evaluating impacts. Financial and technical resources are
being secured from numerous collaborative resources to ensure the
sustainability of the partnerships.
Turning Point continues to tailor public health needs in Oklahoma based on
the real, perceived needs of community members who have joined public health
officials as equal partners in making public health decisions. The Turning
Point philosophy of community health improvement through collaborative state
and local efforts has taken root in Oklahoma and is now built into the
organizational fabric of the OSDH. Not only are the community Turning Point
partnerships thriving but services and divisions within the OSDH seek ways to
collaborate with Turning Point. In addition, other agencies and organizations
outside of the OSDH are very much aware of Turning Point and frequently refer
to the community Turning Point partnerships for ways to accomplish their own
organizational goals within local communities. Turning Point has transformed
public health in Oklahoma, and health status indicators in Oklahoma are
beginning to show improvement. Because of Oklahoma’s Turning Point
initiative, the centralized public health system is reorganizing itself to
take the following steps:
- Accept recommendations from stakeholder groups and coordinate untapped
expertise among physicians and other health professionals, businesses,
education, public health agencies, citizen groups, and the faith community
- Share responsibility for a community’s health
- Find ways to share resources among agencies at the state and local
levels
- Use available public health resources differently and with greater
flexibility at the local level
- Accept accountability for the outcomes of public health decisions at
both the state and local levels
These steps — which may appear to be fundamental and obvious —
represent an extraordinary system change for Oklahoma. For the first time,
communities have an equal voice in public health decisions. For the first
time, public health workers within the OSDH see their role as supportive to
community-based decisions and initiatives. And for the first time, community
members see the important role they play in ensuring a healthier state for
future generations. The results have been astounding, with numerous health
education initiatives and sustained community system changes (6), including
the following:
- Removal of sugar drinks and unhealthy snacks from school vending
machines
- Passage of local health and safety ordinances
- Establishment of community health centers
- Founding of a new county health department and development of another
- Development of community trails for exercise
- Adoption of exercise and healthy eating by thousands of Oklahomans
through Turning Point’s Walk This Weigh campaign
- Enhancement of substance abuse and tobacco use prevention efforts
In addition to the health education initiatives and system changes
occurring at the local level, numerous changes are happening statewide, including the following:
Oklahoma Task Force on Health Disparities
This
legislative task force is an outgrowth of Turning Point’s effort to impact
health outcomes by reducing health disparities (7).
Oklahoma Certified Healthy Business Program
To date, 120
Oklahoma businesses have been certified as healthy by providing wellness
opportunities for their employees. As a subcommittee of the statewide Oklahoma
Turning Point Council, key partners include the Oklahoma State Chamber of
Commerce and the Oklahoma Academy for State Goals (8).
Public Health Institute of Oklahoma
An outgrowth of the
Oklahoma Turning Point Council, the Public Health Institute of Oklahoma was
created in early 2003 to be a neutral public health organization promoting
positive health practices through collaboration among government, academia,
and communities. The institute will 1) develop and expand funding resources
for public health improvement projects; 2) build and develop community assets
for health improvement, including leadership skills; 3) increase public health
communication and networking; 4) advocate for core public health functions; 5)
assist in reducing health disparities; and 6) evaluate components of local
communities and the public health system (9).
Final thoughts
The health education initiatives and community system changes in Oklahoma
did not happen randomly. It took people who were not afraid to redefine their
relationships with each other. Key leaders in Oklahoma’s counties and at
the OSDH were committed to spending the time necessary to build relationships
and think differently about how to approach public health. Now, it’s
not about the “state” people or the “local” people. It’s about us,
working together to build healthy communities.
Turning Point will continue in Oklahoma. Organizationally, Turning Point is
a division within the OSDH, under the Community Development Service. Plans are
underway to hire additional Turning Point staff to support the efforts of
Oklahoma’s current Turning Point partnerships and expand into additional
counties. The expanding activities of Turning Point also include work with
faith-based organizations to eliminate health disparities and increase access
to primary care services. Turning Point will continue to play a critical role
in health improvement efforts in Oklahoma, both inside the OSDH and alongside
many other agencies, organizations, and individual partners who have been part
of Turning Point since 1997.
Perhaps the impact of Turning Point was best described by Ed Kirtley, past
chairman of the Texas County Turning Point initiative:
Undoubtedly, the most important personal change from Turning Point is a
better understanding of my community. . . . [M]y involvement in Turning Point
created a new enthusiasm for public health and the potential for making an
impact. I felt empowered to really create change — something that without
the synergy of the group I would not have thought possible to do. Turning
Point taught each of us that we can change and can more effectively serve our
community if priorities and solutions are developed and implemented locally (10).
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Author Information
Corresponding Author: Neil E. Hann, MPH, CHES, Community Development
Service, Oklahoma State Department of Health, 1000 NE 10th St,
Oklahoma City, OK 73117-1299. Telephone: 405-271-6127. E-mail: neil@health.ok.gov.
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References
- Wilcox LS. Health education from 1775 to 2005. Prev Chronic Dis [serial online] 2005 Oct/s.
- Areas of responsibility for health educators [Internet]. Whitehall
(PA): National Commission for Health Education Credentialing, Inc [cited
May 12, 2005]. Available from: URL: http://www.nchec.org/becomeches/eligibility.asp*.
- United Health Foundation. America’s health: state health rankings — 2003.
Minnetonka (MN): United Health Foundation; 2003. p. 64.
- Oklahoma State Board of Health. Investing in prevention: 2005
state of the state’s health report. Oklahoma City (OK): Oklahoma State
Board of Health; 2005 Apr.
- Turning Point. Building healthy communities in Oklahoma through
partnerships. Funding application to The Robert Wood Johnson Foundation.
Oklahoma City (OK): Oklahoma Turning Point; 1997 Jun.
- Oklahoma State Department of Health. That was then, this is now:
five-year summary of Oklahoma’s Turning Point initiative. Oklahoma City
(OK): Oklahoma State Department of Health; 2003 Dec.
- Cain B, Toure O. An act relating to public health and safety, creating
the Oklahoma Task Force to Eliminate Health Disparities. Senate Bill 680.
Oklahoma City (OK): Oklahoma 49th Legislature; 2003.
- Oklahoma Certified Healthy Business Program [Internet]. Oklahoma City
(OK): Oklahoma Turning Point Council [cited 2005 Apr 22]. Available
from: URL: http://www.okturningpoint.org/*.
- Public Health Institute of Oklahoma [Internet]. Oklahoma City (OK):
Public Health Institute of Oklahoma [cited 2005 Apr 22]. Available from:
URL: http://www.publichealthok.org/*.
- Kirtley E. Thoughts about community health in Guymon. The State of
Oklahoma health: 2002 town hall meeting report. Oklahoma City (OK): The
Oklahoma Academy; 2002 Oct.
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