From Roots to Results: A Qualitative Case Study of the Evolution of a Public Health Leadership Institute Building Capacity in Collaborating for Equity and Justice

Abstract

Policy, systems, and environmental change are now widely accepted as critical to sustaining improvements in community health. Evidence suggests that such systems-level change is most effective when driven by community-based partnerships. Yet, after more than three decades of building community-based partnership work, health inequities have continued to deepen. To address health inequities, current and historical distributions of power are increasingly recognized as important considerations in efforts to ensure all individuals have the opportunity to attain their full health potential (i.e., achieving health equity). Building on social determinants of health literature, social injustice and powerlessness are put forth as fundamental causes of health inequities. Focusing on power as a root cause of health and health equity through application of Wolff and colleagues’ six principles requires substantial changes in contemporary public health practice. This case study uses document analysis of a single case, the Community Teams Program, to assess the evolution of a statewide public health leadership program’s efforts to build the capacity of coalition-based teams to catalyze community change in line with Wolff and colleagues’ principles. Deductive, selective coding of the materials surface four themes in the program adaptations: (1) the need to focus on power as a root cause, (2) shifting power through relationship building, (3) storytelling as a way to shift narrative, and (4) building mechanisms into the curriculum that hold coalitions accountable for applying and sustaining learned skills. The themes demonstrate philosophical, pedagogical, and organizational changes to center power building approaches in health promotion. Findings are triangulated by reflections from the program director and recorded reflections of participants captured in existing evaluation data.

Keywords

capacity building community coaching health promotion leadership public health qualitative methods

Policy, systems, and environmental change are now widely accepted as critical to achieving and sustaining improvements in community health. Evidence suggests that such systems-level change is most effective when driven by community-based partnerships (Roussos & Fawcett, 2000). However, it has long been noted that accredited training in public health does not adequately prepare public health professionals to sustain long-term action via partnerships (Weiner & Alexander, 1998; Wright et al., 2000). Since 1990, leadership development programs for public health officials emerged all over the country in response to the national call to improve the competencies of public health professionals to work in community-based partnerships (Wright et al., 2000). And despite three decades of effectively building capacity to support community-based partnership work (Ceraso et al., 2011; Lasker & Weiss, 2003; Umble et al., 2005; Umble et al., 2011), avoidable and systematically distributed differences in health—or health inequities—have continued to deepen (Braveman, 2006).

It has thus been argued that in addition to engaging in coalition-driven work, it is vital that community members most affected by the priority health issue hold decision-making roles in the coalition and that the focus of the coalition’s work center on addressing the root cause of the health inequity (Wolff et al., 2017). Systematic imbalances in power were named as fundamental causes of health inequities that need to be appropriately addressed if we are to expect improvements in population-level health outcomes (Commission on Social Determinants of Health, 2008; Givens, Kindig, Inzeo, & Faust, 2018; Israel, Checkoway, Schulz, & Zimmerman, 1994; Prilleltensky, Nelson, & Peirson, 2001; Speer, Tesdahl, & Ayers, 2014). Although a highly contested topic, power can be understood as the ability to bring about individual or collective will (Givens et al., 2018), including the ability to make the decisions, influence the decision makers directly, or via worldview shaping. Power and the absence of power are thought to affect health directly through psychosocial processes as well as indirectly by shaping the conditions for health (Commission on Social Determinants of Health, 2008).

Furthermore, as Wolff et al. (2017) emphasize, endeavors that fail to build and share power with those most affected and/or fail to address root causes of health inequities are more likely to perpetuate the underlying imbalance of power and, thus, the inequity. The authors then outline six principles for collaboration that they suggest are essential for effectively collaborating for equity and justice (see Table 1 for the list). As discovered by one statewide public health leadership institute, the traditional public health leadership institute model that emphasized academic knowledge and subsequently grounded the work in evidence-based interventions did not sufficiently prepare practitioners to adopt these six principles in practice.

Table 1.

Principles for Collaborating for Equity and Justice (Wolff et al., 2017).

1. Explicitly address issues of social and economic injustice and structural racism

2. Employ a community development approach in which residents have equal power in determining the coalition’s or collaborative’s agenda and resource allocation

3. Employ community organizing as an intentional strategy and as part of the process

4. Focus on policy, systems, and structural change

5. Evaluate your work appropriately in order to honor and build on existing community engaged scholarship

6. Construct core functions for the collaborative based on equity and justice

In order to support broader adoption of the six principles for collaborating for equity and justice, this article offers a case study of the evolution of one public health leadership institute, the Healthy Wisconsin Leadership Institute, over the course of 12 years. Via systematic evaluation of program documents, surveys, and key-informant reflections, this case study illuminates the curricular and pedagogical changes needed to support the development of public health leaders who are more capable of collaborating for equity and justice in accordance with the principles delineated by Wolff et al. (2017).

Healthy Wisconsin Leadership Institute

Like other leadership programs and coalition training frameworks (Butterfoss, Morrow, Webster, & Crews, 2003; Umble et al., 2005; Wolff, 2001), the Healthy Wisconsin Leadership Institute (HWLI) was created to support coalitions to utilize strategic, community-driven approaches to improve community health. Since the first Community Teams Program (CTP) cohort was launched in 2006, the goal of HWLI’s capacity building approach has been to ensure that graduated community teams apply and sustain key practices and skills to advance health equity. Modeled after the National Public Health Leadership Institute (Umble et al., 2005), its participants have included individuals from multiple sectors including professional and volunteer affiliations working to advance the public’s health and committed to a team-identified health priority in their community. Although curriculum and pedagogy have changed considerably, program components have largely remained consistent. Over the course of one program year, team cohorts receive (1) in-community team site visits, (2) three 2-day retreats, (3) coaching and technical assistance, (4) distance learning, and (5) peer-learning opportunities. Over the past 12 years, HWLI has provided coaching and training activities designed for health improvement initiatives to 83 community collaborations (Emery, Hubbell, & Miles-Polka, 2011). Initially designed with a focus on building skills around professional public health competencies (Wright et al., 2000), HWLI staff have engaged in continuous quality improvement processes, regularly refining the curriculum and adapting it considerably over time. Most notably, the program has shifted from a more traditional public health core competency-based curriculum, to one that supports participants in power-building partnerships with those most affected by inequities to individually and collectively influence decision-making structures in their community. As a result, the evolution of this case provides an opportunity to explore how the six principles of collaboration for equity and justice (Wolff et al., 2017) can be operationalized and observed in leadership training programs.

Method

Program Evaluation Design

This study qualitatively explores one Midwestern, statewide leadership program’s pedagogical trajectory over 12 years. Case study designs provide a rich opportunity to explore how and why a phenomenon is influenced by its context (Baxter & Jack, 2008). In this single case study design, each year of the program served as an embedded unit (Bowen, 2009; Meyer, 2001). Program materials and evaluation documentation from across the duration of the program were iteratively examined in order to identify themes and infer participant readiness to collaborate for equity and justice. To guard against selection bias, the full repository of historical program documentation was included (see Table 2 for a list of documents and data analyzed). Due to the secondary nature of the human subject data (e.g., evaluation data) and primary focus on documentation analysis, this study was categorized as exempt by the University of Wisconsin–Madison Institutional Review Board. Program materials were the primary source for describing curricular changes. Two-year follow-up surveys and participant program evaluations served as the primary source for evaluating community outcomes.

Table 2.

A Sampling of Documents Reviewed and Data Analyzed.

Documents reviewed	Data analyzed
Orientation materials sent to teams for Years 1-12	Summaries of the CTP, the stated purpose of the program, and global learning objectives; expectations of participants and supplementary materials assigned or provided analyzed for the conceptualization of power in community health improvement projects or use of community organizing language
Press release regarding the creation of the CTP in 2006	Description of the purpose and learning objectives of the program
Agendas and PowerPoints used for distance learning and in-person workshops	Learning objectives, planned activity description; language used in didactic materials
Full curriculum binders distributed to participants for all years except (2009-2010) cohort 4	Program description and global learning objectives; content of materials presented in PowerPoints; learning objectives for each session
Staff notes from Years 1, 4	Responsivity to participant need, ideas for adjustment
Evaluation reports from each year but 5, 8, and 9	Evaluation data include pre-post and retrospective pretests about awareness, knowledge and behavior of participants as well as interview data; qualitative input regarding what was most useful to them and what their greatest takeaways were from participation
10-year retrospective survey, raw data (N = 30; reporting from cohorts 2, 4, and 6-10)	Qualitative input regarding what was most useful to them and what their greatest takeaways were from participation

Note. CTP = Community Teams Program.

Analysis Procedure

A comprehensive review of each year’s curriculum over 12 years of the CTP was performed by an external evaluator to guard against confirmation bias. In order to identify evidence and motivation for shifts in both content and delivery, the evaluator analyzed available data using deductive, theory-driven coding (Fereday & Muir-Cochrane, 2006). The six principles delineated by Wolff et al. (2017; see Table 1) served as the theoretical framework for the investigation and as categories for codes. First, codes were assigned for indication of capacity-building toward each of the six principles. Next, the presence and frequency of each code was cross-referenced with cohort years and compared against evaluation feedback and staff notes from that year, when available. Themes regarding substantive shifts in the curriculum over time emerged via iterative comparison of coding patterns across the subunit of cohort year. All coding was conducted by a single coder, the external evaluator. The themes inductively identified by this evaluator were then validated first by reviewing with the current program director and long-time staff member of the program and then comparing against the recorded reflections of participants captured in existing evaluation data.

During the analysis process, program staff referred to community technical assistance reports and staff notes to provide further contextual detail to flesh out analytic interpretations and more fully describe the nuance of how each theme reflected program implementation experiences. Notably, the CTP continuous quality improvement efforts facilitated by staff recognized participant satisfaction as only one element for understanding the effectiveness of the program. Program staff were in regular contact with teams through coaching visits and calls to determine if curricular content was building capacity to meet community change goals. This meant that in some instances, an activity that was well received in participant evaluations might be modified or discontinued if it was not supporting teams in building their capacity to achieve their goals. Similarly, activities that might have been less popular, but appeared to be advancing team capacity, were augmented.

Findings

Analysis of the frequency of codes related to each principle demonstrates patterns in content and pedagogical changes over time. Iterative review confirmed that all six collaborating for equity and justice principles are evident in the CTP throughout the course of its pedagogical refinement (see Table 3 for a crosswalk of the six core principles with related competencies and activities). This article focuses on articulating practices that support Principles 1 through 4 and 6.

Table 3.

Crosswalk of Targeted Competencies and CTP Pedagogy for Each of the Six Principles of Collaborating for Equity and Justice (Wolff et al., 2017).

Principle for collaborating for equity and justice	Competency for applying this principle	CTP pedagogy for developing competencies for collaborating for equity and justice
1. Explicitly address issues of social and economic injustice and structural racism	• Embrace risk taking and discomfort • Critical analysis skills for assessing historical and contemporary social relationships • Ability to communicate effectively • Cultural humility • Learn how to manage conflict in groups • Storytelling with a wide angle lens	• Create brave spaces via the development of collectively generated group agreements for each team • Offer team-based trust-building activities • Use improv to practice building on assets and risk taking • Reiterate equity concepts at every point of contact with program participants
2. Employ a community development approach in which residents have equal power in determining the coalition’s or collaborative’s agenda and resource allocation	• Empathy and understanding of context • Appreciation of community wisdom • Commitment to building on strengths • Ability to facilitate the integration of many voices into one vision	• Emphasize the value of community engagement • Model appreciative inquiry and an asset-based lens • Learn and practice various stakeholder engagement strategies ♦ • • Community-facilitated logic model guide ♦ • • World Cafe ♦ • • Community Conversations
3. Employ community organizing as an intentional strategy and as part of the process	• Ability to self-reflect on cultural relativity/situatedness • An under standing of relational self interest • Ability to listen actively	• Assumptions activity • 1:1 meetings • Issue cutting • Community conversations • Stakeholder analysis • Asset mapping • Power mapping • Storytelling training
4. Focus on policy, systems, and structural change	• Understand the social determinants of health • Apply the social ecological model to intervention planning and determining root causes • Policy advocacy • Ability to frame a message to address policy, systems, and structural change	• Conduct root cause analyses of community health issue • Practice messaging for decision making audiences • Practice using story to advocate for PSS change • Receive feedback on an intervention planning matrix and subsequent action plan
5. Evaluate the work appropriately in order to honor and build on existing community engaged scholarship	• Recognize the value of community engaged research evaluation • Build evaluative measures into logic models and action plans that encompass community input	• Use assessments of coalition best practices • Use appreciative inquiry to capture community input and analysis of equity and power when considering evidence-based strategies
6. Construct core functions for the collaborative based on equity and justice	• Embed transparency and accountability into coalition documents • Foster partnerships and relationships with those most affected by inequities • Include equity and a commitment toward structural change in the collaborative’s vision, mission and values	• Explore the relationship of individual temperament and group functioning • Create a team charter to define how the core functions of the collaborative operationalize equity • Explore prioritization tools (nominal voting, priority grid)

Note. CTP = Community Teams Program; PSS = policy, systems, and structural.

Four themes emerged from our analyses: (1) the need to focus on power as a root cause, (2) shifting power through relationship building, (3) storytelling as a way to shift narrative, and (4) building mechanisms into the curriculum that hold coalitions accountable for applying and sustaining learned skills. Each theme is linked to a component of the current CTP curriculum (see Table 4 for curriculum focus areas; i.e., social determinants of health and health equity; collaborative leadership and community organizing, and storytelling for structural change; infrastructure for sustaining powerful coalitions), and are expanded on and contextualized by the data in the next section. Importantly, each of the themes relate to the collaborating for equity and justice principles. Thus, findings are described by theme and the associated collaborating for equity and justice principles.

Table 4.

Curriculum Focus Areas, Learning Objectives, and Benchmarks for CTP Year 12.

After completing the CTP year-long program, teams will be able to:
Curriculum focus area	Objectives	Benchmarks
Social determinants of health and health equity Vision: Coalitions focus their analysis and interventions on societal structures with attention to systems of power.	Define social justice, equity, and power	• Connect shared definitions of social justice, equity, and power to community health improvement work (Cutting Equity Issues Toolkit)
	Identify root causes of community health problems at multiple levels (e.g., individual behavior, organizations, systems)	• Conduct a root cause analysis (Strategic Planning for Community Action Toolkit)
	Identify community assets to address structural inequities	• Use appreciative inquiry to apply an asset-based lens to one-to-one meetings and community conversations (Community Engagement Toolkit) • Use one-to-one meetings and community conversations to engage community (Community Engagement Toolkit) • Practice using appreciative inquiry and having one-to-one meetings as a strategy for developing relationships to build power (Community Engagement Toolkit)
	Prioritize issues that affect equity	• Fill out intervention planning matrix to identify structural approaches that address community health issues (Strategic Planning for Community Action Toolkit) • Use issue cutting, equity analysis, and power analysis (Cutting Equity Issues Toolkit)
	Address root causes of inequities through sustainable structural changes	• Develop an action and evaluation plan that addresses inequities (Strategic Planning for Community Action Toolkit) • Develop a plan to sustain your work (Sustainability Toolkit)
Collaborative Leadership and Community Organizing Vision: Coalitions sustain relationships, intentionally engaging and building power with those most affected by inequities and injustices.	Champion and advocate for social justice and equity	• Promote a social justice and equity vision (Cutting Equity Issues Toolkit)
	Consider a perspective different from your own and demonstrate curiosity and a desire to understand	• Use one-to-one meetings and community conversations to identify self-interest and engage community (Community Engagement Toolkit)
	Strategize building power on issues that affect equity and expand the sphere of influence of the coalition	• Map and assess the power landscape to build or influence the distribution of power (Cutting Equity Issues Toolkit) • Prioritize a winnable issue campaign that includes building a base of people who care deeply about the issue (Cutting Equity Issues Toolkit) • Support or create opportunities to take action on equity issues (Cutting Equity Issues Toolkit)
	Develop relationships with those most affected by inequities and support their leadership capacity as changemakers	• Honor community wisdom and build relationships with those most affected by inequities using appreciative inquiry and an asset-based lens (Community Engagement Toolkit) • Establish shared history, values, vision, and team agreements to foster shared accountability to advance equity (Community Engagement Toolkit)
	Create a coalition infrastructure that invites and supports diversity and collaboration	• Commit to leading with social justice and equity (Sustainability Toolkit) • Practice trust and culture building with consideration of different temperaments (Community Engagement Toolkit)
	Create and implement strategic community engagement plans	• Consider who is most affected by inequities (Community Engagement Toolkit) • Assess current engagement approaches and use a sector analysis (Community Engagement Toolkit) • Complete community engagement plan and incorporate into action plan (Community Engagement Toolkit)
	Operationalize and sustain equity principles and coalition best practices	• Assess equitable practices by completing a coalition assessment (Sustainability Toolkit) • Operationalize equity by starting a coalition charter (Sustainability Toolkit)
Shaping Narrative Vision: Coalitions use strategic communications to elevate community voice, address public solutions, and advance health equity.	Shape an equity narrative around community health improvement efforts	• Develop and refine a core message (Narrative Toolkit)
	Frame narratives that prioritize structural change over individual behaviors	• Frame community health improvement messages thematically (Narrative Toolkit) • Focus a concise message on social justice and equity (Narrative Toolkit)
	Identify and use community assets to shift community narrative	• Use appreciative inquiry to apply an asset-based lens to honor and lift up community wisdom (Community Engagement Toolkit)
	Use story to amplify the voices and experiences of those most affected	• Illustrate concepts of social justice and equity through storytelling (Narrative Toolkit)
	Craft and tailor messages that engage a variety of audiences (e.g., policymakers media representatives, neighbors, etc.) in social justice and equity	• Identify key stakeholders (Narrative Toolkit) • Craft messages for specific audiences (Narrative Toolkit)

Note. CTP = Community Teams Program.

Focus Explicitly on Power as a Root Cause: Social Determinants of Health and Health Equity

Principle 2: Employ a community development approach in which residents have equal power in determining the coalition’s or collaborative’s agenda and resource allocation.

Analysis of program materials demonstrate increased incorporation of community power-building in content, philosophy, and delivery over time (e.g., Principle 2; Wolff et al., 2017). Philosophical shifts were evident in changes to the purpose statement for the program, with an increased focus on community assets. For example, in Years 1 through 5, professional development and “technical and scientific skills” were more prominent. By Year 6, the purpose statement shifted to “build the skills and capacity of people to lead community initiatives to improve public and community health.” However, by Year 10, the opening statement of the program overview (see below) situates the work in community development language (see Walzer & Cordes, 2012, for an overview).

Across Wisconsin, people are organizing to take action on the priority health issues in their communities. For many communities, making headway on their issues requires a new way of working. This means building skills in engaging with the community from the beginning; exploring root causes; thinking about how to create sustainable change; developing an action plan; and building strong, multisector partnerships. This is hard work!

According to staff reflection, many teams joined the CTP with a background in using educational approaches to motivate individual behavior change. As a result, without addressing power in the curriculum, teams were apt to focus on interventions intended for individual behavior change. Given the concern that a focus on individual behavior change could actually exacerbate existing conditions of power and powerlessness, significant changes were made to the CTP. For example, the CTP initially emphasized didactic strategies to increase conceptual understanding of root causes of health outcomes and the importance of policy, systems, and structural change. Over time, more emphasis was placed on power and power building through experiential learning approaches over didactic delivery of content.

Experiential activities and coaching questions that support teams to understand the role of power and focus coalition work on addressing root causes and structural inequities were embedded throughout the program. For example, the curriculum includes several worksheets designed to support teams in generating action ideas that address the social determinants of health and conditions of power by provoking thinking around root causes and multilevel influential factors. The increased focus on understanding power as a root cause includes analyzing the role of power in maintaining current structures that are detrimental to health. This supports teams in conceptualizing the need to build community power to change these structures. Over time, staff observed that this change in approach supported shifting the focus of teams’ work from traditional individual behavior change interventions to action steps that target structural changes related to the social determinants of health.

Shifting Power Through Relationship Building: Collaborative Leadership and Community Organizing

Principle 1: Explicitly address issues of social and economic injustice and structural racism.

Principle 3: Employ community organizing as an intentional strategy and as part of the process.

While the goal of the CTP has always been to advance community capacity to impact health through collaborative leadership skill building, the program did not always focus on power-building as an essential approach to collaborative public health work. In early program years, teams were trained on collaborative leadership skills, but best practices for coalition building and community engagement were offered at the end of the program. This timing of content may have unintentionally minimized the importance of relationship building as a critical component of community engagement. To be authentic in the process and realistic about how much time it takes to build relationships—especially with those most affected by inequities—community engagement is now introduced at the beginning and is a focal point throughout the program. Skills in coalition building and collaborative leadership are practiced by drawing on community organizing approaches. Teams are trained in one-on-one conversations, mobilizing residents, and identifying strategic goals—such as resolutions or organizational policy changes—that they can accomplish in a relatively short amount of time. These “early wins” can help teams build momentum toward larger policy goals.

With the increasing focus on power as a root cause, leadership skill building content shifted from a focus on more technical leadership skills—such as effective agenda writing—to a focus on relationship-building and power-sharing skills. Evaluations suggest participants initially experienced discomfort with this shift (DiAngelo, 2011), for example, statements like “‘Did NOT like the cultural sensitivity”’ and “power is not relevant to our group.”

As a result, the agenda was adjusted to allow more time for teams to wrestle with the concepts and receive support in personalizing the relevance of power, legacies of harm, and the value of considering these dynamics when intending to work with members of communities most negatively affected by imbalances in power. Topics such as recognizing assumptions and bias, building trust, active listening, and fostering empathy began to proliferate in Year 7. Program time was subsequently devoted to developing skills around cultural humility and increasing understanding of its importance to equity work. Activities to support trust building and risk-taking—such as engaging in improv exercises—became core components of the program to build specific skills for advancing authentic community engagement.

Similarly, documents show the program pulled heavily from community organizing practices and literature to build capacity of participants to communicate authentically with each other and with community stakeholders (e.g., Principle 3; Wolff et al., 2017). This evolution is exemplified in topic changes such as “working effectively with diverse types of people” to “how to engage community self-interest, not based on assumptions (Year 10).” Additionally, beginning in Year 10, training in community engagement practices—such as conducting one-to-ones, facilitating a community logic model, and cutting an issue—feature more prominently in the syllabus.

Wolff’s first principle (i.e., explicitly address issues of social and economic injustice and structural racism) is reflected clearly in the program evolution from introducing equity-related concepts abstractly, to explicitly naming structural injustice, thus giving program participants permission and time to practice, embodying this principle themselves. Early program materials included stressing the importance of “celebrating diversity” and highlighted the “benefits of inclusivity,” but did not support teams in identifying the root causes for the absence of inclusivity (e.g., White supremacy, cultural genocide, the legacy of slavery, etc.). Similarly, in the early years of the program, there were references to “disparities” without naming injustice as a precursor. Finally, there was a strong focus on individual traits such as temperament and how they affect coalition group dynamics, but no naming of identity hierarchies or historical contexts of injustice.

Workshop agendas accordingly demonstrate the shift toward prioritizing power analyses from a community organizing perspective. In Year 7, topics related to “Gain[ing] awareness of privilege and power relations (what it is and why it matters)” became central to the curriculum. So, too, did engaging in cultural humility practices, with time devoted to participant self-reflection. The focus on cultivating cultural humility signifies a commitment to building the skills to be in intergroup spaces in ways that actively acknowledge and engage with the presence of intergroup tension, a skill seen as essential for effective power building (Perkins, Hughey, & Speer, 2002).

In the 11th year, participant evaluations suggest that shifts in pedagogy outlined above were important adaptations for building capacity in operationalizing an equity and justice-based approach to collaboration. By developing skills and practices to better prepare participants to take risks and authentically engage and build power with those most affected by inequities, program staff noted a difference in participant attitudes suggesting that program changes might still have been a “stretch” but were perceived as contributing to transformational learning.

These attitude shifts are noted by remarks such as the following:

One-on-ones were helpful in that they pushed me to engage differently than I would have otherwise. Episodic vs. thematic framing of issues was really enlightening. (Cohort 11)

Looking back, I love the way you started the first site visit- with an exercise on assumptions that got us out of our comfort zone- really helped to set the tone for the year. The she/her/hers bit was a stretch for most of us (WAY OUT THERE for several members of our team), and I think it was a good thing.

This has helped me to learn to listen to ALL views.

Storytelling for Structural Change: Shaping Narrative

Principle 4: Focus on policy, systems, and structural change.

In parallel with the shift in public health practice from an emphasis on individual behavior change to structural changes, the CTP curriculum has similarly translated this change into its communications curriculum. The curriculum evolved away from a focus on health education communications and social marketing skill-building to an approach that supports storytelling to shape narratives for advancing equity. By learning and practicing critical skills in storytelling, message framing, and message tailoring for a range of stakeholder audiences, teams work to strategically influence power through their narratives (Hinson, 2016). In order to support teams in using story to build power, the curriculum emphasizes communicating authentically from lived experience and contextualizing stories in systems and structures (Frameworks Academy, n.d.; e.g., Principle 4; Wolff et al., 2017).

Program document analysis show that while “effective communication” is heavily featured across the lifespan of the CTP, changes in the conceptualization of what skills are needed to communicate effectively are demonstrated by the intentional and gradual incorporation of vulnerability and lived experiences as key elements of effectiveness. In the first 5 years, workshops on effective communication were dominated by official public health skills such as “develop messages appropriate for communication with community or target groups and for communicating with the media,” which instructed participants to “lead with the scientific evidence.” Using these skills, teams frequently communicated their health priorities through data and examples that unintentionally reinforced a personal responsibility narrative instead of emphasizing structures and systems.

The incorporation and development of storytelling as an essential skill first emerges in the curriculum in Year 6 with a workshop session on “story circles as a collaborative leadership skill” and was considerably expanded in Years 7 through 12. Also, in Year 6, effective use of messaging and framing for public solutions emerges as a priority, which focusing on training in public storytelling that frames an issue by adopting a “wide-angle lens” in order to build support for social policies and programs (Frameworks Academy, n.d.). Activities designed to increase comfort in risk-taking and telling stories begins at the first workshop with trainings in improvisational theatre, personal story reflection, story circles, and public speaking. Additionally, teams work repeatedly to craft messages for different audiences. This work culminates in the production of a video story that frames a team’s selected community health issue in a manner designed to generate an understanding of the systems that produce it rather than focus on behavioral choices that contribute to it.

Holding Coalitions Accountable to Applying and Sustaining Skills Obtained by Building Mechanisms Into the Curriculum: Program Infrastructure for Sustaining Powerful Coalitions

Principle 6: Construct core functions for the collaborative based on equity and justice.

Collaboratives working to advance health equity and social justice need regular and consistent support, communication, and accountability to sustain needed practice changes. As the Institute of Medicine noted and program experiences verify, “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change” (Institute of Medicine, 2000, p. 4). Accordingly, communities in the CTP are challenged to move from a service model focused on “doing for” to a community collaboration model that prioritizes “doing with” those most affected. Increasing coalition transparency has invited democratic engagement and accountability both inside and outside coalitions.

Although the CTP has always stressed the importance of community involvement, staff reflected that in the program’s early years, few teams exhibited collaborative partnerships with residents. Despite consistent urging to prioritize building coalition leadership with those affected by inequities, few coalitions actually had meaningful leadership roles and representation from those groups.

To create accountability to the curricular principles and to support sustained coalition practice changes, much of the curriculum content is now organized in toolkits for applying skills learned. These toolkits serve to systematize best practices and planning for sustainable community health improvement (see Table 5 for toolkit descriptions). Program materials show an emerging emphasis on transparency and accountability practices in service of equity. This includes the practice of collectively generating values and ground rules at the first site visit, modeling of soliciting and adjusting to feedback in-person at the end of each contact with teams, and the development of coalition charters. Coalition charters serve to both cement the learning that teams generate during their time in the CTP, as well as transparently outline a commitment to equity and how equity is operationalized through goals and objectives, coalition structure, roles, decision making, and operating procedures (e.g., Principle 6; Wolff et al., 2017). Within the charter, teams identify to whom the coalition is accountable and how they are engaged in the work. Importantly, the checklist asks teams to name how they build leadership and power with those who experience oppression and marginalization in their community. The charter is meant to be a living document that teams continue to refine as their commitment to equity deepens and as their team composition shifts to be more inclusive of those most affected by inequities.

Table 5.

Tools for Taking Action: Toolkits Used for Direct Application of Learning Content.

• Community engagement: Asses and strategize to engage multisectoral partners, including those most affected by inequities in identifying and addressing the team’s priorities

• Strategic planning for community action: Analyze root causes, select interventions, and plan for action to address complex community health problems

• Cutting equity issues: Consider opportunities to build power and take action toward equity by analyzing social problems and breaking them down into concrete solutions

• Narrative: Develop skills to effectively communicate the team’s message and shape narrative to affect equity

• Sustainability: Assess and grow the team’s capacity to operationalize equity for community health improvement

The impact of incorporating accountability measures for sustained change is best illuminated by the example of a team that used the charter as a way to center the leadership of members of their community most affected by discrimination targeting transgender, intersex, and gender-nonconforming people. Their charter centered racial justice as it intersects with gender justice in their guiding frameworks; committed to collaborate with leaders in transgender communities of color and to share decision making with these same leaders; and repeatedly emphasized the importance of listening to the views and experiences of those most affected by transgender health issues. In this way, they leveraged the charter as method for holding themselves accountable to the pursuit of equity within coalition practices. The work of this team set a precedent for embedding charters into the curriculum as an accountability measure for operationalizing equity.

Finally, the program itself evolved pedagogically to model core tenets of authentic relationship building via transparency, consistency, and being open to constructive feedback. For example, comparisons of program orientation packets over the years demonstrate increased transparency relating to the goals of the program with the emergence of an explicit outline of the program’s guiding principles, frameworks, philosophies, and learning objectives. Benchmarks of progress through learning outcomes also became standard, as did providing participants with a set of expectations for the work at the front end of the process of relationship-building between the CTP staff and community team members (see Table 4 for current learning objectives and benchmarks). Additionally, program staff now regularly model vulnerability and a desire to grow in relationship via the institutionalization of regular mechanisms for formal and informal input. At the conclusion of each point of engagement, teams are encouraged to share what went well and suggestions for improvement. Critical feedback is often shared both in the group format as well as via written evaluations, allowing staff repeated opportunities to model what it looks like to embrace tension as an opportunity for growth and if needed, repair relationships.

Discussion

Health promotion efforts have long worked to more effectively advance health equity, and while power has been an important part of community-based research circles (Minkler & Wallerstein, 2005), increased attention has been paid to the role that social and institutional power play in shaping health in broader areas of public health practice and systems change efforts (Givens et al., 2018). The core principles delineated by Wolff et al. (2017) are critical to informing an emerging field of health promotion efforts working to explicitly address health inequities—a field of health equity practice. In order to reach community health equity and justice goals, a greater understanding of and a willingness to adopt training and capacity building approaches that actually work to operationalize health equity initiatives in communities are needed.

This article describes how the Healthy Wisconsin Leadership Institute has evolved over its 12-year history to address this need through a year-long training program, which 83 teams from across the state have experienced and helped shape. The resulting curriculum is organized around three components: social determinants of health and health equity, collaborative leadership and community organizing, and shaping the narrative. Table 4 details how each of these components—which correlate closely with many of the six principles proposed by Wolff et al. (2017)—are operationalized through specific training content and tools.

The curriculum goals are for participants from community teams to understand the concepts, gain the skills, and successfully implement the concepts in their community through their collaborative team, setting a high bar for success. This article illustrates how the curriculum has been continually refined by honing in on elements that helped teams successfully implement the principles in their communities.

Limitations

The findings and reflections provided in this article should be interpreted in light of the limitations of a single case study methodology that uses document analysis and the current program director as a key informant. While we took several measures to account for bias, it is important to note that what is embedded in the documentation of a program is not necessarily a pure reflection of what actually occurred. Program staff focus on being responsive to the immediate and emergent needs of teams and pride themselves on their capacity to meet the teams where they are; this at times requires dynamic facilitative adjustments and adapting of agendas. Additionally, use of key informants is essential for establishing validity of the findings through triangulation of data (Bowen, 2009), but using the perspective of a current leader in the program runs the risk of confirmation bias. Similarly, the use of theory-driven categories for deductive coding runs a similar risk of confirming a pattern that the most influential changes contributed to program effectiveness (Meyer, 2001).

Future Directions

The data presented here from HWLI’s 12 years of experience in the field support that this training effort is coming closer to articulating and operationalizing the concepts necessary for successful collaboration for equity and justice. Future work would benefit from the identification of quantitative measures of the six principles to allow for statistical comparisons of team-level engagement in the principles across cohorts. If found, differences in engagement rates in the six principles among those that completed the program in the first 6 years compared with the second 6 years would support the conclusions that the thematic curricular changes described in this case study did, in fact, result in an improved capacity to collaborate for equity and justice. Additionally, a systematic review in the shifts of team composition and focus area would provide more insight into the overall impact of the CTP on advancing initiatives with a sharper focus on health equity statewide. Team composition and focus area varied greatly over the years, but there are trending issues that create clusters from one cohort to the next. For example, when there were large amounts of funding for tobacco prevention, there were more teams focused on engaging community in tobacco policy. More recently, the greater emphasis on social determinants of health and health equity nationally and statewide have resulted in team compositions that are more focused on equity and more likely to include participants from communities most affected by inequities. Additionally, as it has evolved, the CTP is increasingly known as a program that is inclusive and supports community-driven and equity-focused initiatives. Finally, the patterns reported in this case study align with other reviews of the essential capacities needed to support collaboration in coalitions and add to the literature by stressing the importance of centering power in this work (Foster-Fishman, Berkowitz, Lounsbury, Jacobson, & Allen, 2001; Zakocs & Edwards, 2006). Coaching that draws on community organizing principles, as described in this study, represents a promising approach for supporting and sustaining health promotion coalition practice shifts that can build power and advance health equity (Christens & Inzeo, 2015; Cohen, Higgins, Sanyal, & Harris, 2008).

Footnotes

Authors’ Note

The Healthy Wisconsin Leadership Institute receives program funding from the Wisconsin Partnership Program of the University of Wisconsin School of Medicine and Public Health. From 2005 to 2014 the Healthy Wisconsin Leadership Institute received funding from the Advancing a Healthier Wisconsin endowment of the Medical College of Wisconsin.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support from the Wisconsin Partnership Program (OAC Grant #2890) supported the development of this article.

ORCID iD

Lesley Wolf

Supplement Note

This article is part of the Health Education & Behavior supplement issue, “Collaborating for Equity & Justice.” The supplement issue was supported by an educational grant from the Robert Wood Johnson Foundation. The entire supplement issue is available open access at .

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