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Culture Matters: Direct Service Programs Cannot Solve Widespread, Complex, Intergenerational Social Problems. Culture Change Can

      Over the past 3 decades, scientific discoveries in epidemiology, neuroscience, epigenetics, and network and systems theory have created a new paradigm for understanding the origins and dynamics of social and health problems. The big question is how to translate that knowledge into effective and—also cost-effective and sustainable—solutions that can improve not just the health and well-being of individuals, but of communities as a whole.

      What We Know About the Problem

      The landmark Adverse Childhood Experiences (ACEs) study established that accumulation of adversity during child development, including abuse, neglect, and household dysfunction, is the most powerful determinant of the public's health.
      • Anda R.F.
      • Felitti V.J.
      • Walker J.
      • et al.
      The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology.
      We have also learned about the power of networks to carry information, connect like-minded people, and provide a flexible yet sustainable infrastructure for social movements.
      In this same time period we have experienced a fast-paced journey that transitioned from knowledge acquisition and management by experts, to distributed knowledge that is managed and shared by the population as a whole. Knowledge is changing so fast that detailed plans and programs can become obsolete before they can be implemented.
      In this new paradigm, it is becoming increasingly clear that direct-service interventions are necessary but not sufficient to produce transformative health improvements, generate population-based change, or catalyze the social movement necessary to address the scope of the problems generated by ACEs. Direct services reach only a small portion of the people affected, and the cost of direct services prohibits their use as a primary strategy for preventing ACEs, their intergenerational transmission, and the wide and complex array of serious health and social problems they cause.
      Addressing all of these challenges together is a tall order. The answer lies in helping communities develop the capacity to reshape their own culture, from one that perpetuates cycles of trauma to one that reduces the array of ACE-related problems simultaneously and promotes health. We call this approach the Self-Healing Communities Model (Fig).

      Porter L, Martin K, Anda R. Self-healing communities, a transformational process model for improving intergenerational health. Robert Wood Johnson Foundation. Available at: http://www.rwjf.org/content/dam/farm/reports/reports/2016/rwjf430225. Accessed July 18, 2017.

      Figure thumbnail gr1
      FigureA transformational process model for improving intergenerational health.
      Reprinted from Porter et al.

      Porter L, Martin K, Anda R. Self-healing communities, a transformational process model for improving intergenerational health. Robert Wood Johnson Foundation. Available at: http://www.rwjf.org/content/dam/farm/reports/reports/2016/rwjf430225. Accessed July 18, 2017.

      Why Focus on Culture and Capacity?

      Culture comprises the abstract, learned, and shared rules/standards/patterns used to interpret experience and shape behavior.
      We are not consciously aware of most of our culture. Instead, culture becomes our autopilot. However, we have the ability to consciously take control of our perceptions, thoughts, and behaviors and generate a culture that promotes healing and health. To improve generational health and equity, we need to empower communities to recognize their own ability to make change, engender hope that what they do will make a difference, and challenge unexamined patterns that prevent realization of the community's aspirations. The processes communities use to improve hope and efficacy, examine patterns, and make cultural changes are community capacity-building processes.
      Community capacity refers to the ability of a geographically based group of people to come together, build authentic relationships and reflect honestly about things that matter, share democratic leadership, and take collective actions that assure social and health equity for all residents.
      • Morgan G.B.
      Building Community Capacity: A Qualitative Study.
      Increasing community capacity connects people so they can provide support and assistance for each other and generate solutions for locally prioritized issues.
      • Sandel M.
      • Faugno E.
      • Mingo A.
      • et al.
      Neighborhood-level interventions to improve childhood opportunity and lift children out of poverty.
      Better adapted, more resilient communities with high community capacity have extensive, community-wide networks of relationships through which reciprocity can flow and foster the kind of collaboration that is needed to influence whole systems.

      Learning From Washington State

      In the early 1990s, Washington State passed legislation to create a statewide Family Policy Council, with the goal of addressing several social problems together: family violence, child abuse, youth violence, school dropouts, teen pregnancy, youth suicide, youth substance abuse, and child out-of-home placements. Because the Council had a limited budget and a statewide mandate, it was clear from outset that a direct-service approach would not be feasible. Instead, the Council opted to focus on capacity-building. The Council's approach evolved over time into an effective and replicable process for driving and measuring change: the Self-Healing Communities Model.
      From 1994 to 2012, the Council implemented the Self-Healing Communities Model in 42 communities. It assessed local community capacity using a specially designed index and controlled for other socioeconomic factors that might otherwise explain changes over time. Communities using the model for ≥8 years dramatically reduced the rates of 1 or more of 7 major social problems.
      • Hall J.
      • Porter L.
      • Longhi D.
      • et al.
      Reducing adverse childhood experiences (ACE) by building community capacity: a summary of Washington Family Policy Council Research Findings.
      For example:
      • Births to teen mothers decreased nearly two-thirds.
      • Infant mortality decreased 43%.
      • Youth suicide and suicide attempts decreased 95%.
      • Youth arrests for violent crime were cut in half.
      • High school dropout rates were cut in half.
      The economic return on investment was as impressive as the social and health outcomes. The cost of implementing the Self-Healing Communities Model in Washington State averaged $3.4 million per year. Meanwhile, the avoided caseload costs in child welfare, juvenile justice, and public medical costs associated with births to teen mothers alone saved over $601 million, an average of $120 million per year.
      • Scheuler V.
      • Goldstine-Cole K.
      • Longhi D.
      Projected Cost Savings Due to Caseloads Avoided: Technical Notes.

      What Matters Most

      The data from Washington State tell us what matters most when it comes to culture change and community capacity-building.

      Leadership Expansion

      Is the community inviting everyone to contribute to leadership, cultivating new leaders who think about the system as a whole even while they work within their own sector? Are those leaders working together in reciprocal ways to address problems?

      Focus

      Do community members come together to generate a shared understanding of the dynamic factors that generate status quo outcomes? Is the community focused on a strategic body of work rather than single projects? Are they using a strategic framework, like ACEs, to get at root causes of an array of problems?

      Learning

      Do they emphasize learning as a value? Do they bring in outside experts and question their own assumptions? Do they invest in iterative cycles of action and reflection that support changes to the way they work and the work they do?

      Results

      Is the community engaged in monitoring a wide enough set of indicators to see progress and unintended consequences clearly? Are positive results—small and large—used to nurture the community's sense of progress and accomplishment on what is inevitably a long journey?
      The health and social problems we are facing in many communities are highly complex. They are inter-related and intergenerational. If we have any chance of turning things around, we need right-fit solutions that address the complexity of problems and inspire emergent change in different community environments at a modest cost. Building the community capacity to create a culture of health for neighborhoods and families offers us the best hope for doing that in our time.

      Acknowledgment

      Financial disclosure: Publication of this article was supported by the Promoting Early and Lifelong Health: From the Challenge of Adverse Childhood Experiences (ACEs) to the Promise of Resilience and Achieving Child Wellbeing project, a partnership between the Child and Adolescent Health Measurement Initiative (CAHMI) and Academy-Health, with support from the Robert Wood Johnson Foundation (#72512).

      References

        • Anda R.F.
        • Felitti V.J.
        • Walker J.
        • et al.
        The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology.
        Eur Arch Psychiatry Clin Neurosci. 2006; 256: 174-186
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      2. Martin K. Naylor L. Diversity Orientations: Culture, Ethnicity and Race. Cultural Diversity in the United States. Bergin & Garvey, Westport, CT1997
        • Morgan G.B.
        Building Community Capacity: A Qualitative Study.
        ([Thesis]) Seattle University, Seattle, Wash2015
        • Sandel M.
        • Faugno E.
        • Mingo A.
        • et al.
        Neighborhood-level interventions to improve childhood opportunity and lift children out of poverty.
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        • Hall J.
        • Porter L.
        • Longhi D.
        • et al.
        Reducing adverse childhood experiences (ACE) by building community capacity: a summary of Washington Family Policy Council Research Findings.
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        • Scheuler V.
        • Goldstine-Cole K.
        • Longhi D.
        Projected Cost Savings Due to Caseloads Avoided: Technical Notes.
        Washington State Family Policy Council, Wash2009