Equity projects are more likely to succeed if built from the ground up. When a partnership has strong connections to the power structure, it can secure significant changes in policies and the built environment and still not substantially improve the health of target populations. For example, without significant influence from residents and legitimate community leaders, new recreational facilities can remain underused, farmers’ markets can make low-income families feel unwelcome and displaced residents may not enjoy the benefits of their neighborhood’s gentrification. Furthermore, urban agriculture ordinances can fail to serve the population most in need of fresh food, Complete Streets can take years to come to existing neighborhoods, and groups from outside the neighborhood can dominate shared-use fields. For health equity efforts to yield true, lasting change, what the community change is may be less important than who drives the change agenda and in whose interest it is led. For all of its challenges and seemingly slow pace of progress, grassroots action is the best way to create new structures and ultimately generate healthier behavior and more equitable health outcomes for the large and growing populations that are currently experiencing, or are at risk for, health disparities.
Equity does not trickle down or out. Long-term inequitable distribution of investment, opportunity and access to healthy environments is a systemic and structural phenomenon that became deeply rooted over time. It continues even through changes in leadership, the launch of reform initiatives and the existence of good intentions and professionalism within the top tiers of the power structure. Leaders at all levels within the power structure who seek change very often confront powerful barriers. These can take the form of entrenched norms, habits, values, beliefs, procedures, personalities, prerogatives, protections or punishments. Generally, these barriers are insurmountable within an election cycle, by a single elected official or by a few staff operating only within their own jobs. Partnerships tend to find greater success over time if they are able to build a community-based constituency for change with a base of power that is independent, broad, informed and equity-oriented enough to consistently support the internal champions of health equity.
Building quality relationships is an intentional process that takes time. If an initiative is being led or managed by professionals or other stakeholders from outside a low-income or disadvantaged neighborhood or community, it is critical to forge quality working relationships on the front end and throughout the work. Residents and leaders in communities with a history of disenfranchisement, dislocation, disinvestment and other forms of social injustice often have many reasons to mistrust outside interventions, even by people who mean well. They know well the failed history of past attempts to “serve” or even “empower” the community, and they understand the capacity that exists for change from within the community. Authentic relationship building is fundamental to developing partnerships and common knowledge that will be needed to make good decisions, create useful structures, identify the right leadership, involve the right mix of people, strengthen ownership over plans and construct a lasting initiative that can withstand the rigors of the work and yield meaningful results. Rushing it for an externally imposed and/or unrealistic timeline does not work.
Preparation and quality relationships are both fundamental for emerging resident advocates. Residents of disadvantaged communities and other stakeholders with low political influence gain some power and a sense of their capacity to use it through information, education, training and other forms of preparation to engage in advocacy. But learning is deepest and most effective in the context of addressing a real challenge in real time with real partners. When emerging leaders have the opportunity to apply their knowledge and build working relationships with each other and with other change agents, their learning is integrated and their confidence and influence expand. The opportunity for emerging resident advocates to meet and build a working relationship with relevant professionals who are open to their observations and ideas, willing to collaborate and are more experienced working within a system is a particularly powerful one. Attending to the growth of these kinds of networks is very beneficial for health equity.
Scaling policy change can be fraught with tempting shortcuts and challenges to health equity. Communities are often encouraged to scale a successful policy, environment or program in order to increase its reach. This does not guarantee the intensity, context sensitivity or community support that led to the initial success. The further removed a policy change is, both bureaucratically and geographically, from the population it is intended to serve, the more difficult implementation becomes and the more monitoring, adjustment, resource reallocation and community engagement are required down the line. Especially in complex community settings, advocates who plan to bring their approach to scale should focus early and equal attention on how to support community-level action if they want to produce results.
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