National Listening Tour

Report from the

On a Culture of Health

Report from the

On a Culture of Health

In collaboration with NewStories and the Healthy Children Healthy Weight Team at the Robert Wood Johnson Foundation

“You have been telling the people that this is the Eleventh Hour, now you must go back and tell the people that this is the Hour.

And there are things to be considered . . . Where are you living?

What are you doing?

What are your relationships? Are you in right relation?

Where is your water? Know your garden. It is time to speak your Truth. Create your community. Be good to each other. And do not look outside yourself for the leader.” Then he clasped his hands together, smiled, and said, “This could be a good time!”

“There is a river flowing now very fast. It is so great and swift that there are those who will be afraid. They will try to hold on to the shore. They will feel they are torn apart and will suffer greatly.

“Know the river has its destination. The elders say we must let go of the shore, push off into the middle of the river, keep our eyes open, and our heads above water. And I say, see who is in there with you and celebrate. At this time in history, we are to take nothing personally, Least of all ourselves. For the moment that we do, our spiritual growth and journey comes to a halt.

“The time for the lone wolf is over. Gather yourselves! Banish the word struggle from you attitude and your vocabulary. All that we do now must be done in a sacred manner and in celebration.

“We are the ones we’ve been waiting for.”

~Hopi Elder Hopi Nation Oraibi, Arizona

Our invitation

A small team from NewStories has been on an incredible journey in the first half of 2016. The goodwill and spirit and work of people across the United States have given us many insights and stories to share. The deep commitment of those on the Healthy Children Healthy Weight Team at the Robert Wood Johnson Foundation to discovering what it really takes to create a culture of health opens possibilities for new kinds of collaboration and partnerships. Our team -- Kate Seely, Simone Poutnik, Bob Stilger, Zulma Pattarroyo, and Erica Bota -- is honored to share some of what we’ve heard.

Our listening has taken us from the lush mountains of West Virginia to the majesty of the Pacific Coast, from the prairies of eastern Oklahoma to the sub-deserts of New Mexico. We’ve been fortunate to listen to literally thousands of people as they shared what they are doing to restore health, not to mention dignity, and the obstacles they encounter. These insights that ordinary people have about their health provide essential directions for creating a culture of health.

What we heard was rich and powerful and has resulted in a final report of many pages! We’ve written this report both to the Foundation and to the people who shared their stories and experience with us. Nothing hidden here. It is new partnerships between the Foundation and folks who are already stepping forward to make a difference which will move us as people, communities and a nation towards greater health.

We’re not going to try to summarize this report. It took a lot of time to listen and a lot of time to write. We invite you to spend time with it as well. If you can, we invite you to find a quiet couple of hours, with you beverage of choice, and just read from beginning to end. Note the questions and insights that come to you as you read. We’d love to talk with you further about what you see and feel.

That said, the simple summary is this. We spent time talking with and listening to people from all different walks of life.

Children, parents, and grandparents. Activists and community builders. Native Spanish speakers, Cherokee, black, and white folks. Individuals who experience generational poverty and adversity. Folks who are out of work. Folks who are trying to get ahead but can’t. These are the voices of people who matter. We listened. All across this country people, both ordinary people and those who are making a career out of this work, are taking responsibility for their health. They are partnering with each other to make a difference. We, collectively, know enough about what needs to be done. The orientation is shifting from believing that people are provided with good health by medical professionals towards a much more complex landscape that has many actors. It is time to invest in that landscape.

If you are unable to that quiet two hours with this report, let us describe some other ways to explore.

If you first want to find out more about how we approached this listening and where we went, skip to the end of the report and the Background section. It describes what NewStories and RWJF were aiming for as we began the project and highlights where we listened and how. This section also includes an array of photos from different sessions as well as the graphic recordings of our many community conversations.

The Healthy Kids Healthy Weight Team at RWJF shared some of the Key Questions with us that the team has been exploring. For the most part, they are quite different than the questions being asked at the community level. We kept these key questions in the back of our heads as we listened in community and found a number of insights and experiences to share. If you want to review what the Foundation has been asking, check out this section.

Most of us have ideas about How Change Happens. Those ideas influence what we see and hear. And, as we engage with others, our ideas grow. Our views on change undoubtedly influenced our listening and this short section of the report illuminates what we are seeing now. As you read this section, please notice how your own ideas about change are similar to and different from ours.

As we started to write this report, we became aware that a Culture of Health prospers in a particular Landscape. That’s really not surprising. Culture of anything is held by certain markers and attributes and characteristics. It’s too easy, however, to unintentionally use the term “culture of health” in a somewhat glib and superficial way -- almost relating to it as

a series of desirable transactions. It is much, much more. A culture of health is a system and there are certain elements which support the development of that system. As you read this section, we invite you to note what else is present in this landscape for you. What is it, when tended, that is most likely to move us towards a culture of health?

In our listening, we wanted to know what people are actually doing -- how they are Taking Action. We’re often reminded of the wisdom of a colleague many years ago who rubbed a time between his fingers and said good ideas are a dime a dozen, it’s the one’s you do something about that count. In our listening we were interested in what people were already doing, in what was helping them and what was holding them back. In this section we look at some of the local practices which stood out for us. As you read this section, please note what questions come up for you about this collage of action.

Our listening was an exploration of new possibilities for Grantmaking and Community Engagement by RWJF. A core question we carried with us into each conversation was if the Foundation wants a Culture of Health to flourish in the US, what might it do? With the huge investments and high aspirations the Foundation has, how might it make even more of a difference. We realize that running RWJF is already a big job. Our question is about where arenas of new possibility and experimentation might be opened. How might RWJF engage in communities differently and watch what happens while at the same time attending to the ongoing business of running a major foundation?

We invite you into this report. Enjoy!

Our thanks

We must begin this report with our deepest gratitude to both the Healthy Children Healthy Weight team at the Robert Wood Johnson Foundation (RWJF), and to the people and communities we were welcomed into, whose stories we were privileged to hear.

It is no easy task to reorient a team of people, let alone a large, national health foundation, towards authentic community engagement. And yet, big steps have been taken. Part of the reason we were able to do this work on such a short timeline is because of the relationships and presence that the foundation already has established. Everywhere we went, we found traces of RWJF and the good work being supported. We heard stories of years-long partnerships and support. We heard of projects, grants, research, and individual staff, all of which has already done wonders to help people and communities across the U.S. Wherever we went, the trail led back to RWJF. We offer a deep

thank you to you all for asking the hard questions that you are asking, and for entrusting us with a piece of this work. We hope we can help illuminate at least a part of the path forward. And our deepest gratitude to the people and the communities that we were welcomed into. You shared your truths, about your own lives, about what you believe needs to happen to build healthier people, healthier families, and healthier communities. We could never have expected the warm welcome that we received. For us, this has been the biggest gift of all -- to see how, in the face of generations of adversity, people continue to come together, to work towards something better, because it’s the only thing to do. And you continue to open your arms and doors to those of us from the outside to learn what it is you are doing, at the local level, to lift each other up. Our deepest thanks to you for the generosity in your sharing and your welcoming.

During the Spring of 2016, NewStories conducted a national listening tour in diverse communities in four states across the U.S., both to better understand the lived experience of marginalized families and to explore a model of community engagement.

While there have been gains in health in the U.S., there are also highly disturbing trends that directly affect health, such as childhood poverty rates, education gaps, and obesity rates. The answer might just lie in more community engagement. The Healthy Children Healthy Weight (HCHW) team is asking itself how to talk with and engage communities in a more consistent and effective way, and how to make this common practice within the foundation. The HCHW team is also wondering, largely, what are the policies, practices, and changes that will raise awareness

and change the way people treat themselves and each other in communities.

On the brighter side of health in the U.S., there is an explosion of how we collectively understand how the mind and the body are connected. What we experience when we are young and how trauma affects us is much better understood today. Recognizing the intersectionality of issues as we build a culture of health offers both the challenge of confronting complex and interrelated problems, as well as the opportunity to ask ourselves new questions and see things in a new way.

RWJF is in the midst of a major strategy redesign process. “Emergent strategy” implores us to constantly sense and adapt to changing environments. As Kristin Schubert, Director of the HCHW team, stated in our opening meeting “In a sense, there is nothing new about this. We have always been doing this. We are

in direct relationship with one another always. As living beings, we are constantly adapting to the context around us.” What this means as we work to build healthy communities, however, is that we are concerned with a systems challenge, one that looks not only at the conditions present around us, but the conditions we are a part of in our organizations as well.

We turned to people in four parts of the country: West Virginia, Eastern Oklahoma, New Mexico, and Northern California. We were in many, many circles, events, and conversations with thousands of people, listening for what they know about creating a culture of health. This is the work they do every day. These areas are profiled in the Background.

The recommendations and actions we propose in this report are as much about community change as they are about organizational change. It is not only about RWJ supporting community change external to the organization (both in the way you do your grantmaking and the way you consider your role in communities), but RWJ doing the work inside the organization to be a part of community change. As Kristen Schubert said in the beginning of this project: “We are in direct relationship with one another.” We are not separate from one another, and we must be in relationship with one another, even when it’s difficult. We are all a part of the systems that create and maintain inequities. If we truly want to remedy that, we must start with looking at ourselves.

One guiding question rose to the top as the aim for the listening tour. The goal has been to learn, directly from parents and caregivers, how the Robert Wood Johnson Foundation can engage families to support a culture of health. Additionally, this listening tour sought to answer the questions: What is the living experience for all families, especially marginalized ones? What do marginalized families need to thrive? And finally, what issues are important to families in need?

The final section of this report, Background, reviews how we envisioned this project and what NewStories, together with RWJF, saw as indicators of success. The bottom line, really, was that none of us wanted another report that would get lost on an electronic shelf somewhere. We wanted to find the starting points for a new community engagement strategy to build a culture of health that will hopefully lead to further exploration and engagement.

Our engagement process is detailed towards the end of the report, however, to summarize, we:

1. Chose locations, beginning with 10 and whittling it down to four based on the short timeline of the project.

2. Conducted outreach, starting with our personal and professional contacts.

3. Held one-on-one meetings with individuals in a first inperson visit to each region

4. Convened conversations and listened in to conversations or events that were already planned.

5. Made sense of what we had learned, wrote this report, and will soon share it back with the communities themselves.

We humbly and wholeheartedly submit these learnings to you with the hopes that we can at least partially transmit the wealth of learning we experienced, the privilege that we felt in seeing such incredible people working towards a culture of health, and the wisdom that comes directly from communities themselves. As we heard time and again, “We know what needs to happen to change our community.”

What we learned about How change happens

Manyof the insights we gained in this listening tour are insights that shed light on the power of people and the challenges they face due to our current system. Throughout our work over the years as conveners, listeners, facilitators, hosts, and believers in social change, we have some thoughts about how change happens, which were augmented by this listening tour. As a part of the this narrative, we intend to shed some light on what we’ve learned about how change happens.

Across the U.S. people are standing up for health because they can and because they must. Their own health challenges may have forced them to their knees. Concern for someone they love may have kicked them into action. A new insight may have opened a window on a possible future that had been invisible before. They somehow found a starting point.

I was in juvenile justice for seven years. Looking back, it’s been my college experience. Once you’re a criminal you’re not always one. Self education and self knowledge superside. I was alone from when I was 12. I got discharged when I was 25. I had no services or support system. But I wanted to change myself so bad. One day I was walking in this park and had a vision to do for others what I had lacked. A mentor taught me how to control my anger. I’m seen as a quiet leader who has the ability to draw people towards me and I support them.

Askari, Community Organizer, California

They muster whatever confidence and courage they can and they turn to those who will join them on the journey.

A place -- a particular piece of ground, a building, or a whole community -- becomes their field of practice. They begin and they learn. They start where they see the most need the greatest opportunity. Their initiatives often grow and expand quickly beyond the initial scope as they take action and learn what else is possible.

People show up in many different roles. Some are organizers of community. Others have deep knowledge and expertise in a certain area.

Our darkness started with my son getting his appendix taken out. The doctor handed me the pain meds and I did not question him. I handed them to my son. Two years later he was still on them. He is in recovery now. My vision is to create a place for people in recovery to find meaningful things to do, community that supports you and loves people out of their darkness.

Mary, Oklahoma

One person is a catalyst for change. Another connects the system with itself and makes sense of the patterns. One person returns after a long time away while someone else shows up as a newcomer -- both bring insights and experience from “away.” Still another works at a much more for intimate level, helping people navigate the systems that surround their lives. Sometimes they start alone and move forward through sheer force of will. Most of those who stay in it for the long haul turn to others for support, guidance, labor, and eventually co-ownership. It does take a village to create a culture of health.

Often they have little or no structural authority. No one else told them they could or should do what calls them. Almost always they started with no money. They asked others for help because, dammit, it’s the right thing to do. They shared stories and ideas and models. Even if they wanted to, they could not compel others to do anything, so they had to work with the powers of invitation and attraction rather coercion.

took two hours each way. They could be overwhelmed by the immensity of the challenges they see, and sometimes are. But they can’t give up. Lives are at stake. Their community is at stake. Their home.

They find a place to begin. Often they concentrate on one part of the puzzle -- but they are ready and willing to follow it wherever it might take them. The work of Grand Nation in Vinita, Oklahoma, began with a focus on drug abuse. Quickly they realized they needed to support people in living their whole, complex lives in ways that are healthy. They keep from being overwhelmed by focusing on one thing at a time. They keep from being ineffective by seeing the deep connections that weave together all aspects of life.

No one taught these folks to be systems thinkers and most would likely shrug at the term. But because they are working in the living web of community, they know that everything is interconnected -- obesity, transportation, economy, nutrition, stress, trauma, diabetes, drug abuse, exercise, medical care, incarceration, and more. How? Because their cousin is in prison for cooking meth after he lost his job because he was too overweight to walk that far and public transportation

In community after community, the overall story is exactly the same even while the particulars are often wildly different. Creating a culture of health is long term work. It won’t happen overnight. As the Navajo say in New Mexico, health means “having a clear mind and a strong heart.” We make the path towards health one step at a time.

To summarize, what is it that actually shifts culture, beyond focusing just on the individual’s behavior?

n We start with whatever is most real for the community. We start where people are, not where we want them to be. Working with what people themselves care about most -- rather than what some outside expert says is most important -- begins to rebuild the fabric of community.

n While changes can be imposed from the outside with funding and mandates from external public and private authorities, nothing really catches on or lasts until community itself has its fingerprints all over it. When communities have ownership of what they are doing, they’ll change it when it doesn’t work and improve it when it does.

n The greatest disease is disconnection. There is disconnection within communities, between generations,

people of different ethnic or economic backgrounds. Disconnection exists within organizations, where work in silos causes wasteful use of resources.

n The greatest disconnection is between those with formal decision making power and those affected by those decisions. Connecting people locally and translocally in conversations that matter, sharing questions and stories and wisdom and models seeds cultural shift.

n This work is not carried out according to some masterplan. We make the path by walking it, guided by a sense of common purpose and direction, being comfortable with not knowing. Time and time again we’ve heard people say “leap and you’ll grow your wings on the way down.”

n It’s messy. What we do at first often doesn’t work. But lives are at stake and we’re in it for the long haul -- so we keep learning, and moving forward. We don’t get distracted into creating things that look nice, but don’t work. People tell us ‘It’s not just the big things, but also the little changes that count. It’s amazing how quickly change can happen when we come together.”

n Everyone’s contribution is honored. We do this work together. We actually don’t have to be friends or even like each other -- but we must encounter each other with curiosity, generosity, and respect.

n Work begins with a rich mix of people, places, possibilities, and problems where people try things and see what makes a difference. They use each other and the internet and whatever else they can find. When purpose is clear enough, they’ll find the knowledge and skills needed.

n This on-the-ground experience is studied and people learn what to do next. As they go along, they develop procedures, principles and policies to guide and enable future work. This enabling framework emerges by noticing what works and what doesn’t and by getting clear about what needs to be amplified and what needs to be dropped.

HCHW Theme Learning Questions

Atthe end of May, after we had done all of our “prospecting” and were ready to move into the deeper, broader listening your, RWJF provided us with a list of the current learning questions being worked in the Healthy Children, Healthy Weight Team, including an indication of which questions were priorities.

With support from our contacts at RWJF we chose not to change the composition of meetings we had scheduled, nor to alter our approach to ask these questions specifically. Rather, we included them as a focus in our own listening. Here’s what we heard:

Healthy Food Systems & Practices

To what extent do pricing incentives/disincentives (including taxes) influence the purchasing and consumption of SSBs and healthy foods particularly among the most vulnerable (without undermining equity goals)?

Oakland community organizers were opposed to the tax on sodas. In West Virginia the question arose if a higher tax on tobacco will actually make people stop smoking or if it will just mean that less money will be available for their children’s food. In both cases it felt to people like a solution imposed on them and they did not think of tax as support to make healthier choices. On the contrary tax was perceived as a punishment, especially if easier access to healthier drinks was not provided.

The stories we heard in all places about why people stopped drinking sodas were mostly because of significant health challenges, like diabetes to the point of facing death or losing a leg. The number two reason was that people who were significantly overweight found their personal motivation to lose weight and ceasing to drink soda was a quick win. Often this coincided with becoming part of a support community and learning healthier habits. Most people know how unhealthy sodas are, some are addicted and some simply don’t see it as a big enough problem, i.e., they don’t feel the effects yet.

“I was 300lbs. One day I looked myself in the mirror and decided something needs to change. I started boxing and eating healthy. No more sodas. Grandma supported me. It wasn’t always easy.”

(Young man, 15, Stockton)

In Stockton community organizations got together to propose to city council the “healthy by default kids’ beverage ordinance,” meaning either water or milk shall be served as the default beverage in children’s meals. It was celebrated as a success and is the second law of its kind adopted by a U.S. city, following the city of Davis, California.

“I see five year olds get fed too much sugar. They get hyper, teachers can’t deal with them and eventually they end up in prison. In Stockton we incarcerate more children under 10 than anywhere else in the country.”

(Sammy Nunez, Founder of Fathers and Families, Stockton, CA)

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In summary, external controls like sugar sweetened beverage taxes do not appear to be something which significantly reduces soda consumption. It may well do so and statistically surveys may indicate this is the case. But for the most part it appears that people stop or reduce soda consumption when they become personally motivated to do so, and when they have a support system that helps them find and choose better alternatives.

2. For those who live closer to stores with healthy options, convenience of fast foods, worry about higher costs for good food, actual higher costs, unfamiliarity of the food itself, and lack of knowledge in preparation are barriers.

The stuff that’s good for you is priced way higher than the stuff that’s bad for you. (Community Member, Tulsa, Oklahoma)

What are the trends around public demand for healthier foods and beverages, how is industry responding to those trends, and how can RWJF leverage those trends?

In all places we heard stories about ‘food deserts’ and how hard it was to access healthy foods. We also learned how even when more healthy choices were available, many did not know how to prepare them properly. We also heard many times how, for children, when healthy choices were available, the kids didn’t want to eat them, and/or didn’t have time to eat them.

Community organizations offering cooking classes were highly appreciated and used by communities all over. There appear to be several related issues:

1. Some live in food deserts where stores with more nutritious foods are miles away. Time, energy, lack of transportation, and cost of transportation make those stores inaccessible.

Some of us have to drive 40 miles to find fresh food. All we have here are gas stations, dollar, and liquor stores. (Community member, Cherokee Nation, OK)

I need convenience. Whatever gets us fed the fastest. (Foster parent, Tulsa, Ok)

We eat too much street food and fried things. And too big portions. I decided to make a change and lost a lot of weight. But how do I do that with my family? One thing I started doing was to just invite them for a walk after sharing a meal. I lost 30lb and my family is now getting curious how I did it. They started walking more and eating less and it’s working. (Patient at Indian Health Clinic, Tulsa, OK)

School meals look disgusting and the only “vegetable” kids are familiar with is pizza. People have to get familiar with what healthy foods are. (Stockton Parent)

3. Changes in systems are sometimes needed to make healthy eating attractive and easy. Healthy food often takes more time to prepare and more time to eat.

Do you know how many pounds of carrot sticks and celery and oranges I see dumped in the the trash everyday? Kids just won’t eat that stuff the government makes us feed them. (School cook in Boone County, West Virginia)

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We saw that kids were not eating the healthy choices we made available and wondered what we could do. We started timing how many minutes kids had to eat -- by the time they got their food and sat down, it was only 7 minutes! And, besides, they were anxious to get outside to play. They just didn’t eat the carrot sticks and celery. It took time and patience, but we convinced the teachers to give up 10 minutes of teaching time and we convinced the administration to put recess before lunch. They eat their carrot sticks now, and are prepared for an afternoon of learning. (School nurse in Tulsa)

Changing the food we serve our kids at school has been an incredibly hard thing to do, the bureaucracy and logistics has been overwhelming. (School Teacher, Kanawha County, WV)

4. Sometimes vendors make arbitrary omission of more healthy foods. Perhaps also big chains are less responsive to local requests and support.

We were surprised when the KFC in Turly, OK, took the healthiest option, grilled chicken, off the menu. When we asked why, they just said “corporate policy.” (Community member, north Tulsa)

I’m running a daycare and had real trouble finding fresh food for my babies. I talked to WalMart and for weeks tried to convince them to have more fresh veggies and fruits available. Nothing happened. One call to the local manager of our local store helped and a few days later they were stocked up with fresh groceries I wanted. (Day Care Founder & Health Council Leader, Las Vegas, NM)

5. Helping people begin to remember what healthy food is by helping them grow their own is what works best and community gardens at schools mean that kids establish a new relationship with food and ask their parents for veggies and fruits. Throughout Cherokee Nation, for example, community gardens at schools are a strategy to fill food desert gaps. Schools are also using the gardens for their science classes.

The kids planted a tomato seed and tended it as it started to grow. They watched as the fruit formed and when it got ripe, popped it into their mouth. Then they asked their parents for more. (Teacher in Anthony, New Mexico)

We did not hear anyone talking about an “industry response.” It may well be going on, but it is not very visible, especially in the more economically challenged areas where we did our listening. Paying attention to local nuances, noticing the local situation, and supporting local action to make more of a difference may be the important keys.

Healthy Schools

What language/narrative compels education decisionmakers, teachers, and parents to support and eventually generate action to advance healthy school environments?

Perhaps more than anything, a language of listening and paying attention is required. In general, our sense is that people do not need to be compelled. There are enough people ready and willing to do good work, and already doing it. They need to be supported, and these changes should be as easy as possible, not as hard as possible. Many people do, in fact, want to do the right thing.

Things have changed over the last 10-15 years. Importance of nutrition and exercise, ACES, and social determinants of health are no longer secrets. Enough people already know that language. And the ones who know are the ones who can invite others to come along.

What do they need? They need to be able to find those they can turn to so they can take action together -- like the people who made small changes in the school lunch regime in one school in Tulsa. They need access to stories about best practices and promising practices which have worked elsewhere. Sometimes they need a little money to start something new.

Those who will take action are already compelled -- but they are compelled by their love of children and their belief that child health is of primary importance.

What policies help foster healthy school environments, in alignment with WSCC (Whole School, Whole Community, Whole Child)?

It was beyond the scope of our work to look at which national policies may be helping to create healthy school environments. We did hear stories, however, of resentment about things created outside of communities and then imposed on communities.

n The Boone County school cook we mentioned above was just plain angry about outsiders telling her how to feed her kids. Her resentment was high enough that she wasn’t interested in hearing how the Indian Health Center in Tulsa made carrot sticks work. Bright and strong-willed, she wasn’t about to have someone from the outside tell her what to do.

n In New Mexico we heard stories about how the new State Secretary of Education’s efforts to get New Mexico to rise on the national ranking was just creating too much stress for both teachers and students and not showing the desired effects.

Something different happens when members of community come together and begin to formulate local policies to improve health.

n Members of the New Mexico Health Equity Partnership are stars in this area. They are supporting communities in doing Health Impact Assessments to provide data to policy makers and influence decisions that have severe impact on community health.

n The newly formed statewide ACEs Coalition in West Virginia is bringing professionals from across the state together, supporting them to become a community of practice creating policies and actions that help to overcome the powerful effects of ACEs.

n In Oakland, school-based health centers are being implemented and widely used across Alameda County, and restorative justice practices are being implemented across the whole Oakland Unified School district, which focus on building community and help kids develop social emotional skills. Every child in Oakland receives free breakfast at school.

n And seen from the ground level, policies must lead quickly and effectively to new practices and actions. The line between policy and practice becomes blurred as each informs the other.

n The Indian Health Center in Tulsa knew that district mandates for more student exercise were not enough, so they started offering a one day training for educators on how to incorporate more movement in their classes. A teacher is keeping data on the correlation between physical activity and academic performance which will be used to support further change in policy and practice.

n In Cherokee Nation the Vian Peace Center is collecting data on how hunger is seriously affecting children. Many, but not everyone involved in raising children knows this is true, and the Peace Center believes that more hard data will help others see how pervasive hunger is in the Nation.

Early Childhood and Education

High quality informal and formal child care are critical to healthy development. What are the most effective ways of promoting quality in both systems? What does quality mean within both systems; what does it mean to parents, to ECCE providers, and to “the field”? Does it differ across different populations? What does each group need to provide high quality care?

We encountered three very different kinds of stories:

1. Kids who are cared for by grandparents and aunts and uncles and unemployed single parents, being given as much love and attention as possible, often with caregivers stressed, tired and with minimal resources. We encountered so many good people providing this kind of care. They know their own limitations. From our perspective what’s needed most is ways of convening them at very local levels with each other and the professionals committed to supporting them. Together they will discover what they can do and what they will do with the resources they have at hand. That’s one of the things that happens at the Indian Health Center in Tulsa -- people come together and figure out what’s the next step in supporting kids. It’s what happens at La Semilla in southern New Mexico

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that brings young children into community gardens with their kids. It happens with Keys 4 Healthy Kids in WV where child obesity clinics work with both children and caregivers, and where the organization provides education, toolkits, and follow-up to community organizations. These are hyperlocal and very nuanced efforts.

2. Kids neglected and abused in their family of origin, or by relatives, or by formal systems of foster care. We heard about this everywhere, particularly in the context of the child abuse and neglect that follows from parental drug addictions. The stories we heard in West Virginia were most pervasive and poignant. Simply put, the number of kids who need different care is staggering.

Programs like Handle with Care, mentioned later in this report, help to reduce the inadvertent deepening of trauma when kids arrive at school unafraid and unprepared after a hard night at home. Quite honestly, mostly what we encountered was people shaking their heads and saying they just didn’t know what to do.

3. Children for whom their formal childcare system is main source of continuity and health. In West Virginia we had the opportunity to meet with a coalition of formal childcare providers that is convened and supported by the Universitybased County Extension Service. They’ve been meeting for several years and have had a chance to build trust and learn how to listen to each other. They told us, for example, about the many challenges they had met and overcome as they followed guidelines from Keys 4 Healthy Kids to improve childhood nutrition. They showed what happens when there’s an alchemy of external knowledge -- the guidelines -- and

a committed community of people who will figure out how to make it work. They know they have to figure out how to work more with the families of their children. They know, for example, that if they can help a family have three dinners together a week, there’s a 65% less likelihood of drug abuse. The only way they can provide this support is through daily, informal conversation with parents. They also know they are the one source of consistence in the lives of many children -- 70% of their kids are from at-risk families with no transport and living in food deserts.

From our perspective what’s necessary is listening and convening and trusting that good and caring people will make good choices. Knowledge and ideas can be provided to help, but the people who have the direct contact with children are the ones who have to figure out how to use their resources to make a difference.

HCHW T H eme Learning

Ques T ions

Given the growing funding and subsequent action in the PreK movement (age 3-5) and the significantly less funding and action in the P(pregnancy) to 2 space, and the importance of quality across systems, how should this factor into our focus area(s)? From a systems perspective, where are our resources best allocated to have greatest impact?

In general we heard stories about how important prenatal nutrition is and the importance of support for teenage moms. In one West Virginia community we heard, on the one hand, the story of one high school that simply turned a blind eye to the significant levels of teen pregnancy among its students. No, we’re not going to make contraception available or increase sex education, or provide support for young moms. That contrasts with a story about Chandler High School in WV or the Teenage Parent Program (TAPP) in Kentucky, where the school made a commitment to pregnant moms and brought them further into community -- achieving both an unheard of 97% graduation rate and a high rate of college placement.

People in the Indian Health Center in Tulsa talked about how they needed to support mothers in being healthy as the first step in preventing childhood obesity -- without blaming or shaming them. In New Mexico people talked about how essential

it was to help young moms who didn’t know anything about good nutrition from their family of origin learn how to take good care of themselves and their babies.

“One of the moms I work with drank 10 -12 liters of soda per day and her kid wouldn’t stop crying. Instead of dropping soda, she stopped breastfeeding.” (Community Worker, Lincoln, West Virginia)

You’ll find that we keep coming back to the same principles and values in this report. Convening the people who care. Helping them talk and learn with each other. Nourishing them with good ideas from outside their immediate experience. Sharing their own stories widely for inspiration as well as information.

Child Health

What are the bright spots where children’s health and health care systems are connected to and integrated with services and supports that families need to improve child health and reduce disparities?

These bright lights are everywhere and you will find them highlighted throughout this report. Years ago in a U.S. Presidential Campaign one of the slogans that developed prominence was “It’s about the economy, stupid.” On this listening tour, what people said time and time again in many ways was “it’s about the children, stupid.”

Growing food, preparing food, exercising, having spaces to exercise, seeing others making wise choices, finding hope, getting role models, respecting each other, trusting human goodness and compassion. The people we encounter are not new age idealists. Some were, but most were not loud and passionate social activists. They were solid folk who stepped forward because they saw an opportunity and a need and they knew they could make a difference.

They are changing the landscape of community by creating a culture of health.

Landscape of a Culture of Health

So what does the landscape of a Culture of Health look like? What shows communities are on their way towards health and wholeness? What are the landmarks which, when present, mark the emerging aliveness of a culture of health?

We returned to the RWJF Culture of Health Action Framework to give us some guidance and looked at the four action areas you have identified:

1. Making Health a Shared Value

2. Fostering Cross-Sector Collaboration to Improve Well Being

3. Creating Healthier and More Equitable Communities

4. Strengthening Integration of Health Services and Systems

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Places of Care

where people meet - gardens, centers, clinics

Systemic focus

over time on critical health issues - obesity, addictions, unemployment, incarceration, and diabetes

People

which

A call to healing

Convenings

The question, of course, is what makes progress in these action areas most likely. What aspects of community life, when tended, makes these four things possible? How do these Action Areas live in community and how do we find the way into that territory? We identified what we consider to be six key landmarks:

n Places of Care where people meet -- gardens, centers, clinics

n People consciously serving in particular roles -- catalysts, gatekeepers, organizers, caregivers

n Values that create welcoming boundaries where people turn to each other with curiosity, generosity and respect

Values

n A built environment that promotes health -- parks, walkways, bike trails, open spaces

n Systemic focus over time on critical health issues - obesity, addictions, unemployment, incarceration, and diabetes

n A call to healing not just physical or mental symptoms, but generational pain and trauma

n Convenings which call people together for inspiration and learning and renewed action

These six stood out as markers in the landscape of a culture of health. The more frequently they were present, the more it seemed as health was being restored.

Spaces That Grow Community

A culture of health is a lived experience, created as people open to each other -- listening, sharing tears, hearing laughter. The spaces which invite us to be intimate, vulnerable, and strong, moving into the close proximity of each others lives are where this culture is created. We noticed three kinds of spaces that helped in growing community: community gardens, community centers, and clinics in communities.

Community Gardens

In every location where we listened, community gardens are playing a vital role. People in many different places spoke of how their grandparents or even parents had garden plots outside their backdoor. Food was raised, harvested, preserved and eaten out of those gardens. As one man in West Virginia put it, your most important grocery store was the one just on the other side of the porch. Just two or three generations ago, there was a real connection to food and that connection is now vanishing. People have become more and more accustomed to buying foods packaged for shelf-life rather than nutritional value and that are often saturated with sugar. We’ve literally forgotten what

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food is. Sugar sweetened foods and beverages are fast to eat and provide an immediate high. People involved in feeding kids in schools and childcare centers often remarked about the challenges of getting kids to eat fresh fruits and vegetables -- foods that just aren’t that familiar. They take more time than the kids have to eat them. It takes our kitchen workers more time to prepare -- and often they don’t know how! Community Gardens shift relationships with food and with people.

n Kids love nurturing something they’ve planted grow from seed to table. They form a relationship with food that is intimate and personal. And they see that food comes out of the ground before it goes anywhere else.

n The community garden is a place where people have conversations with each other about the ups and downs in their lives - fingers in the soil together, side-by-side, working in the garden becomes a place where people are able to be more vulnerable.

n The garden becomes a foundation for other learning. Once people are growing food, they want to know how to take care of it -- to harvest it, to preserve it, to prepare it, and to eat it.

n Community gardens act as an incentive for people to start a garden in their backyard. As one woman in New Mexico said, with a smile on her face my husband always used to disappear for hours at a time into his shop. Now I watch him go out into our garden and smile as he puts his fingers into

Working outside in the garden together, with our hands in the dirt sharing stories is therapeutic. We can overcome some of the difficult things in our life by cooking or growing food together, talking, being a community.

La Semilla, New Mexico

n And, by the way, the garden produces really good vegetables and fruit and during times of harvest, the gardeners have more than they can eat and they have to figure out how to pass it into community - which helps grow community

These gardens crop up everywhere. They’re on vacant lots. They’re in the backyards of elderly people who have land and need labor. They’re at schools and childcare centers. They are out the backdoor of assisted living facilities.

We bring fresh food into our elementary school in Wayne County. Our classrooms help people learn about sustainable agriculture; our produce is sold in the Wild Ramp grocery store in town. These are our community centers! West Virginia parent

Sometimes a garden is just a garden. It’s there on the corner, people come together and grow food on the same land. Done. Other times it is the cornerstone of something much more -- a whole community learning program on growing and eating real food.

Centers of Community

The Welcome Table in North Tulsa is a center of community. Started by a Unitarian minister and his physician wife when they heard how life-expectancy was 14 years less in Turley, where they were born than it was just one zip code away. They said that’s got to change and they created what they called “a third place” -- a safe space where people could gather to support each other in building healthier lives. Over the last five years The Welcoming Table has grown as a center of community. They have meals -around welcoming tables, of course. There’s a nearby community garden. They run a food pantry. They help people get clothes and housing and anything else they need. It’s a place of “commitment creep.” The woman who had to be convinced to volunteer one afternoon a week in the food pantry now hopes for one day a week off -- but she is busy everyday, out looking for the healthiest food she can find to offer to people through the pantry.

They don’t have much of a budget -- and really don’t want one. They watch for where people have energy and work with it. It is a place where people gather to help themselves and to help each other.

This space has evolved into something that brings community together, where people feel welcome, respected and seen. I see you and you are valued. People who are not the volunteer types come here and feel the fire. They want to contribute. People who benefit from our services gradually start getting involved in our operations. Everybody is training everybody else with joy. There’s scarcity mentality in our community and we’re trying to counter that by always being generous, by celebrating abundance.

Welcome Table, Tulsa, Ok

In Stockton, the Youth and Family Empowerment Center run by Fathers and Families of San Joaquin is another example. Immediately upon entering the building the welcoming warm and friendly atmosphere is palpable. It is a place for healing and regeneration for families and communities, it’s a place that creates opportunities for people to to learn and give back to their communities. This place was started by a formerly incarcerated man ten years ago to mentor parents and children.The center now offers various programs to strengthen families, including healing circles, parenting and financial literacy classes, various youth empowerment, and elders support programs. Fathers and families also puts emphasis on intergenerational mentoring and healing the disconnect between generations.

Clinics in Community

Sometimes a clinic is just a clinic. People arrive, checkin, wait, are seen by a professional, and then go home. In the communities where health is a priority, a clinic can also something much more. It is an important home, a place where people feel cared for and respected. A place that helps them take care of their health.

The Indian Health Center in North Tulsa is one example of where people take charge of their own health. Yes, it does have top notch medical care with a robust administrative back end that brings in public and private dollars to make care affordable. Because of their own culture they attract and retain excellent professionals and they know how to do scheduling in ways that get people in and out without long wait times.

AND, there is so much more. Exercise rooms as well as an extensive calendar of group activities. Rooms for 12-step and other support groups to meet. Classes in preserving and cooking foods. Other classes in diabetes, drug addictions, trauma. Staff available for conversation. They don’t have a community garden right now -- but are looking for where to start one. A gathering spot, treatment services, a learning oasis. It’s all rolled up together to help people focus on their health.

Cabin Creek Health Systems in Boone County West Virginia plays a similar role, grown out of different soil. The people of Boone County are proud coal miners and have been for generations. They’re also mostly unemployed and underemployed. The elders often suffer with black lung, COPD, and emphysema. Drug addictions are chronic problems across

Nobody out there actually gives a damn about us. If they could plug this creek and flood this valley, they’d be happy. This here clinic is all we have. 72 year old coal miner

all generations as well as a diabetes being a common condition. People here have lived on Cabin Creek for generations and life has not been easy. But the one thing they know they can depend on is Cabin Creek Health. It’s always there for them. They can get their medicine at a reasonable price. The doctors and nurses are great. The staff work them with diabetes, cascading respiratory problems, and help them get family members off drugs. They find community at the Clinic and it makes their lives just a little bit better.

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The lines between community gardens, centers of community, and clinics in community often become blurred. What seems essential for creating a culture of health is that there be places where people gather, and where their health and well-being is a priority. A place where there is a strong, energetic, informed invitation to restore health. They are places where people are cared for -- not in the ways where people feel objectified and “less-than” -- but in a respectful meeting of people who care about each other with dignity and respect.

People

People step into crucial roles necessary for a culture of health to prosper. Some are catalysts, others organizers or gatekeepers, some caregivers, and others who show up with willing hands and open hearts to do whatever is needed. It takes them all.

Deborah moved to Las Vegas, New Mexico, and was called to make a difference. She started paying attention to the stories

she heard of corruption in the privatized prison and how the prison was basically a revolving door -- people went in, got out, and returned again. She led the successful effort to de-privatize the prison and to create local systems to help ex-cons lead more productive lives. Deborah lives on $4000 a year from a pension and gets extensive personal support in the form of housing, transportation, and food from people in the community who value her and her work.

Richard had a life as a concrete finisher in Tulsa. He made good money. And then a little girl opened his heart. He was grilling hot dogs at a charity event and she asked him mister, can I have a hot dog? I don’t have any money. Sure, he said and put one in a bun for her. She started to eat and then turned and pointed at her family: mister, what about them? They’re hungry and have no money either. He started feeding people. Finding the hungry and feeding them. He used all of his money and was living out of his truck and finally realized he needed to find another way. His aquaponics farm will open in a few more months. The plan is that 30% of what it produces will go into the free food economy of eastern Oklahoma, some through the Vian Peace Center, which is a local food bank that Richard and Jackie, his wife, created and run. The farm will make a good living for them – not to be rich, just to have enough. The farm will also be the anchor tenant for a new grower’s cooperative of small farmers Richard plans to knit together who will have the capacity to serve large markets like Walmarts. Richard gets stuff done. He is not an organizer. He’s a bit of a one man band and unless he attracts an organizer to his cluster of work, he will burnout. But he is a dynamo.

April and Craig in West Virginia are quite a duo. Together they run Cabin Creek Health Systems. They have an unflappable presence and each tend different parts of the large system of care, with five clinics -- all that many in this rural area have. They just do what needs to be done and they do it with kindness. They coordinate a large team of professionals who provide the care. They find funds and they find certifications and they find people.

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People depend on them. They deliver medicine and care and love and dignity. They are there, solid, providing ground on which their patients, their community members, can stand.

Christina in Anthony New Mexico knows that food is important. Growing it. Tending it. Harvesting it. Preparing it. Her mission in life is to reintroduce people to food at La Semilla Food Center. Her passion for people and the land and that which grows from it guides La Semilla. She is teacher, an organizer, and farmer. She is one of several core staff who lead this vibrant organization.

Sammy in Stockton, California, founder of Fathers and Families of San Joaquin, an open-hearted, inspiring man full of passion and energy, was convicted for gun violence at age 18 and is now giving back to his community in any way he can. He’s a leader, political activist, and mentor who knows that healthy families and communities are the cornerstone of a healthy society. That protecting children, honoring women, and respecting elders is essential. And that safe, strong, and resourceful communities treat individuals and families equitably and honestly; promote positive family images and recognize family strengths; and create opportunities for individuals and families to achieve health, wellness, and their human potential.

Our lives have filled with these people and their stories. What do they have in common and how are they part of this landscape of a culture of health? They are each people who build and serve community from a place of calling. They create this culture of health. Most are not trained in systems thinking -- but they each are systems doers. They know everything is connected. We kept being reminded of this in encounter after encounter. Drug abuse, nutrition, lack of income, transportation, housing,

obesity, incarceration, medical care -- they are all connected. They know they can only work on one part of the system at a time, but they carry an awareness of it all.

And not surprisingly, children are always at the center of the system. The licensed child care providers who know that what they feed their children is likely the only solid nutrition they will receive all day. The grandfather raising his son’s children. The mom raising her deceased sister’s children. The people who create foster homes so children can be saved from abuse. The ones who say with sadness that we must forget about the adults and care for the children. Standing in the contradiction that true child health requires healthy families but how to move forward when families are seemingly irreparably broken.

If we want to build a culture of health, these are the ones we need. They need to be trusted and supported. They know what work needs to be done. The somewhat astounding good news is that it doesn’t take rocket science to build a culture of health. The issues and principles and practices are widely recognized and understood. People know what’s important. They know how to do it and where to turn. They understand. They need to be listened to and witnessed. They benefit from being connected to one another. Sometimes they need particular kinds of learning to guide them into even deeper work. They don’t need to be told what to do. They are action learners. They stumble and they fall and they pick each other up. They are in this work together.

Values

Certain values -- speaking the truth, doing one’s part, welcoming others, making a path together, taking a risk, respecting both self and each other -- are the threads which weave together a culture of health.

You know this, of course, given your own prior work on making health a shared value point. Let us share a little of how it has been most alive in our listening. These are simply the values of healthy community. Perhaps they are more present in communities where money is often scarce and people know they must turn to each other. How do they treat each other?

because no way can this be done alone. They find those they can trust.

They speak the truth and share deeply personal stories with each other. Some shame may be there, but it is mingled with pride. They have been beaten down and they are surviving. There really isn’t room for posturing here. The petty politics of boardrooms and committee meetings don’t have much of a chance. Lives are at stake -- and they know it because they see it every day and it breaks their hearts. They turn to each other,

Welcoming others is essential and it is what people in community know how to do. They know that they need each other. Even if they don’t particularly like this person or that, mostly they know they are all in it together. This welcoming happens at multiple levels. It is the welcoming of community folk in Williamson, West Virginia, who come together for a morning to talk about a new “health passport” program being launched through the Health And Wellness Center. They don’t talk so much about will this work, but rather about what they will do to make it work. It is also the welcoming of top professionals from across the state who come together in a newly formed statewide coalition on ACES. The energy is a bit different -- they have budgets and people they report to. And, there is a deep welcoming and appreciation that we must work on ACEs together.

When people come together with this spirit of welcome, they know they must make the path forward, together. There’s no single master plan. Of course, there is much to be learned from the work of others. But programs that help to create a culture of health must be planted in local soil. People must come together and try and fail and succeed and keep coming back. Some get worn out and step aside. Others step forward. The programs need to be funded, but they do not stop when the funding disappears. People just keep looking for another way. They know the direction they want to head and they find the next step and the next. The work of Grand Nation in Vian, Oklahoma is one example. Community folks, no longer turning a blind eye to the rising tide of drug abuse in this small rural community, turned to each other and said we gotta do something. They didn’t where to begin. But they figured it out and now, five years later, work in many aspects of the life of their community.

They take a risk, both in terms of speaking of their own personal frailties, and by their willingness to do something they have no idea about how to do. The woman who now runs the food pantry at the Welcoming Table in Turley, Oklahoma, didn’t even want to be there. But she sighed and agreed to come for one afternoon a week.

Now, she tries to get one afternoon a week off! She uses the small resources they have to drive her big truck to food banks and stores and restaurants and farms to find the healthiest food she can to share with her neighbors. She took the risk of having her heart opened even further and the risk of doing many things she had never done before.

She has come to respect herself and each other. She is not alone in this. The work of building a culture of health is based on respect. It is based on helping people regain their pride and their confidence. Restore dignity and health will follow. A young man from Santa Fe lives in the house built by his grandfather and where his father grew up as well. He sees how his neighbors are plowed under by gentrification and pushed further away to places that are food deserts with no jobs and dwindling hope. So three times now he has organized the opposition to the City’s increase of bus fares, which just increase the cost and decrease the likelihood of people getting good food and good jobs. He names what the city tries to do as disrespectful and unkind.

These phrases only begin to describe values which are present when a culture of health is restored. They reach into this sense of people connecting with each other and with the land and with the very nature of life. A culture of health emerges from a lived experience of caring and being cared for. Really, it is just what community is truly about.

Built Environment

A built environment which provides easy access to the beauty of nature that is walkable and bikeable and sensitive to the needs of those with mobility challenges provides the pathways that connect community. What are the characteristics of a built environment that define this landscape?

Bikeways and pathways. Affordable housing. Parks. Art. Beauty. Nature. Farmers Markets. Stores with real foods. Buses and bikes.

It all exists together.

At the Welcoming Table in Oklahoma, the volunteer staff pay attention to the details: noticing the family that consistently overlook good available food choices and engaging them in a

I used to take three meds for blood pressure. Then I moved from east to south Charleston where I could ride my bike and walk, I had a grocery store and everything changed. It’s not just about treatment, it’s about assessment of causes.

Deshaun, Charleston

conversation that eventually reveals those foods require water to prepare them as well as a way to heat that water -- something they lack in their ramshackle home. It’s hard to be healthy without affordable housing.

In Williamson, West Virginia, people are walking again. Walking clubs and keeping track of personal achievements -- and doing so with others. In New Mexico, the health councils created walking maps with safe routes for pedestrians that doctors can use to prescribe walking. Nothing new was built, just re-using those same old town streets and byways.

How do we construct build environments that support a culture of health? What is the combination of public will and public policy that creates cities and towns and villages that are both livable and healthy? What are the questions and opportunities we must pay attention to?

Critical Health Issues

In each community we visited, people were coming together around particular pressing health issues. What was most striking was that people -- moms and dads, teachers, government workers, health professionals, community members, children -- knew what the issues were and knew what needed to be done, even if they were not completely sure what to do next. A West Virginian doing her doctoral dissertation at Johns Hopkins on community health expressed it eloquently: what’s going on in every community is exactly the same and totally different. Concern about diabetes, and also shortness of breath, tiredness, and lethargy are entry points for working on nutrition and exercise as antidotes for obesity.

It’s not long before conversation turns to the economy and lack of jobs. People without income don’t have the cars or money for gas to drive 30 miles to the store that has fruits and veggies they can’t afford to buy. Their esteem is low and stress is high and it gets taken out on the spouse and the kids, perpetuating cycles of trauma and abuse. Helpless leads to just one more drink or hit, a longing for escape.

The quest for nutritious foods leads to a recognition of food deserts, the decision to grow community gardens, work to create farmers markets and other public/private partnerships, operation of food banks and mobile food pantries that are at least trying to improve nutritional quality.

A glance at drug abuse reveals families and communities where hope is short supply -- no jobs, isolation, no vision of any future in particular, sometimes chronic pain and sometimes making meth the only visible path making money and getting temporary release from despair.

My mom was an addict and she chose addiction over me before I was a year old. It floors me that addiction can have such a stronghold over you that you can abandon your own child.

Jennifer, Oklahoma

Then the conversation turns to who’s in jail and who’s out and likely headed back. The revolving door of incarceration makes it easy to blame someone until that someone is a cousin or neighbor or son and you know that when they come out they

can’t get a job and even if they find one, they can’t get a loan for a car or a home. --

I was in and out of jail. That’s what I knew. I was born into this world, I didn’t create it. People take their lives when they don’t believe change is possible. It’s a mental health issue. I spent most of my life angry. The circumstances in our lives shape us. Trauma is poison. Now my life is about creating power, about caring and seeing each other as people.

John, Oakland, CA

And always people talk about children. Grandparents raising grandkids. Older siblings raising the youngsters. Agencies trying to improve the quality of foster care and foster homes because it’s the only chance kids have. Parents trying to recover dignity and their role as parents. Childcare centers that are the only points of stability in stressed and overworked households. How can all these, and more, be supported in the struggle to raise healthy children.

I do volunteer work to keep busy. I want to understand more about my community. I just got my kids back. It’s not easy, but I’m taking them to the park to spend quality time. I also take them to the library and they love it. I try to do more for my kids than I do for myself. I’ve been sober for 2 years now.

Larinda, Stockton

In communities where a culture of health is growing, community members know they can only do one thing at a time -- but they also know the restoration of health requires the transformation of life. They see the interconnected system and they reach out across all boundaries to form relationships with others who are making a difference as well. Some are content to focus on one particular issue or opportunity and do more good than harm as they try to keep things from getting worse while unsure of how to make things better.

A Call To Healing

There’s an acceptance of how both historical trauma as well as stresses and adverse experiences encountered in life play a critical role in well-being. People just know that these traumas don’t vanish but can be seen and acknowledged in ways which diminish their power.

Vicki Downey, a Pueblo elder in New Mexico, knows that health cannot be restored until trauma is released. She simply goes where called. Working mostly with women and mostly with native populations, she shows up. She spoke of a particular trauma circle developed in Pueblo communities where women sit in a circle, each holding a rock. The first woman, from the oldest of times, speaks of the oppression of the European colonialist who excused their egregious behavior with a papal decree that natives were less than human. And she places her rock in the

sack and passes it to the next woman in the circle. They each tell a story of exploitation and disregard as the sack passes, getting heavier and heavier. Finally, the woman of our current times is presented by this heavy sack of rocks, overflowing.

Another hispanic elder we met a little later says there’s too much focus on historical trauma -- people just need to get out and exercise and eat better. But she says these words with kindness and respect. People are different, yes, and when members of community find the place they can step forward -- not trying to do everything, but just doing what is theirs, health happens. When they turn to each other and do it together, a culture of health becomes visible.

Convenings

Creating a culture of health requires that we come together as communities, having conversations that matter -- exploring, wondering, synthesizing as we learn from our own experiences, hear about the experience of others, and work together to co-create a host of new possibilities.

We need each other to create a Culture of Health. Community is required and community learns about itself when it is convened. We have witnessed two levels of convening and would love to see more of a third: 1) Local; 2) Regional; and 3) Translocal.

Of course, local. Within systems and organizations. Across communities. This listening tour itself was a context for more convenings. We helped to bring people together who had a hunger to hear each other’s stories and to also tell them to people like us, from “away.” In a connected community, people turn to each other and they listen, learn, and cocreate. Some of these convenings are the meetings we’re familiar with -committees and groups and community gatherings. Others are a little less visible -- the conversations side-by-side in the community garden or while nibbling on a handful of berries in a farmer’s market.

We saw one stark contrast to these kinds of convenings when we were in West Virginia. We were invited to show up one morning in a small town where a mobile food pantry would deliver foods. There was no convening. There was just a sense of helplessness. People waiting in line to get their number -- arriving hours early so they could be first. People waiting in line for their number to be called. Some conversation, but mostly waiting. Subdued voices. Waiting. The mobile pantry provides an important service. Is there a simple convening around things like a mobile pantry that also helps to build community? What else might be done that helps to restore a sense of dignity and possibility? Can pressing immediate needs be met in a way that also restores hope?

The gathering we hosted at the Church of the Restoration in Tulsa was one memorable example. Reverend Davis, a black elder now blind, called his people together. Until June they did not sit in the same room with each other. Because of Reverend Davis’s dual career as minister and health department official, several ranking members of the city and county departments of health were there. Because his church is a sanctuary,

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members of the community with little or no money were there. One woman reminded us that since she had a garden, she was not poor -- she just didn’t have money. Others came because they heard something interesting might happen. Sitting in circle with each other, one after another shared part of their story with each other. Their hope and their longing and their frustration and anger.

As our three hours drew to a close, one woman said we need to keep doing this. I didn’t know all of you before and there are more out there like us. What if we start to have a potluck meeting once a month to be with each other and think together about what we can do here? A date and time were selected. They will meet again.

When this kind of engagement is present, there is a chance health will be restored.

We didn’t know of three regional convenings when we selected the regions for the listening tour. But once we started reaching out to people we were immediately invited to join the Cherokee Community Leaders Conference, the Try This West Virginia Conference, and the New Mexico Health Equity Partnership gathering. In each case, a region wide system was being convened. To support each other, to learn with and from each other, to find information, solidarity, and inspiration in each other’s presence.

When creating something new, it is so easy to feel alone and isolated. And that can lead to despair and to giving up. The people at these gatherings were not giving up, they were going deeper with each other as they gained strength. As meeting designers, we were both impressed and noticed areas of possible improvements. Bringing our graphic recorders and sometimes a little of our design skill was a welcome addition. A culture of health is hard to build or sustain without these kinds of connections.

And, we also found ourselves yearning for the next level. We call this level translocal and it is where people from very different local systems over a wider geography gather from time to time to share and learn. We did not encounter such gatherings on this tour, but we know them from our prior experience in extended communities we have helped to convene. While it is very important and inspiring to gather together with people from West Virginia, it goes one step further when one sees that what we face and how we face it in West Virginia is not all that different than what people face in New Mexico or Oklahoma or Oakland or Stockton. We are in this together.

Taking Action

Aswe explored in this landscape of a culture of health, one of the key questions that guided our listening was what are families already doing to improve their health? What was clear from the very first calls we made to begin organizing this listening is that the level of public understanding and awareness of health issues and what needs to be done to get healthy is substantial. People stepping forward in their families and in their communities see the relationships between diabetes, nutrition, weight and exercise, they know about stress, anxiety, and other social determinants of health. They understand that drug abuse, joblessness, and incarceration are all part of a seemingly never ending downward spiral of poor health.

So what are they doing? In every region we visited people are stepping forward because they see something they can do that will make a difference. We’ve written about this in the section on how change happens as well. What emerges from these individual efforts is a mosaic of practices which have the potential, if amplified, to create a culture of health.

Throughout the tour people shared their stories about what they were doing to help members of their families and communities be healthy. We’ve mentioned some of these in the preceding section describing the landscape and we will risk being repetitive and include them here with more detail as well. We’ve used the four kinds of practices named in David Snowden’s Cynefin Framework to categorize what we heard:

The Cynefin framework has five domains.

n Obvious (replacing the previously used terminology Simple from early 2014), in which the relationship between cause and effect is obvious to all, the approach is to SenseCategorize - Respond. Here we apply best practice.

n Complicated, in which the relationship between cause and effect requires analysis or some other form of investigation and/or the application of expert knowledge, the approach

is to Sense - Analyze - Respond. Here we apply good practice.

n Complex, in which the relationship between cause and effect can only be perceived in retrospect, but not in advance, the approach is to Probe - Sense - Respond. Here we sense emergent practice.

n Chaotic, in which there is no relationship between cause and effect at systems level, the approach is to Act - SenseRespond. Here we discover novel practice.

The fifth domain is Disorder, which is the state of not knowing what type of causality exists. In this state people will revert to their own comfort zone in making a decision. In full use, the Cynefin framework has sub-domains, and the boundary between obvious and chaotic is seen as a catastrophic one: complacency leads to failure.

We’ve seen many examples of all four of these kinds of practices and have tried to select some based on our understanding:

n Best Practices are the things that can actually replicated elsewhere. The kinks are worked out, a lot has been understood. They will still vary from place to place -- but the core ideas are sound and they make a difference. They work. Let’s spread them.

n Good Practices are things that have been around the block several times. Edges are still rough, but something powerful is starting to become visible. These practices can be improved in their current contexts and they are far enough along that others may find valuable starting points in their contexts.

n Novel Practices are the new ideas which are being tried, tested and developed. They appear to have potential and are clearly worth watching and supporting. How they will evolve and what impact they will have is still unclear.

n Emergent Practices are actions being taken in response to very specific situations. They’re working and can be improved. They are generally not something which can implemented elsewhere -- they are very context-specific -but they are important to notice.

Best Practices

The term Best Practices comes from the never-ending search for how to make things replicable and scaleable. Even if a best practice, most things grow in the unique conditions of particular communities or systems. Directly transplanting them elsewhere, without the flexibility to take on the local context, leads to very uneven results. Best practices we encountered are:

n Spaces of Care - Gardens, Centers, Clinics

n Handle with Care

n Health Impact Assessments

n School Based Health Centers

n Keys 4 Healthy Kids

n Healthy Nutrition in Institutionalized Settings

n Bicycle Hubs

n Local Partnerships

Spaces That Grow Community

In the Landscape of Health, on page XX we detailed some of what we heard about three kinds of spaces -- community gardens, centers of community and clinics in community. We wanted to bring them forward as part of the landscape because they are so important. And we need to emphasize here that they are, in fact, best practices. These three spaces are essential in communities where healing is taking place. They are literally the ground for that healing.

The mechanics and the particulars are different in community. But what we noticed across the country is that where people are taking health seriously, they are in fact an essential and best practice.

Handle With Care

There’s a lot going on for families all over this country. Lots of stress and dysfunction which lead to traumatized children. This is a particularly prevalent story in West Virginia where the rate of removal of children from birth families for either foster or institutional care is one of the highest in the nation.

Kids arrive at school after a night of horror at home -violence, drug abuse, visits from the police. Likely little or no food. Homework certainly not done. A sleepless scary night. Teachers and administrators don’t know what’s happened and just become irritated with Johnny or Sally not performing well. A simple practice was created. When police are called to a home at night -- or any person called into a tense situation -- one of the first things they do afterwards is fill out a simple form and send it to the child’s school. The principal and teachers know to handle with care. They don’t tell specifics, they just let people know to go easy and be supportive rather than doing more to traumatize the child.

Handle with Care is one of those things that doesn’t take much money. Is very straight-forward and has an important stabilizing impact.

Health Impact Assessments

Health Impact Assessments (HIA) are a frequently used tool in New Mexico where we discovered that they were used by many organizations and communities. We also heard about their use in Stockton and met, as well, with the Oakland-based nonprofit, Human Impact Partners, who have trained many organizations an individuals in New Mexico.

The HIAs are a compelling example of how people working to address a variety of health concerns in their communities can develop both clarity and and capacity to communicate to others. An HIA of a statewide ballot initiative in California reclassifies low-level nonviolent crimes to misdemeanors and redirects funding to treatment and prevention. An HIA of alternative

school discipline policies in Oakland, Salinas, and Los Angeles, are improving health impacts. In New Mexico one of many HIAs is being conducted to analyze how uranium mining in McKinley County affected the physical, emotional, economic, and spiritual health of communities. (For more examples in NM or nationally follow these links.)

HIAs are the way that community can work from real issues and concerns, combining them with hard data, developing language that makes the landscape accessible to others, and formulating policies that will support future work.

HIAs have been around since the 1980s and there is a wealth of resources available about how to conduct them. What’s particularly significant in New Mexico is that HIAs are being carried out by enough people in enough communities that they are creating a common vocabulary for action and learning.

School Based Health Centers

In Oakland school health and wellness centers started in the 1980s and are now in 16 schools in the district. Triage services are now offered throughout the district. The centers offer medical and mental health services, education, dental and youth development, meaning health education, youth advisory and health care enrollment services for families. There are still a lot of unserved sites. The progressive health and wellness policy recently reorganized all the services to put the student at the center. It focuses on school gardens, safe routes to school, nutrition and movement, as well as indoor air quality. Capacity building and training is done with school staff, behavioral health services, including trauma support and restorative justice, are practiced widely, and parents are offered nutrition education. Work has been done on integrating sex education into different subjects like the arts or english and there are over 80 wellness champions across the district. The health policy has been translated into plain simple language, as well as translated into the 50+ languages present in the district, to make it more accessible for everyone.

KEYS 4 Healthy Kids

Dr. Jamie Jeffrey, knew that the work she did as a peditrician in Charleston to treat children was important. And she knew that she had to go upstream and figure out what could help them be more healthy before coming into her office. A researcher, she meticulously searched the web to find out what was working elsewhere to help children be more healthy. She knew she could not transplant those practices into West Virginia, but she could be informed by them.

Starting in one area in Charleston and then another, she set out to create a new program that would help kids be healthy, focusing on eating, exercise, and the spaces and support needed to facilitate improvement in these areas. KEYS provides education, toolkits, and ideas that can easily and immediately be implemented back at home to community leaders, as well as follow-up opportunities to ensure that practices don’t get forgotten. Given her success, she and her team are currently taking this initiative statewide. Dr. Jeffrey no longer serves as a pediatrician. She knows she can make more of an impact on child health by growing this program.

Child Nutrition in Institutionalized Settings

People working in childcare centers and schools are aware that the food they provide may well be the most nutritious children receive all day. Frazzled parent or parents -- stressed by not having a job, self-medicating on drugs, trying to get multiple kids where they need to be on time -- often result in a quick trip to McDonald’s or a stop at the corner convenience store or whatever happens to be in the fridge or cupboards. The school breakfast and lunch and a backpack of food to take home for the weekend is often most of the potentially good nutrition kids get all week.

Licensed childcare centers in West Virginia have completely revamped their feeding programs. They’re buying fresh fruits and vegetables and avoiding frozen and processed foods. They’re letting go of old cooks and hiring new ones and training them

on how to prepare nutritious meals for their kids. Schools in Tulsa have recognized that it takes more time to eat carrot and celery sticks than twinkies and that kids need to be hungrier to eat something not sweet rather than just throwing it away. So they’ve changed the order of the school day, putting recess first so kids burn off energy and are hungrier, then added 10 minutes to eating time (up from the actual 7 minutes kids had after they went through the line and picked up their food) so that the kids go back to class with enough good calories to see them through the afternoon.

Much of what is going on in these feeding programs are promising practices -- more work and refinement is needed. What’s a best practice, however, is concentrating on nutrition in institutionalized settings as a way to improve child health.

Bicycle HUBs

We encountered only one, in Tulsa, but it immediately stood out as a best practice. The Adult Cycling Empowerment Earn-A-Bike Program, the only program of its kind in the state of Oklahoma, has helped over 600 adults gain reliable humanpowered transportation.Transportation was a key health issue in every area we visited. Housing costs force people with limited incomes further and further away from population centers. That means they have to travel further to get to stores where they can buy nutritional foods at all -- let alone at reasonable cost -- and they often have to travel further to get to any jobs they have. Many can’t afford cars. And public transportation in areas where we listened is very, very scarce. They collect old bikes wherever they can. People can pay $35 to buy a bike, or they can spend 5 hours helping to repair and rebuild bikes. One of the astonishing things the Bike HUB reports is that 50% of the homeless people they serve are able to change their status when they have a bike -- they can get and keep a job, and have the money to pay for housing again.

Real Local Partnerships

Finally, at a process level, we noticed that everywhere people know that they have to turn to each other to get the job done. In our experience there are two kinds of partnerships. One is where a bunch of people -- usually professionals -- sit around a table and say nice things to each other. They’re cautious and careful. Sometimes meaningful action emerges -- but often not. The other is where people are called together with clarity of purpose about a community problem or opportunity. Something needs to be done and it needs to happen now. Usually family members of those most affected are front and center. And people know they need each other. NOW.

Good Practices

When we grouped practices we had encountered into these four areas, we noticed that much of what we classed as good had to do with learning. Probably no surprise here. If our intent is to create a culture of health, we’ve got a whole lot of learning to do. And that includes learning how to learn in different ways.

Over the last 20 years or so there has been an explosion of PhD and Masters programs around leadership and systems thinking and entrepreneurship. Likewise there are numerous certificate program and seminars and workshops in the same territory. In our experience, these programs often don’t reach either people working at the grassroots or those working in health-related areas. But there is a need, and people are creating the learning opportunities themselves. Promising prototypes exist -- and there’s room for improvement.

These promising learning practices fall in several categories:

n Annual events that convene people from many communities and systems.

n Skill building

n Professional development

n Community conversations

Annual Events

As mentioned, we encountered them in West Virginia, Cherokee Nation and New Mexico. Each different with similarities as well. In West Virginia there’s the “Try This” conference where, for the third year in a row people from all across the state come together to share what they are doing to improve health in their community. This June about 400 people came. In Cherokee Nation, for many years, the Office of Community and Cultural Outreach has convened a Cherokee Community Leaders Conference -- about 400 people came this June. In New Mexico about 150 people came to the New Mexico Health Equity Partnership gathering, also in June. We were able to be present at all three. This report is not the place for a thorough exploration of each of these events. There is always room for improvement in terms of clarity of purposes, design of different tracks, creating conditions for self-organizing, and structures and processes for supporting people once they have returned to their home turf.

What’s clear is that there is a hunger to be together and to support each other and learn with each other. These annual affairs are important for exchange of information, for deepening clarity on values and principles behind cultures of health, for inspiring each other to just keep going. They create community and they deepen competence.

Skill Building

Everyplace we turned, people are coming together to learn skills.

n There is a program in Kentucky people in West Virginia want to bring into schools. The program works with teenagers who are pregnant or already have kids. Rather than stigmatizing them by ignoring them and turning an eye the other way, the program is a full on encounter -training them in all aspects of parenting and child health as well as providing childcare on-site during the school day. The program is now achieving a 97% graduation rate among girls who would have normally dropped out in the past with 90% going on to postsecondary education.

n In Stockton, through the Family Resource and Referral Center, stipends are being paid to teenagers to go out and do research in the community around different community issues. They are developing research and inquiry skills, improving their self-esteem, contributing to the community, getting paid and not getting into trouble!

n Schools are trying things in new ways -- like the ‘eat, exercise, and excel’ program in Kansas where they’ve made it a priority to give every child more water and vitamins, started to eat lunch family style in the classroom, and converted the cafeteria into a exercise center used for at least two physical exercises each day.

n At the Indian Health Center in Tulsa this takes the form of merging health care and community building. So they are offering cooking classes, wellness fun and family days, reintroduction of games from their indigenous culture, and other activities that begin with the belief that people here really care, want to be well-rounded, and will always do more than is absolutely required.

n This skill building takes place in different regions in “summer camps” where individuals and families come to build new skills around healthy living. In Vinita, Oklahoma, where Grand Nation focuses on drug abuse, the summer camps are to rediscover the fun of playing physically demanding games together while eating good food.

n One of the things that people running the many farmers markets that now exist is that people have to learn how to use fresh foods - especially those they have never seen before. Selling fresh food requires teaching people how to cook again.

n In Tulsa they’re giving kids things they can do when they get mad, rather than striking out, and tools to identify and manage their own anxiety.

n In New Mexico they are teaching teenage girls how to use entrepreneurial skills to improve health at their schools and in their communities.

Safe Spaces

After school programs create an intimate space to help children deal with trauma and other adverse experiences, rather than pulling them into magnet programs during the school day. The pullouts tend to be traumatizing because of the identification and separation.

Community Conversations

In all regions people are working to build community again. They are convening conversations because they know that their communities themselves have many of the answers about how to restore health. In Oakland, one participant remarked “when you have chronic disempowerment and little or no infrastructure,

there is no community”. We don’t know what we don’t know and what some expert from the outside has to tell us usually falls on deaf ears. So a question like why should I go to a doctor when I am pregnant if I’ve never done that with my previous kids (immigrant mother, Stockton) becomes something that can then, perhaps, best be approached conversationally with peers rather than by listening to an expert.

In New Mexico an organization has recognized that wealth disparity is a bigger issue than income disparity and they regularly host mealtime conversations to help families build their assets -- social, skills, and physical -- to get ahead.

Novel Practices

Everywhere people are doing things that grow out of unique, complex, local situations. They create good outcomes locally and can be studied for inspiration.

The “Try This” movement in West Virginia is a prime example. We mentioned it above as a good practice because the annual conference is similar to ones in other regions. The overall movement is also a very novel practice. This movement is in its early stages and shows much promise About five years ago a reporter for the Charleston Gazette got disgusted with the ways in which people in West Virginia always put themselves down. She wrote a series of articles about the wonderful things happening all over the state -- things people had forgotten how to see. West Virginians have, for a long time, been the victims of negative narratives from the “Big City” newspapers. When one is told you’re dumb, poor, stupid, and backward so many times,

it becomes internalized. Kate Long set out to offer a counter narrative that celebrated what was working in West Virginia. After the series was published, people started saying “we want to know more about these amazing things our neighbors are up to across this state.” In 2014 the first “Try This” conference was held and it has evolved into a movement -- an ecosystem of pride -- with mini-grants supporting local work and with people from across the state coming together to help each other take new action.

Deborah, mentioned before, moved to Las Vegas, New Mexico, and started paying attention to the stories she heard of corruption in the privatized prison and how the prison was basically a revolving door -- people went in, got out, and returned again. She led the successful effort to de-privatize the prison and to create local systems to help ex-cons lead more productive lives.

In Cherokee Nation, women are the ones who have the authority in families and communities and it is often the women who step forward when they see something that can be done. That’s where Lorraine Hummingbird in Locus Grove stepped forward to create a Free Store. A member of the Cherokee Elder’s Council, Lorraine visited many people in their homes and saw what was needed as well as what others had. In many ways the Cherokee are a tightly knit community that takes care of its own. She saw that some people had more than they needed -- clothes, housewares, furniture, food -- while others had less than they needed. She saw a Free Store as a place where surplus and scarcity could meet around Cherokee values of tribe and community.

Emergent Practices

All over the place, people are trying new things and seeing what will work. They may eventually lead to novel or promising or even best practices. The practices will change as those leading them make that journey. We will not try to list them all, but want to give you a flavor of what people are talking about and wanting to do -- things they see as intimately related to creating a culture of health, that require an emergent approach:

n Coal’s not coming back. But we’ve now got more flat spaces in West Virginia, where mountain tops have been removed. Are mountain top farms the way? Can we use appropriate technology to rebuild the soil in one- to two-years rather than the four to five it would take naturally?How can we use that land and what training can help former coal miners find new prosperity?

n Could there be an annual Culture of Health summit and lab where people from several different regions could be supported as they map both needs and assets developing more skills to make a difference?

n Could we build community across different ethnic groups with cooking classes and shared food?

n Let’s work from inspiration rather than working at replication. True innovation is local.

n What would it take for us to build a community based on generosity to counter scarcity thinking?

n Support the gatekeepers and guides who help people navigate bureaucracy.

n Keep watching for the whole system. What is the relationship between lack of transportation and incarceration and childhood poverty?

These questions and principles, and ones like them, all need to be explored further as people keep trying new approaches and see where they will lead.

Inour listening, we heard content related to the HCHW team’s current learning questions, which is included previously in this report. We also heard a lot from participants about community engagement. These recommendations relate both to community engagement and grantmaking. Throughout the course of the tour, we also heard recommendations that elevate questions that the HCHW team may not be considering currently, recommendations that begin to look at the internal conditions that need to be present within HCHW (and more largely within RWJF) in order to continue the journey towards effective and continuous community engagement. We hope these recommendations will be helpful as the HCHW team considers the process we suggest for authentic community engagement, and the proposals we provide as paths towards that end.

1. Do place-based work and provide long-term funding

Do place-based work over a long period of time, providing consistent, flexible, and timely funding to address the intersections of health in specific communities and/or regions. Build relationships with people and places. Invest in integrity and alignment, not in proximity. Invest in the

capacity of people, and fund people who know the ecosystems they are a part of. Know the communities that you engage with and their specifics. Health challenges can be population-wide and nation-wide, but solutions and approaches need to be community-based.

u Support natural alliances that are already occurring. People are working with those they feel connected with. They find each other out of necessity and work together. Fund people to work together more in the connections they already hold. When you see an opportunity for two people or organizations to work together, provide the space for them to know each other.

u Fund community healing work. There is a lot of pain and trauma in this country stemming back to colonialism that needs to be addressed as we build cultures of health. As of now, “healing [seems to be] a revolutionary act” (Sammy, Fathers & Families of San Joaquin). Conversation and sharing stories does not erase trauma or grief but it makes it easier to breathe.

u Fund organizing. Organizing has been an important part of social movements historically.

“We know what needs to be done. We need power, and we don’t have it” (Oakland organizer). People need power to build a culture of health. Funding organizing efforts will help build power in local communities.

u Employ people within the communities themselves to be the links between communities and the foundation.

u Know the communities in which you work. Even if you don’t fund all of them, know the actors and initiatives that are building a culture of health in the communities you are a part of. Find what’s already working in communities. Connect the dots. Help people see connections they might not see.

u Get close to communities. The closer we get to our community the more humility we have when doing our work.

u Provide multi-year funding so that communities may do the long-term work of building a culture of health.

2. Fund people you trust and build shared accountability

The extra activities here at the clinic help us understand that people here really care. Being well rounded and doing more than necessary. It helps build my trust in them. The cooking classes, wellness fun and family days, playing cultural games like stickball, are all great ways to meet other families and build community. I feel less alone that way.

Laretha, Tulsa, OK

When someone trusts you, they will tell you anything. And then the stories get bigger!

Tina, Oakland

Trust is the result of many smaller actions that lead to healthy, honest, open, relationships. Therefore, build relationships with people that have similar goals as you. Create the relationships for people to bring their own experience and knowledge into the conversation so that the picture can be more complete. Be ok with people’s ideas being different than your own; have the necessary (and sometimes difficult) conversations to find the way forward, together. Be in relationship with

people to understand what solutions they see. Listen to understand what more is possible. By taking actions such as these, the bond of trust will be built.

“We know what we need. You need to trust us and support us in finding our own solutions.” (Oakland community organizer)

u Begin with the relationships you already have. Find logical entry points into communities, like regional funders, regional networks of funders, partners you already have, organizations you have already funded or worked with.

“Our job is to help our communities. We don’t always know what that means, but we know they’ll tell us.” Mark from Cherokee Nation Community Outreach

u Be ok with people’s ideas being drastically different than your own. When they are, ask questions to better understand their perspectives and approach.

u Ask questions to understand. Listen to the answers.

Ͱ Study Otto Scharmer’s Levels of Listening.

u Convene people to share ideas and generate solutions collectively.

u Be clear and honest about what you can and cannot do.

u Be present yourselves.

“If the foundation wants to know what life is like here, they should come here themselves” (Phoenix organization and community leader). This wasn’t a message across all communities, but it was true across some. If the foundation wants to engage more deeply in communities, it can become a held value, and be practiced inside the organization. (We explore this view more in the community engagement model.)

u Be clear about what you don’t want to fund. One participant in West Virginia shared that she had applied for support to address substance abuse in West Virginia, and received the response that the foundation wasn’t supporting substance abuse, but that wasn’t clear in the beginning. If they had known, they would have applied for another project.

u Tell applicants why you didn’t fund them so that they can learn from it. “Don’t hide behind vague language - if you want us to take a risk and be truthful with you, model that behavior for us.”

3. Engage community members to be decision makers

“Community Health Centers in Tulsa have 50% of their boards made up of users of the centers. We often have the wrong people at the table. They are not the ones who need the services, they shouldn’t be deciding what happens.” (Community Health Worker, Tulsa)

“Sometimes the structures you impose don’t work for us, things are different here, for example, common evaluation. Can we develop that together so that it works for all?” (Funder, West Virginia)

Many participants in conversations, from local foundation staff to community members to organizational leaders, spoke of shared decision-making as a way to bolster trust and amplify the good work already being done in communities.

u Create advisory committees made up of community members to advise on projects and make funding decisions.

u Engage community to make funding decisions.

u Find ways to let the communities themselves decide how the money is used.

“Let us decide how we use the money. It’s not my money, it’s not your money, it’s our money” (Community organizer, Oakland) “It’s just time to do this work. We know what to do about ACEs, social determinants of health, nutrition, equity. We know what else is possible and it’s time to get going!” (Community health worker, West Virginia)

4. Provide Flexible Funding

“If we raise an issue likes ACEs in a community, other needs will rise to the surface. If surfacing traumas like ACEs, organizations must be ready and able to respond to the consequences. They need access to funding to be able to respond, and not to have to go through the bureaucratic process of securing a grant.” (Director of a teen pregnancy program, West Virginia)

u Have flexible dollars within the HCHW team that organizations already receiving grants can access easily in whatever structure makes most sense for the Team

u Have line items in budgets that are for flexible purposes

u Fund as movements happen – in the moment, and quickly.

Organizations are working in systems, they are not working on isolated issues. They need dollars that are not project-based, but rather dollars that respond to the present needs in a given time. Sometimes that is about bolstering a project, sometimes it’s about filling a gap, sometimes it’s about paying a debt to increase the financial health of the organization. Whatever the need, if the foundation funds based on trust and shared responsibility, the needs of the whole organization and the systems they are working to influence can be considered and addressed in a timely fashion.

During this tour, we also got to hear Alicia Garza of Black Lives Matter speak to a group of funders, during which she said: “Fund us to innovate and test and iterate and find out what works. And don’t ask us to define deliverables in advance -- support us in finding ways to notice what’s happening and to define the measurements that tell the story of the work we’re doing. Movements and organizations are responding to crises now and need funding to do that. Philanthropy in its current moment doesn’t know how to fund Black Lives Matter.” (Alicia Garza, Black Lives Matter)

5. Create learning and connection opportunities

“The convenings that I attended through that grant were really good. The process and the agenda design were focused on authentic relationships, and so we got to know each other and learn from each other in a real way.” (Quinta Seward, Safe Passages, Oakland)

The needs are so great, and the pressures so high, that to take a step back from the work feels almost impossible. And yet, we know that the power of learning from each other, and creating relationships of mutual support, can be some of the most meaningful work that we can do. As grantmakers, you have the power to build these types of spaces for grantees. While doing this, of course, we must be aware of the demands that are included in attending a convening.

u Provide convening opportunities for grantees, community leaders, and partners that are culturally grounded, and that provide opportunities for authentic engagement. Focus on creating and/or deepening relationships and sharing learning.

u Fund learning within grants -- within organizations, within local systems, in regions and trans-locally across regions.

u Provide opportunities for grantees to slow down.

“Food banks need the time/opportunity to slow down for long enough to have the conversation as to what it would look like to not need so much food distributed.” (Chad Morrison, Mountaineer Food Bank)

u Engage participants as a part of the design to ensure that their needs will be met and the demands will not be too high.

u Share failed practices and learnings.

u Bring faith leaders together similarly to how we bring nonprofit leaders together.

6. Fund Positive Communications Strategies

We need positive stories of community change and survival. So many of the current narratives reinforce how broken communities are, highlighting the negative statistics of health challenges and disparities, pitting communities against one another. One conversation participant said “stop telling us how broken we are.” Christina, from La Semilla in New Mexico, said “there is an incentive to keep telling the painful stories as a way to secure funding. We need you to incentivize progress.” There are so many hopeful stories out there. Stories of communities coming together. Why not tell those stories?

u Fund and/or develop communications strategies that start with what’s most important to people. For example, in West Virginia, if bass fishing is what people care about in a community, then message campaigns around fishing and move the conversation sideways into health.

u Fund communications campaigns that humanize people.

Ͱ One patient at Cabin Creek Health Center began to share his story of feeling forgotten. “For years, mining companies have come in here and coal has left, trucks and trains flowing constantly down this creek. Nothing has stayed. And now that coal is on the decline, the government doesn’t do anything here. They don’t care about us. We are forgotten. If it were up to them, they’d dam this creek and flood us all.”

“I had a list of challenges from the head down of physical and mental disabilities. Get moving! Neurotransmitters, dopamine all happening. Now I don’t take any pills - just through transforming our community gym. I’ve got good people to mentor me. This is for everyone, bipolar, full of demons, black, white, addicted, obese or thin. I started small and now I have a whole community behind me. The devil is a liar, he wants us to stay home addicted. Get up!” (Community change agent, West Virginia)

In Oakland, Olis Simmons of Youth UpRising! stated:

“Community cohesion - this is the thing we don’t talk about. How do we not tell the story of the downtrodden, but the solution to be uplifted?”

u Fund communications campaigns that paint marginalized and broken communities in positive lights. Tell positive stories.

Ͱ A participant at the ACEs coalition in West Virginia stated, after sharing that she had “experienced them all,” the need for narratives that tell the whole story of the impacts that ACEs have and how people find health and wholeness after these traumas. She has done a lot of healing herself, she is a survivor. What about that story?

7. Work in partnership

With authentic community engagement, the wealth that each individual brings to the table is valued; our collective work is to make space for different experiences and knowledge. Marginalized communities know themselves, and hold that knowledge and experience as they work towards solutions. Foundations bring academic rigor, and dollars, among other gifts, to the table. Government, schools, and small businesses bring different gifts.

“We need to look beyond the surface of our issues into our humanity, at our values and beliefs. Otherwise we just keep creating bandaids.” Las Cruces, NM

u Work in partnership with other local foundations and regional networks of foundations. They know what’s happening on the ground.

u Let local partners know of upcoming opportunities so that they can inform their communities.

u Involve stakeholders in strategy development.

u Be aware that when your strategy changes, it affects communities.

While all partners certainly do not bring the same gifts to the table, if welcomed and leveraged, these gifts can lead to something that no one actor could do alone. This, however, is some of the most difficult work we can engage in. It is the psychological work of working with “othering,” with privilege, class, and power, and with the systems that oppress some and lift others up.

“At first I thought it was about changing policy, It is not. It’s really about power, and we ain’t got it. The answer? Build power! Lack of power is killing people.”

(John, Oakland)

“To be cast as ‘other,’ lesser than, is a self perpetuating cycle we cannot get out of.” (Mike B, Kanawha County Health Department, West Virginia)

u Work in values-based relationships with mutual accountability.

u Practice not knowing. We don’t always have to have the answers, and even when we think we do have them, we may not. If we are aware that our “answer” might not be THE answer, and if we allow ourselves not to know, we can work to build a potential solution with others, in partnership.

u Create partnerships where guidance is both given and taken.

u Do the necessary cultural and personal work to be able to welcome those who bring different gifts to the table. Continue to do this work and increase awareness of how we can build effective partnerships.

8. Learning within the Foundation

Building a culture of health requires that different actors and actions be connected within communities. This type of connection is required at all levels of the system, including within the foundation. Teams need to know what each other is doing, where the opportunities for collaboration or enhancement

lie. You have an opportunity to share information with each other regarding the communities and partners with whom you work. By doing so effectively you will share the knowledge you are amassing as well as the practices you are employing to have impact.

u Promote learning among different teams. Program staff need to be able to talk with one another to break down silos, learn from one another, and discover, collectively, the levers for change. To do this, program staff will have to speak truth to power in the context of philanthropy, as the culture of philanthropy doesn’t support this currently.

u Create spaces and systems for teams to come together in learning and sharing. Just as we encourage retreats for our grantees, we need to create spaces for ourselves to learn from and share with each other. This could (and should) be on a consistent basis, and it can also happen as a deeper, more expansive retreats, away from the office, where people have an opportunity to get out of their everyday spaces and think in new ways together. Engage in deep conversations for learning at RWJF -across teams, across issue-areas. Be in relationship.

u Align your community engagement efforts. If different teams or consultants are working in the same communities, align them in their efforts. Create the systems for such alignment to be possible.

u Pursue excellence over perfection. Begin somewhere and follow what works. Iterate on what doesn’t work. Trust that if you are in partnership with other staff and with communities, that you can find the best answer together. This recommendation applies both to learning within the foundation as well as to community engagement. We cannot let perfect be the enemy of the good, and we can do excellent work, even when imperfect.

9. Create policy from the lived experience

We collectively create results nobody wants. The disconnect between policy makers and their experiencing the impact of the decisions they make is part of the issue. Often policy makers don’t know about the lived experiences of communities, they lack context and have to make decisions based on generalized or incomplete data. We see great potential in creating policies from the lived experience. At the New Mexico the Health Equity

Partnership gathering, 64 representatives of several community organizations from all across the state came together to do exactly that. Building on the breadth of advocacy, research and lived experiences, participants provided recommendations, that are rooted in community strengths/assets, to inform a statewide policy agenda that would lead to a healthier and more just New Mexico.

u Engaging communities in policy making. People in communities feel the disconnection between policy makers and their awareness of the impact the policies that they create has on communities. Communities want to be involved in policy making.

Ͱ One idea we heard was the formation of community boards that would vet local policies before they could be passed. Another idea was the need for capacity building of local policy makers especially around diversity and equity in policy making. It was felt that all policies should directly address poverty and equity and take the impact on families into consideration.

u Invitational vs punitive policies. In West Virginia the question arose if a higher tax on tobacco will actually make people stop smoking or if it will just mean less money for children’s food will be available. In Oakland community organizers were opposed to the tax on sodas. In both cases it felt to people like a solution imposed on them and not one they would feel supported by to make healthier choices.

Ͱ In Stockton community organizations got together to propose to city council the “healthy by default kids’ beverage ordinance”, which means either water or milk shall be served as the default beverage in children’s meals. It was celebrated as a success and it is the second law of its kind adopted by an American city, following the city of Davis, California.

u Programs and policies are both important. Communities told us that foundations should not just focus on policy change. In Oklahoma, New Mexico, Oakland, and Stockton we heard many stories about the impacts of programs on people’s lives. For example how valuable summer camps are for children especially from poor families. Often that is the only place where kids get a meal during the summer when school is out. For example free cooking and parenting classes offered by the Indian Health Center in Tulsa were seen as invaluable by the parents.

POLICY

Thisproject has been an action-learning initiative from the very beginning. It is a listening tour that has been guided by deep listening throughout. At the outset of the project, NewStories and RWJF met to listen together for the deepest intentions behind the project and looked for what success would really mean. Based on those insights the NewStories team started to talk with colleagues across the country to find what regions were the right places to begin this listening.

How We Defined Success

In March, NewStories and the HCHW team came together to kick off this listening tour. We refined the objective of the tour, we explored what success and failure would look like, and we began to explore what authentic engagement meant as we designed and conducted a listening tour that aimed to learn from communities that experience hardship, aiming not to be extractive but rather additive.

After our initial meeting together in March, one main question rose to the top as the aim for the listening tour. The goal has been to learn, directly from parents and caregivers, how the Robert Wood Johnson Foundation can engage families to support a culture of health. Additionally, this national listening tour sought to answer the questions what is the living experience for all families, especially marginalized ones? What do marginalized families need to thrive? And finally, what issues are important to families in need?

Other things that were mentioned were both issue-based and process-based. For example, given the emergence of the HCHW team, there should be a deeper focus on obesity during this tour. And how do we listen to families in a regular way as a foundation? What are the conditions that need to be present to support that? How can engagement mean less about studying and more about understanding? And how do we engage affected populations versus having an issue-based objective?

n What you have read in this report relates to three different layers of this objective:

n Stories that provide insights to the HCHW current learning questions;

n Stories that provide insight as to how communities are building a culture of health, stories of everyday people interested in making change; and

n Insights and recommendations from our experience as to how RWJF can deepen community engagement values and practices.

Authentic Engagement

RWJF and NewStories both shared the intention that this process not be extractive, but that it add value to communities we engage with. While designing and conducting this tour, we never lost sight of that. We thought creatively about what we could leave behind. As NewStories, our gift lies in process design and facilitation. And so, we offered that to communities. Instead of asking community leaders to convene focus groups for us, we asked what the conversations were that they already wanted to have with their communities that related to the goals of the tour. We also sat in on gatherings that were already planned. We offered our design thinking support, our facilitation support, and graphic recording. In some places, like Phoenix, given the short timeframe of the tour we weren’t able to have community conversations, but the seed has been planted and watered, and is waiting to grow.

We have also prepared this report knowing that we will share it with the communities themselves. It is a small step, but one we feel will give something back to the individuals and communities that shared so willingly with us. There is more work to be done, and we have offered our partnership to all of those who have been involved in this listening tour.

What would success look like?

At the daylong co-creation meeting between RWJF and NewStories we asked everyone to brainstorm how failure, success and epic success of this project could look:

epic SucceSS

q Diagnosis only and same old story: things are hard (food, money, jobs, transport etc)

q Families don’t benefit and we inadvertently antagonize, alienate, marginalize, use & take advantage of them

q Sessions and report don’t provide added value for partners we work with

q We don’t make miss-steps or learn from them

q Our process for authentically engaging families do not change ie report sits in the closet

u Clear insights and expectations for how RWJF acts

u Deliverable is more than stories of parents, learn new perspectives from diverse groups (geographically, income, race/ethnicity)

u Families start to get a sense of empowerment from participating in these sessions

u Outcome of those sessions includes a clear set of actions, not just diagnosis

u Sharing valuable and useful info from the focus groups w community partners and participants

u Triangulated insights from other engagements with partners (e.g., Southern States listening tour and Baltimore engagement)

u We have new strategies & tools to do our work more effectively - increase our impact and make actual changes to our processes at the foundation that take lessons learned from this effort -> to better engage families in all our grantmaking steps/learning

u Mixed results, a lot learned from missteps, a lot to do better next time

p Great (meaningful & authentic) & valuable insights from families to inform our work

p We get great real life stories

p New relationships built and ongoing

p Families walk away feeling heard and valued, and they have gained new skills/ knowledge/empowerment/solution

p Clear immediate pathways for participants & partner organizations for the ‘now what?’. People are empowered and mobilized to act

p RWJF start to set a new norm for how we engage with families directly and continue this kind of work with all themes, consistently, & intentionally

p We have a process in place for continuously refining strategy based on parent & youth voice

p This helps us to change the world

FAiluRe SucceSS

Epic Success

We have learned deeply about a model for engagement and include recommendations and proposals (as a separate document) as to how RWJF can deepen your engagement with communities, both in terms of building relationships and in terms of organizational practices and capacity building. Through existing relationships of our own, we have built and deepened relationships with local actors on the ground who are excited and interested in the questions that RWJF is asking and who are interested in engaging on a more consistent basis. Many are interested in partnership. We heard countless times that people felt grateful to be involved in these conversations. From the mouth of one participant in West Virginia: “This has been so cool. Probably the coolest thing I have done. To be involved in a national conversation about health? Really amazing.”

Success

Using a systems view, we have followed the people employing emergent strategies that are trying to build a culture of health in their communities. We have talked with parents and caregivers, and with individuals who are also community leaders, stepping into roles to help their larger communities be more healthy. We have spoken with individuals coming together to address ACEs across their state, government workers, nonprofits, activists, academics. We have spoken with grandparents who are worried about their children and the way their grandchildren are being raised. We have talked to young people who, with just $1,500, are building community gardens to address obesity and food access challenges. We will share this report back with them, as a way of supporting their interest in learning from one another.

Failure

We heard from some groups about their disregard and distrust of our efforts. In the words of one participant in West Virginia: “We’ve heard it all before. People come here asking questions and offering ideas, and nothing ever happens. The only good thing that’s happened here is this health center. The only thing.” We also had challenges engaging people who were in a more transactional engagement with the organizations that convened them. For example, when attending mobile food pantries, events where recipients had to register with their IDs, receive a number, and wait in line to get their food, the deeper questions around community health and challenges fell completely flat. We have learned from these mis steps, and will share insights throughout this report.

How We Engaged with Communities

This section details the community engagement process we used during this project.

income families towards a culture of health. In some cases we had contacts with community leaders directly. We started with people we are connected to/know best and moved from the ‘inside out,’ i.e., rather than starting with cold calls we started with the relationships we already had, and from there learned of relationships that already existed in communities. Relationships undergirded this whole tour. We started where we could, and followed threads where they took us. We worked to understand the ecosystem and context as much as possible in this initial phase.

Given ample freedom to choose locations, we knew this tour would not give us a representative sample of the U.S.. We chose locations as diverse as possible based on culture, demographics, as well as geography. We contacted more regions and locations than we ended up working in, due to our short timeline. We began considering ten regions, and ended up working in four.

Step 2: Outreach

We reached out to people in our networks - both professional and personal - and asked them to connect us with community leaders and organizations who are working with low

We created a short visual description of the project to share with our contacts, and had initial conversations about what we were hoping for. Where the conversations seemed to lead somewhere, we followed that. Our aim was to understand who the health leaders were in communities and what roles they filled. It ultimately turned out that these individuals ranged from community members who have stepped into both traditional and nontraditional leadership roles because that was needed in their communities, to nonprofit leaders, to healthcare professionals, to small business owners. Very often, these people were parents and caregivers themselves. And more often than not they had stories to share themselves. We quickly learned that labeling people “citizen leader” or “parent/caregiver” was an unnecessary distinction to make.

Communities and circles already exist. It began to make more sense to listen in circles where the trust had already been built, instead of creating new circles in which to listen. Circles did not need to be “identity-based,” unless defining identity as being a part of a certain community.

These initial conversations were done mostly at distance -- with in-person meetings when possible. As we identified community leaders and gatekeepers, we began to set up one-onone conversations for a first trip to the regions we were listening in. We did this in several locations in parallel. This way, we we were able to iterate and improve our approach as we progressed,

making effective use use of the short amount of time available for the listening tour. In short, this phase of the tour consisted of:

1. Identifying potential regions/locations.

2. Having initial conversations with personal and professional contacts in regions from afar.

3. Amassing contact information of citizen leaders.

4. Setting up in-person meetings with citizen leaders.

5. Meeting in-person with citizen leaders. When possible, identifying opportunities where our facilitation could be of service or in synergy with conversations the community already wanted to have and we could help catalyze.

6. Reflecting and sharing learnings as a team. Identify what is similar across regions, and what is different.

7. Letting regions go as necessary, as it became clear that goals or timing did not align.

Ongoing: Learning about context, trust building, and authentic engagement

On our first trip to each region, we spoke one-on-one with community leaders and gatekeepers to learn more about the local context, build trust, and discuss how we could best convene families and caregivers directly. In this case, building trust meant listening, asking questions, sharing our goals, asking for reactions to those goals, and following the ideas and inspirations that emerged. Building trust meant acting in solidarity, which has

a horizontal approach, honoring the knowledge and experience in the communities themselves.

Authenticity meant being clear about the scope and timeframe of the engagement, and clarity around what promises we could and could not make. With this listening tour, we were clear about the questions that RWJ was asking themselves about community engagement and grantmaking strategy, and that that there was no guarantee that funding would follow after the tour was over. We were clear about the timeline. This clarity also included being honest about not knowing what RWJ would do with the stories and information gathered from the tour, and what the future might look like. We could not promise continued relationships or engagement. What we could promise was to share the information back with the communities themselves. And we shared our own intentions with the project - to make this report something that would be alive and dynamic for the foundation, with information, models, and proposals that team members could work with and make sense of in different ways. We used an appreciative inquiry approach in this tour. Rather than focusing on diagnosing what was not working, we looked for what people are already doing to build a culture of health locally. Inherently, who, and what, is still falling through the cracks emerged as well, including what the continued challenges are. In our interactions, we paid attention to cultural and relational dynamics, being especially sensitive to power and privilege.

We listened deeply. There is much work to refer to on different levels of listening. If there is one central learning from this report, it is that listening is the most important central tenet to authentic community engagement. One model we work with is Otto

Scharmer’s Levels of Listening.

Listening is an important part of building trust and recognizing power and privilege. We can listen at different levels, as described in the image above, levels where we either bring or suspend our own perspectives and judgement. There are decisions that we can make about how we listen, and what goal

we have with listening. As we work to learn about communities that we are not a part of, Factual Listening and Listening from Within (levels 2 and 3) are desired levels of listening. As we grow towards building possibilities together, a much deeper and longer-term commitment, we ideally move into Generative Listening, where solutions begin to emerge that we may not have imagined previously. (With this tour, we didn’t get to Generative Listening (level 4), given the time frame or the level of engagement in the communities.)

incarceration, housing, in the language of foundations, but I can also talk about if from the grassroots voice. We need more of these translators” (Olis Simmons, Youth UpRising, Oakland). In our work, the initial work we did with our own contacts, and subsequently the citizen leaders and gatekeepers served in both building trust and working with and through individuals who were already a part of the communities in which we were conducting the listening tour. We didn’t always see success in this phase of the project. For example, in Oakland, in a circle with community organizers, while people were sharing very honestly and openly, some of the desire shared was that RWJ be present if they were going to convene another circle of community members. They didn’t want us as “translators.” “If RWJ is interested in deeper community engagement, then they should be here themselves.” “And what about employing people in the communities themselves as translators? We need jobs, and we know these communities, we are a part of them. Community engagement means investing here.”

Step 3: Location-specific interaction design and gatherings

We cannot expect to do this work of generating solutions or possibilities alone. Different circles and communities talk about a culture of health in different ways, and we all see both the challenges and potential solutions differently. Understanding the local context is a challenging piece of work, and is a critical piece in laying the foundation for continued work in community. Having translators who can speak both the language of the foundation and the language of the community is an added bonus if possible. “I can talk about all of this stuff - policy, mass

Through our conversations with community leaders we began to identify possible paths forward. Sometimes this meant attending a conversation that was already planned, for example, the Statewide ACEs Coalition in West Virginia, and paying close attention to the conversations about parents and caregivers. Sometimes it meant convening a group of patients at the only Federally Qualified Health Center in a region and conducting a more facilitated conversation. Sometimes it meant meeting with a group of community members in someone’s home. Given the short time frame of the project, we worked hard to sense what opportunities were arising, and followed those where we could. Flexibility was important during this stage. Our aim was to be smart with our use of resources and time.

Failures and Learnings

Time: Conducting this tour in a finite amount of time was a good thing, however, the short amount of time to prepare for the tour, including building relationships, learning about the context of a place, understanding if there was an opportunity to convene circles, and finally, convening circles of authentic engagement where the HCHW learning questions could be directly addressed would have taken much more preparation time and a much deeper level of engagement, however defined, for this project.

Sometimes, the gatherings didn’t work. Specifically, attending mobile food pantry distribution events with the hopes of talking with users did not work. These gatherings were very transactional and not conversation-based. People arrived, registered, picked up food, and left. Having conversations was nearly impossible. The setting of the events were not such that asking people invasive questions about the health of their families and communities was comfortable nor appropriate. We employed practices to try to invite people into conversation, and they rarely worked.

Ongoing: Harvesting

Throughout the entire tour, including the preparation stages, we were making note of insights and stories that would serve the larger purpose of this tour. During both the one-on-one conversations and the larger group gatherings, we took detailed notes ranging from direct quotes to insights to summarized stories. We trusted that we would all be making note of different aspects of conversations as a way to round out both the contexts and the stories we were listening into. We also had two graphic harvesters with us to capture the larger flow of conversations and reflect back the gatherings and the individual voices to those who had shared with us.

Step 4: Collective Sense Making

Throughout the two months of listening, both in the oneon-one conversations and the larger group gatherings, we came together as a team as often as possible to share our insights and learn with one another. From these conversations, we made adjustments to our community engagement approach.

At the end of the listening tour, we came together as a team to make sense of the stories we had heard in order to turn the tour into a digestible report and recommendations. We reviewed all of our notes, taking snippets of conversations and putting them onto Post-its on a large, open wall. We then began to cluster Post-its, coming to some sort of understanding of the different types of insights and stories we had. Through this clustering process, and the iteration involved, we built both a structure for the report, and found our red threads -- the themes that tied the report, and largely, the tour, together.

Step: 5 Feeding the Information back to Communities

Throughout the tour, both in designing and conducting it, we have been conscious of power and privilege, and not wanting to be extractive with the tour, but to have both the listening sessions and the end product be useful to the communities themselves. Participants in the listening sessions also shared how valuable it was to be able to learn from outside of their daily circles and communities. Throughout the tour, we have spoken as a team of the desire to bring all of the actors together across regions for them to share and learn from each other.

When writing the report, we held the communities and individuals in mind as an audience for that product. While we would ultimately like to bring people together physically to learn from each other, share ideas, and build relationships across regions, sharing the report is a first step in feeding the learning we have experienced back to the communities. We expect continued conversation around the report with those who receive it.

Questions we asked

n What are you seeing that’s making a difference in creating a culture of health that includes marginalized families?

n Who is falling through the cracks and how? Who is not getting access to nutrition or health care? Who has a set of disabilities that is making it hard for them to access services? Etc.

n What are the main challenges and obstacles related to health?

n What is the support you and others need?

n Who are some of the local people you are most inspired by?

n Who else should we talk to?

n How do we talk about this in a way that’s empowering and doesn’t turn people into subjects(objects) and applicants, ie leads to further marginalization?

n How do we best - in this context - engage families in a way that is generative and respectful of their story?

n What are some potential roadblocks we could face?

n What should we be aware of that we’re not?

n Would it be valuable for you to be part of a national gathering around a culture of health?

Who Did We Listen To and Where?

While the listening tour was not a comprehensive overview of the entire country, we did listen in a diversity of locations. And, while we don’t presume to know everything about the communities that we engaged with, but we did get a sense of what some of the challenges and bright spots are.

California Arizona

New Mexico Oklahoma

West Virginia

California

Arizona New Mexico Oklahoma West Virginia

Albuquerque

WestVirginia is a state blessed with the riches of a deeply interwoven community, and individuals who are hell-bent on making positive change. People are systems thinkers (and systems “doers”) working to transform entire communities, like the folks at Healthy in the Hills who are addressing the intersections of eating, physical exercise, community belonging, and income and employment. They are individuals who play different roles in their communities because they have to. They are individuals who love their state and want to tell positive stories to help shift the narrative of the current identity of the state. West Virginia is a state of incredible natural beauty - forest and rivers and mountains.

Albuquerque

Anthony

64 16-74 20% 80%

Since the founding of West Virginia in the 1860s, the economy has been based on coal mining. As coal begin to decline over the past 30 years, health and economic challenges have intensified, including obesity, diabetes, Chronic Obstructive Pulmonary

Las

Race/Ethnicity: Mixed

Anthony

25 8-63 20% 80%

Race/Ethnicity: Mostly latino, indigenous and a few white

Disease. People are out of work. Substance abuse plagues West Virginian communities. On top of all of this, transportation is extremely difficult given the mountainous landscape making it hard to access the services that do exist, not to mention a job if there were one to be had. Broadband access is also extremely low. West Virginia is experiencing population decline, and many people who can are leaving the state. Communities are fragmenting, and families are broken. The economic identity of West Virginia is evolving, but it is not clear into what. Will it be tourism? Agriculture? Something else? New stories are being told, but the shame of “being number 1 on all the worst lists” is almost palpable.

7 5-75 15% 85%

40/60 African American and white 20 11-65 20% 80%

5 55-75 60% 40%

Race/Ethnicity: Mostly cherokee

Race/Ethnicity: Mostly native and white, 1 black

5 11-55 100%

20 14-65 30% 70% Vian

Race/Ethnicity: Black and native

Arizona New Mexico Oklahoma West Virginia

While we listened in various different circles noted in the table above, we also had one-on-one conversations with individuals from the following communities across the state, the stories of whom are included in this report:

n Lincoln County - conversations with the United Way, Team for West Virginia Children

n Huntington, Wayne County - Facing Hunger Food Bank

n Tucker County - Family Resource Network

n Braxton County - Mountaineer Food Bank

Phoenix

circle name

n Multiple conversations with statewide community leaders based out of Charleston

22-60 50% 50%

Race/Ethnicity: Mixed

Director’s council of Daycare Providers (Participants were from Kanawha and surrounding counties)

Race/Ethnicity: White 10 20-60 100%

Healthy Kids

35 27-68 40% 60% Las Vegas

Government Staff - Bureau of Public Health, children and Families, and community Development

Race/Ethnicity: Mostly white, 2 black

Race/Ethnicity: Indian, latina, mixed and white 10 35-45 20% 80% Santa

Race/Ethnicity: Mostly White

Race/Ethnicity: Mostly White 30 20-80 50% 50% Cabin Creek

Race/Ethnicity: White 20 25-80 50% 50%

Statewide

500 18-70 50% 50%

Race/Ethnicity: Mixed

California

Arizona New Mexico Oklahoma

closely follows West Virginia in the bottom 5 of America’s Health Rankings. Some challenges include obesity, diabetes, a high rate of cardiovascular deaths, limited availability of primary care physicians, drug abuse, food deserts, and a 77% increase in child poverty over the past 10 years. We observed this to be particularly reflected in certain parts of Northern Tulsa, neighborhoods traditionally inhabited by African Americans, where the life expectancy is 11 years less than in other parts of the city.

Eastern Oklahoma is also the home of Cherokee Nation, the largest recognized tribe in the US, which has the best health care system for all tribes. The Nation’s Health services and programs run awareness campaigns like the Cherokee Challenge

and kids campaigning against tobacco. Efforts are being made to fill food desert gaps, including investments in developing community gardens, outreach to elders in rural communities, connections with schools, sponsored 5k runs, and more. And yet this generation of kids is expected to live less long than their parents or grandparents. The following circles are just a few examples of countless efforts to create healthier communities some of which we had the opportunity to learn about at the Cherokee Nation community leaders conference.

Race/Ethnicity: Spanish-speaking Latino parents

15 35-55 30% 70%

Race/Ethnicity: 8 African American, 2 white and 5 mixed/other ethnicities

Stockton

35-50 30% 70%

Race/Ethnicity: Latino, black and white

Stockton

50% 50%

17-85 25% 75%

African American Phoenix Race/Ethnicity: Mixed 15 22-60 50% 50% 0%

45 14-75 65% 35% Stockton Cabin Charleston Charleston Charleston Williamson Cabin Statewide

5 states

16 locations: 7 cities, 9 rural places

We listened to a total of 1019 people

Arizona New Mexico Oklahoma West

In addition we had one-on-one conversations:

n Tulsa - conversation with the Executive Director of the Jewish Community Center, also former Tulsa Police Chief, known for his expertise on community policing

Oakland

Oakland

n Tahlequah - Cherokee Nation Health Programs and Services

Stockton Phoenix

25 5-45 50% 50%

Race/Ethnicity: Spanish-speaking Latino parents

Oakland

15 35-55 30% 70%

Race/Ethnicity: 8 African American, 2 white and 5 mixed/other ethnicities

Stockton

8 35-50 30% 70%

Race/Ethnicity: Latino, black and white

Stockton

45 14-75 65% 35%

Race/Ethnicity: Mostly African American, some native, some white, some latino

Stockton

47 17-85 25% 75%

Race/Ethnicity: African American

15 22-60 50% 50%

Race/Ethnicity: Mixed

Race/Ethnicity: Mixed 64 16-74 20% 80% Anthony

indian Health center

Unitarian universalist community center

Race/Ethnicity: Mostly latino, indigenous and a few white

35 27-68 40% 60%

25 8-63 20% 80% Las

Race/Ethnicity: Mostly white, 2 black

10 35-45 20% 80%

Race/Ethnicity: Indian, latina, mixed and white

Santa Fe

3 42-65 1 2

Race/Ethnicity: 1 latina, 2 white

5 states

5-95 40% 60%

Race/Ethnicity: White 35

7 5-75 15% 85%

Race/Ethnicity: Native and mixed ethnic background

20 11-65 20% 80%

Race/Ethnicity: 40/60 African American and white

5 55-75 60% 40%

Race/Ethnicity: Mostly cherokee

Race/Ethnicity: Mostly native and white, 1 black 20 14-65 30% 70%

5 11-55 100%

Race/Ethnicity: Black and native

16 locations: 7 cities, 9 rural places

California Arizona New Mexico

New Mexico is second only to Arizona in days of sunshine per year. The climate is dry and extreme weather conditions are rare. Elevations in the state range from 2,817 ft. to 13,161 ft.. and while New Mexico is considered a southern state in terms of latitude, its elevation provides for four seasons throughout the state. New Mexico is among the lowest in population density and its population is very diverse, which sometimes leads to barriers to obtaining culturally sensitive health care. Because of this and other social factors, there are real disparities in the health of New Mexicans of various race/ethnic groups.

New Mexico’s high school graduation rate is the country’s worst and it is ranked as second highest poverty rate in the country (over 20% in 2014). Second highest number of deaths caused by drug overdose from the age of 12. The high rates of uninsured adults and children, numbers of people with diabetes,

Stockton

45 14-75 65% 35%

some native, some white, some latino

47 17-85 25% 75%

Race/Ethnicity: African American

Phoenix

15 22-60 50% 50%

Race/Ethnicity: Mixed

syphilis and chlamydia make NM rank among the top 20 countrywide. And it is not surprising to see a 15% rate of tobacco smokers next to a 23% rate of asthma in high school students (both data from 2014). We have visited communities across the state, from Las Vegas in the North to Anthony in the South and we took part in the statewide Health Equity Partnership gathering. We spoke to tribal elders and heard from various ethnic minority groups. This gave us a good sense of both the widespread efforts as well as the challenges in bringing about a culture of health, given the remoteness of many places and deeply rooted historical trauma that’s influencing health in communities.

states

California

In addition to the various different circles noted in the table above, we also had one-on-one conversations with individuals from the following communities across the state, the stories of whom are included in this report:

n Health Council Alliance

n State Department of Health

n New Mexico Asian Family Center and Global 505 - an alliance of ethnic minorities in NM

n Several tribal elders

Arizona New Mexico Oklahoma

5 states

16 locations: 7 cities,

is one of the most ethnically diverse major cities in the country. In this city of about 400,000 residents, people in low-income areas like East and West Oakland are dying more than a decade earlier than people a few miles away in wealthier neighborhoods. Wealth—and, as we know, good health—are concentrated in certain parts of the city. The city’s demographics have changed mostly due to rising housing prices associated with gentrification. As Olis Simmons said: “Having access to housing affects everything - employment, education, stress.”

Stockton was the second largest city in the United States to file for bankruptcy protection as a result of the 2008 financial crisis. Due to a number of socio-economic problems, Stockton has been subject to a series of negative national rankings. In the February 2012 issue of Forbes, the magazine ranked Stockton the

eighth most miserable US city, largely as a result of the steep drop in home values and high unemployment. In 2012, Stockton was ranked as the tenth most dangerous city in America and the second most dangerous in California (behind Oakland). In 2013, Stockton was ranked as the third least literate city in the U.S. In a 2010 Gallup poll, Stockton was tied with Montgomery, Alabama for the most obese metro area in the US with an obesity rate of 34.6 percent.

Like in all places the listening tour took us to we discovered many bright spots listed in the table below and throughout this report.

17-85 25% 75%

African American

In addition to the above circles we spoke to the following:

n Oakland Unified School District Department for Health and Wellness

n Human Impact Partners - providing health data for community organizations

n Youth UpRising

n Oakland Voices - community journalism

25 5-45 50% 50%

Race/Ethnicity: Spanish-speaking Latino parents

Oakland

15 35-55 30% 70%

Race/Ethnicity: 8 African American, 2 white and 5 mixed/other ethnicities

Stockton

8 35-50 30% 70%

Race/Ethnicity: Latino, black and white

Stockton

45 14-75 65% 35%

Race/Ethnicity: Mostly African American, some native, some white, some latino

Stockton

47 17-85 25% 75%

Race/Ethnicity: African American