Competency 11: Working with Communities
Kathleen May, MPH, CHES is the Program Coordinator for the Institute for Public Health Practice at the University of Iowa (UI) College of Public Health. She oversees the development and ongoing management of the health equity and mental health training programs for the public health workforce. She assists with the design, development, implementation, and evaluation of these programs. Additionally, she volunteers as the Community Health Advocate for Far Away Friends, a Ugandan- and Colorado-based nonprofit organization that partners with local leaders and organizations to focus on youth education, community development, and empowerment. She earned her BS in Public Health and MPH in Community and Behavioral Health, both from UI, and received training at UI’s Maternal and Child Professionals to Address Growing Disparities in the Rural Midwest Catalyst Program. She is passionate about health equity, reproductive justice, mental health, and global maternal and child health.
MCH Applied Practice Experience
The public health system is diverse and intricate, broad and specific at the same time. It is also constantly evolving – and that is the beauty of it. It requires continuous growth and learning. This is what I have learned and reflected on during my schooling and various impactful experiences. One such experience was recent and during the final stage of my MPH this past summer (2021).
For my applied practice experience, I participated in the Title V MCH Internship program, working for the Minnesota Department of Health (MDH) in their Child and Family Health (CFH) division. They were focused on a number of priorities that were identified in the 2020 Title V Needs Assessment. I have always been passionate about systems thinking and change, so I indicated my interest in examining the cross-cutting area of safe, affordable, and stable housing, a relatively non-traditional public health (and MCH) focus. This is a newer area of focus for the MDH’s Title V program, so a clear understanding of how the current system works, what partnerships exist, and what partnerships are needed to leverage impact is important to operationalize the Title V Action Plan. As public health places greater emphasis on systems practice and the social determinants of health, CFH is looking to become more involved in housing. They aim to improve access to safe and affordable housing by exploring creative and innovative housing options for families through cross-agency collaboration, highlighting the essential role of partnerships. My overall purpose was to complete a system mapping/gap analysis for housing, with an emphasis on examining whose voices are missing, and to explore strategies and partnerships to increase access to safe, affordable, and stable housing. Understanding the context of a public health issue before taking action is key to avoiding unintended consequences, duplication of efforts, and resource depletion or exhaustion.
Understanding the Impact of Housing
Housing impacts people’s wellbeing as it connects to being healthy, academically successful, and financially secure. Minnesota is currently in the middle of a housing crisis as housing prices are 26% higher than in states next door, with an 8.9% increase from 2017 to 2018. When housing costs are more than 30% of a household’s monthly gross income, they are considered “housing cost-burdened”, and 26% of Minnesota households fall into this category (MDH, “Housing”, 2020). Homelessness, which can negatively impact employment, academic achievement, and health, has increased by 10% in the state since 2015. Additionally, the CFH Expectant Parenting Student Program saw a 38% increase in requests for housing assistance. Furthermore, the disparity in homeownership rates between white and non-white individuals in Minnesota is the greatest in the United States. Rising housing costs disproportionately impact people of color, resulting in eviction and homelessness disparities (MDH “Housing”, 2020). Single Black mothers faced the highest risk of eviction before the pandemic, and continue to remain at a higher risk during the pandemic (Shaw, Lloyd, & Alvira-Hammond).
Delving deeper into the importance of housing within MCH, I utilized the United States Census Bureau’s Pulse Survey that collected state-level housing data during the COVID-19 pandemic. Two measures that I pulled out from these surveys are “confidence in ability to make next month’s payment for renter-occupied housing units” and “likelihood of having to leave this house in the next two months due to eviction.” Percentages of respondents indicating ‘slight to no confidence’ for the first measure and ‘somewhat likely’ for the second measure fluctuated over the course of the pandemic from April 23, 2020, to July 5, 2021, showing that need remained steady even when policies were put in place to assist citizens (United States Census Bureau). At the national level, Pulse analysts found that homes with children are at a greater risk of losing their home, are more likely to report being behind on rent or mortgage payments, and are more likely to report little or no confidence in their ability to make their next housing payment in comparison to those without children (Shaw, Lloyd, & Alvira-Hammond).
Engagement with Programs
To begin data collection, with help from my preceptor, I identified housing-relevant stakeholders to reach out to for an interview or an email exchange. I was able to engage with the following programs: Help Me Connect; Community Solutions for Healthy Child Development Grants; Preschool Development Grants; WIC; Family Home Visiting; Positive Alternatives; Expectant and Parenting Student Program; 17P Quality Improvement Project; Perinatal Quality Collaborative; Maternal Mortality Review Project; Pregnancy Risk Assessment Monitoring System; Adolescent Health Gateway and The Minnesota Partnership for Adolescent and Young Adult Health; Birth Defects Monitoring and Analysis Program; Early Hearing Detection and Intervention; Mental Health Promotion; Adverse Childhood Experiences (ACEs) in MinnesotaI also met with program supervisors, housing contacts and program managers, and other division staff. It was so interesting meeting with diverse groups of people as they all worked towards bettering the health and wellbeing of Minnesota children and families. I especially enjoyed learning about the Preschool Development Grants and Community Solutions for Healthy Child Development Grants because they were heavily focused on the social determinants of health, community engagement and participation, and whole-family health and wellbeing.
Working with Data
After synthesizing qualitative and quantitative information in an Excel file, I began to visualize the MDH CFH housing system using draw.io (a diagramming program) to map out CFH and internal sections with corresponding programs and grants. The draw.io file includes links to the programs, icons representing housing-specific activities, and color-coded programs, services, and partners. For housing, 11 MDH programs, 8 grants, 30 grantees, 1 partner (not grantees), and 17 periphery partners were identified. 4 current CFH housing measures/survey questions were found. I also identified key themes in the interviews, including that staff were unsure how to find CFH’s role in housing, they wanted to avoid reinventing the wheel (i.e., duplication of programs), and that many reported nothing being done in housing besides referrals. 13 promising partners, initiatives, indicators, and tools were highlighted in the recommendation portion of the file. Finally, 53 of the suggested activities from the 19 overarching strategies proposed by the MN Housing Taskforce and Title V Action Plan were aligned with at least one housing stakeholder/partner.
To disseminate my results, a MDH ‘Lunch and Learn’ was organized and I created a presentation, attempting to do the following: (1) help people start thinking about what they can do specifically in housing, (2) explain what housing support means and the different touchpoints that CFH can engage in, and (3) show why this is important and how it would positively impact CFH’s current work. I went over background information, methods, and findings. I also made recommendations based on my project results and analysis.
One key observation included that providing affordable or supportive housing is not enough; preventing homelessness is an activity that CFH could have a role in, especially through engaging young people. Additionally, on the map, there were significantly more programs that refer people or connect them to resources. Direct service in housing was less common. Furthermore, many direct partners or grantees have connections with affordable housing developers, which could be a key stakeholder to engage. Additionally, more research and data collection should occur around housing stability.
There are only two questions in the Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS) and two questions on the Minnesota Student Survey that touch on housing. Other organizations are doing housing research and trying to assess housing impact. A stronger measurement of housing impact would be very beneficial in demonstrating housing importance in health. Thus, I provided potential housing measures and evaluation partners. Strategies were previously put forth by CFH and the Minnesota Housing Taskforce, so I aligned potential partners with each strategy in my final report. I also presented promising partners, initiatives, and tools including the Greater Minnesota Housing Fund, the Cultural Wellness Center, the Olmstead Implementation Office’s Affordable, Safe, and Accessible Housing workgroup, the Corporation for Supportive Housing, and their Racial Disparities and Disproportionality Index.
What I Learned
It was very interesting to see firsthand the reach of public health with the intersecting factors that influence MCH. Stakeholders are everywhere, thus ideas are everywhere. As I went on through data collection, the housing stakeholder map proceeded to get bigger and bigger. There are so many state and local agencies, nonprofits, communities, and businesses doing good work in safe, affordable, and stable housing. Each Board of Directors consists of diverse individuals who bring different perspectives to their priority area. Every strategy to mitigate and reverse this housing crisis is unique. And this is needed to address the complexity of the housing issue and its linkages among resources, policy, infrastructure, and behavior. However, so much of this system is siloed. As I was talking to people, some were not familiar with the organizations and programs I was mentioning. Understandably, it is impossible to be aware of everything happening in a system, but this is where system mapping can be useful. Working together to address this issue will lead to greater effectiveness and efficiency due to pooled resources, diverse voices and backgrounds, and shared passion. As CFH operationalizes its Title V Action Plan, this system’s work will help engage leaders and stakeholders within the community to achieve systemic collective impact towards safe, affordable, and stable housing for MCH populations.
I learned so much from this experience – however, there is always more to learn, especially as systems are complex, dynamic, and diverse. As I begin my new job in health equity and mental health, I continue to reflect on this experience. So – here’s to continuous growth!
Meyer, M., Dunne, S., & Harrison, B. (2021). (rep.). Minnesota’s 2020 Title V Maternal and Child Health Block Grant Needs Assessment. Minnesota Department of Health. Retrieved from https://www.health.state.mn.us/docs/communities/titlev/titlevneedsassessplan.pdf
Minnesota Department of Health. (2020). Housing. St. Paul. Retrieved from https://www.health.state.mn.us/docs/communities/titlev/housing.pdf
Shaw, S., Lloyd, C. M., & Alvira-Hammond, M. (n.d.). As Pandemic Eviction Moratorium Ends, Households with Children Face Greater Risk of Homelessness. Child Trends. https://www.childtrends.org/publications/as-pandemic-eviction-moratorium-ends-households-with-children-face-greater-risk-of-homelessness.
United States Census Bureau, Household Pulse Survey (n.d.). https://www.census.gov/programs-surveys/household-pulse-survey/data.html.