Introductory Chapter: A New Approach to Developing Leadership for Cross-Sector, Community-Based Change

1. Introduction

Our world is changing…and changing rapidly. Change calls for new approaches and a new kind of leadership to help society face the deeply entrenched problems that continue to plague it and diminish the health of its populace. Traditional approaches have failed to move the needle on some of the most Wicked Problems [1, 2], particularly for marginalized groups, including problems such as maternal mortality, obesity, diabetes, and other scourges facing humanity. In the face of major scientific advances in medicine and healthcare over the last century, morbidity and mortality rates in the United States (US) are far behind those of its economic peers [3]. When compared with ten other high-income countries (e.g., United Kingdom), life expectancy rates in the US were the lowest while infant mortality and obesity rates were the highest, despite the US spending twice as much on healthcare [4]. In 2017, health care expenditures in the US reached $3.5 trillion, growing by 3.9 percent and accounting for $10,739 per person [3, 4, 5], higher than any other nation. Despite this fact, the US continues to lag behind on several major indicators of health including investment in preventive care and social services. The CDC’s 2020 Healthy People Goal was to reduce the maternal mortality rate to 11.4 maternal deaths per 100,000 live births [6]. However, by 2018 that rate was not in sight, with a reported US maternal mortality rate at 17.4 deaths per 100,000 live births/year [7]. While this number is no exemplar for a high income country, the wide-ranging health inequities indicate an even sadder tale: as late as 2018 white s had a maternal mortality rate of 14.7/100,000 and Hispanic women a rate of 11.8/100,000, while black women faced a rate more than three times higher at 37.1/100,000 [7]. In 2015-2016 obesity rates hit 39.8%, making the US the world leader in this unhealthy statistic [8]. Again, these obesity rates evince wide disparities by race and ethnicity, with the lowest rate for non-Hispanic Asians (12.7%), as compared with non-Hispanic White (37.9%), Non-Hispanic Black (46.8%), and Hispanic populations (47%) [8].

Racial and ethnic minority populations in the US are disproportionately impacted by chronic conditions and related complications that impose major social and economic burdens of disability, morbidity, and mortality on individuals, families, communities, and the healthcare system [9, 10, 11, 12, 13, 14, 15]. These disparities are further perpetuated in rural versus urban areas [16, 17, 18], among sexual and gender minorities [19, 20, 21], and in those with disabilities [22]. The coronavirus pandemic of 2020 illustrates clearly how the brunt of morbidity and mortality are borne on the shoulders of marginalized communities [23] facing significant challenges in the social contributors to health [24]. Why does the US continue to lag far behind other economically developed peer nations despite its economic and political power? [3, 25] Why are whole segments of the US population consistently burdened by poor health? What can be done to ensure all people in the US have a fair chance of living a healthy life? Solutions to these vexing questions lie in shifting to a culture of health as opposed to the fragmented, often judgmental approach to health currently embraced by the US. Promoting a culture of health requires not only an understanding of health itself, but an appreciation of how social determinants of health contribute to the complexities and variations in health across geographic, economic, ethnic, and social sectors. Challenges inherent in moving toward a culture of health have no defined rules of play or clear end points; rather they are ever-evolving, ever-lasting challenges and thus require an “infinite mindset” on the part of leaders [26]. Such grand challenges have no single winners, but all can lose if the Wicked Problems identified earlier remain insufficiently addressed. An essential element in the shift to a culture of health in the US is leadership that eschews the “winner-take-all” values common in today’s tribalized and polarized world. Developing leaders with the unique abilities required to live with an infinite mindset requires a new approach to cultivating leadership itself. Emerging leaders need not only to build tools and skills, but also explore and challenge their own and their organizations’ values, perspectives, and attitudes. They need resilience to “thrive in an ever-changing world” [26]. Furthermore, they must develop as individuals while simultaneously developing collaborative teams that can be leveraged to work with larger groups to focus on the ever-changing needs of society.

2. A call for a new approach to leadership

In appreciation for the complexity that underlies pervasive health inequities, the Robert Wood Johnson Foundation (RWJF) committed to developing leaders across sectors, professions, and disciplines in and outside of health care to collaboratively address fundamental causes undergirding health inequities in the US. In 2014, RWJF unveiled their new vision for creating a Culture of Health in which “every person has an equal opportunity to live the healthiest life they can—regardless of where they may live, how much they earn, or the color of their skin” [27]. The Foundation called for “different sectors to come together in innovative ways to solve interconnected problems”. Their Action Framework (Figure 1) helps describe their vision for impact.

Figure 1.

Culture of health action framework.

The Action Framework embraces four interconnected Action Areas: Making Health a Shared Value; Fostering Cross-Sector Collaboration to Improve Well-being; Creating Healthier, More Equitable Communities; and Strengthening Integration of Health Services and Systems. In 2015 the RWJF funded four leadership development programs focused on health equity, diversity, and inclusion. The Foundation collectively named these programs Leadership for Better Health: Change Leadership Programs. Specifically, the four development programs are:

• Clinical Scholars, also known as the Clinical Scholars National Leadership Institute (https://clinical-scholars.org/ and at www.ClinicalScholarsNLI.org)

• The Culture of Health Leaders (https://cultureofhealth-leaders.org/)

• The Interdisciplinary Research Leaders (https://interdisciplinaryresearch-leaders.org/)

• Health Policy Research Scholars (https://healthpolicyresearch-scholars.org/)

All programs are centered on health equity and strive to foster innovative cross-sector collaboration, but each program is unique in that it delivers leadership development tailored to the target group. Participants enrolled in each program matriculate through a 3-year experience consisting of both onsite and distance-based engagement. Whether enrolled as individuals or as teams, each participant unit focuses their work in community settings with an aim to address root causes of health inequities that negatively impact the culture of health.

This book presents work from two of the mid-career development programs: Clinical Scholars and Culture of Health Leaders. You will be introduced to the two programs and their respective participants. Both programs strive to support development of a new type of leadership in which collaborative and systemic approaches bring teams of leaders together with others in the community to work toward common goals.

The first section of the book presents four chapters explaining the structure of the programs to give the reader an understanding of the participant experience. Chapters 1 through 3 detail the Clinical Scholars approach to leadership development, explaining the pedagogical structure (Chapter 1), how leadership and the concepts of equity, diversity, and inclusion are interwoven through workforce development efforts (Chapter 2), and the approaches implemented to evaluate outcomes of the Clinical Scholars program (Chapter 3). Chapter 4 introduces the reader to the Culture of Health Leaders program, explaining the structure and goals for developing community-based leaders who are enrolled.

These chapters are intended to enlighten those engaged in workforce development efforts and illustrate that real change comes from the combination of learning and doing. There are important ways workforce development programs engage mid-career participants as learners, building their skills and helping them expand their perspective and talents. This development enables them to focus their efforts on the kind of community engagement that creates meaningful change in collaboration with the communities being served. We hope these chapters illustrate how inspiration and resilience are as crucial as skills building in workforce development. As the Directors of the Clinical Scholars program, we have learned that fostering resilience in inspired and passionate leaders is crucial for them to continue their work despite obstacles and difficulties that continually arise--some on a personal level and others on a societal level. We hope our readers gain ideas and inspiration from this book for their own efforts in developing the leaders of today as well as tomorrow.

Chapters following the program overviews have been contributed by program participants, and in some cases their community partners. Program participants come from different places, circumstances, experiences, and perspectives. Some are academics and some are practitioners, some are community activists, some are at non-profits—and many cross several categories. What they all share is a desire to help make positive change in health equity at the local level by working with communities themselves. The reader will notice clear differences in the chapters compared with many typical project reports or research articles. Each chapter describes the health-equity related project that served as a focus of participant learning and engagement while enrolled in one of the three-year RWJF-funded development programs.

Clinical Scholars Fellows identified a Wicked Problem in their respective communities and developed and implemented community-based approaches to address the problems in a sustainable manner, hence the name Wicked Problem Impact Project. Their chapters describe the approaches, community partnering, and outcomes achieved through their leadership. Additionally, authors were asked to share resources through a Tool Kit, allowing interested readers who find inspiration from these projects to obtain useful information or strategies to assist them in making a similar difference in their own communities. Since Clinical Scholars and Culture of Health Leaders are both leadership development programs that made significant investments in the knowledge, skills, perspectives, and commitment of the participants, the authors were asked to share some reflections on leader learning through their engagement with their programs and the communities they served. Some authors shared insights as teams and others as individuals, all in the spirit of inspiring others to become engaged in the Wicked Problems facing their own communities. The front page of each chapter identifies the RWJF program in which the chapter authors participated.

As you read through this book, you’ll learn how individuals and teams addressed some of the most pressing health equity issues facing communities in the United States. Participants from both programs tackled entrenched Wicked Problems. Projects ranged from taking on the creation of health care structures for transgender and other gender-nonconforming individuals in the midst of healthcare deserts (Chapter 5), and addressing disparities that challenge children with special health care needs or other marginalized communities in getting needed dental care (Chapters 6 and 7), to interventions focused on life skills for youth, parenting, youth-mentoring, and violence prevention (Chapters 8, 9, 10 and 11). These leaders in the quest for health equity detail their work in projects ranging from developing peer-based community mentoring and health-education programs for marginalized adult communities (Chapter 12), to structuring community based efforts to combat the opiate addiction crisis in rural communities (Chapters 13 and 14), and community reclamation of environmentally blighted areas (Chapter 15).

Topics and communities engaged are diverse. The chapters present not only the approach and findings of the projects, but also advice and Tool Kits to help others who face similar health equity issues get a proverbial leg-up on addressing the crises in their own communities. Indeed, a goal of this book is that readers will identify similar challenging issues (Wicked Problems) in their spheres and be inspired to engage their own talents in addressing them.

Further, we hope sharing the structure and design of the RWJF leadership development programs will provide workforce development experts with useful ideas to incorporate in their programs, and help their participants become innovative and effective champions for health and health equity.

The most important outcome for all these programs—and the measure of whether they are worth the considerable investment of the Robert Wood Johnson Foundation—is the ultimate impact of each project on its community and the participant’s continuing influences on health equity through the course of their careers. We know lasting change is evolution not revolution. While more distal outcomes may take several years to culminate in population health changes, the observable changes reported in the chapters in this volume are impressive—and penned at the conclusion of participants’ three-year development experience. Yet we know these projects will endure beyond this experience just as these newly-minted culture of health champions will continue collaborating to address health disparities and help make an America in which every person has the opportunity to live a healthy life.

We hope these chapters inspire, instruct, and guide you as you work to address the complex problems in the culture of health in your own communities. While efforts of each project will have ripple effects for years to come, one of the greatest outcomes would be to extend the impact of the Leadership for Better Health programs into a movement by which all of us are engaged in healing our communities nationwide.