The shifts that come from listening

I've talked about the difference between hearing and listening to community before.

And even though it's something I believe in deeply, I'm still surprised at the shifts that happen when we truly do that.

A couple weeks ago, for work I'm doing in DC around systems-level shifts to school mental health, we brought together youth to generate ideas around how to improve youth engagement in the school context.

Here are some of the ideas that came up repeatedly:

• "Having an area where we can take a break/chill"

• "I WANT A MENTAL HEALTH DAY"

• "Having more relatable/trusted adults"; "Respect is a two way street"

If we asked adults how we can improve youth engagement in the school context, what answers would we have gotten? I'm willing to bet this list would have been completely different.

So far, we've just heard these young people. How can we listen to them? By figuring out how to make more of these things happen! One thing that struck me about these ideas that bubbled to the top are that in theory, they shouldn't be that hard to make happen - but it does require adults setting aside their own perspectives and egos and prioritizing what young people most want.

One student shared how one of their teachers opens their room to students during lunch time, and how deeply they appreciate that space to chill - and only when I heard that did I remember some of my favorite memories from high school were in Mrs. Fort's English lit classroom, where a handful of us would go at least a few times a week to have our lunch.

Several students talked about specific teachers or other adults in the building that made them feel respected. What did that boil down to? The adult cared what the students had to say. They didn't talk down to the students. They made things fun. They listened. The conversation made me think of my favorite teachers through the years - they checked all those boxes too.

We were all young people once, but we quickly forget the day-to-day of that experience and how we felt about things.

If we can truly listen to and act upon what we hear from young people - or whoever your community members are - we might shift not only our solutions but even how we define problems.

But listening isn't always easy.

I've been thinking a lot about how we practice listening. We recently had a friend visit who loves birdwatching and taught our six year old more about birds in a weekend than we could have taught her, well...ever. But my favorite part of the whole experience was the emphasis on being still and listening - it's amazing what you hear when you do that.

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15% and 15x solutions

Do you ever feel powerless to tackle the big problems your community faces?

I often feel that way, and I think many of us do.

On the other hand, do you ever feel like our solutions aren’t enough - not big enough, not disruptive enough, not transformational enough?

Especially when trying to improve community health and well-being, it can often feel constraining to work within existing systems instead of thinking about how we dismantle and rebuild the systems themselves.

My colleague and I are facilitating a national convening next week, and the group will be brainstorming and prioritizing public health solutions to address dementia. We’ve tried to ensure each session incorporates a slightly different approach to brainstorming - to keep things interesting and make sure new ideas keep flowing.

In one of the sessions, I wanted to address both these struggles - sometimes we get stuck brainstorming because it feels like the only way to change things is big, huge, systems-level transformation and we feel powerless to make that happen. On the other hand, sometimes we get stuck brainstorming because all we can come up with are ideas that would make small changes on the margins, but nothing that feels big enough to create real change.

The reality is, we need to brainstorm and move forward on both fronts.

​15% Solutions, a type of Liberating Structure (i.e., alternatives to presentations, managed discussion, and other conventional structures that typically guide the way groups work together), invites those brainstorming to consider: “What is your 15 percent? Where do you have discretion and freedom to act? What can you do without more resources or authority?”

I love the way the Liberating Structures website describes what is made possible through this approach: “You can reveal the actions, however small, that everyone can do immediately. At a minimum, these will create momentum, and that may make a BIG difference. 15% Solutions show that there is no reason to wait around, feel powerless, or fearful. They help people pick it up a level. They get individuals and the group to focus on what is within their discretion instead of what they cannot change.”

I have found it works well to pair this 15% solution question with another question borrowed from Liberating Structures that’s about getting 10 times (or we’ll make it 15 times to make it parallel with 15%!) bolder - “If you were [fifteen] times bolder, what big idea would you recommend? What first step would you take to get started?”

What’s made possible through this approach is the flip side of what’s made possible via 15% solutions - there are bold, transformational things that would move us towards transforming community health (or whatever you’re trying to transform!) and while they may not be within our control, we can identify some initial steps to take towards them.

I think pairing these questions together is powerful. You can have participants brainstorm 15% solutions on one color of post-it note in the first part of a session and 15x solutions on another color in the second part of the session.

We can both be empowered by the things we can do fully within our circle of influence and inspired by the things that are more aspirational and transformational - which may take a lot longer (even generations) to accomplish but can still be pursued by starting with a first step.

​Let me know if you have tried this kind of brainstorming before or have other approaches that have worked well!

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The value of ONE right door

Have you heard the phrase "no wrong door" before?

A Google search didn't bring up a standard or formal definition, but the description I found that most aligns with my understanding of the concept is this:

"The vision for No Wrong Door is that every door in the region’s healthcare and human services system should be the right door with a range of services being accessible to everyone from multiple points of entry."

This is a lovely and logical idea in theory.

But I have come to question how well it works in practice.

I work closely with a school mental health collaborative in DC and at our meeting a couple weeks ago, one of the members shared with us results from an evaluation of DC's school behavioral health expansion. There were bright spots and progress to celebrate, but one thing that stood out to me in terms of challenges that remain was that about half of students reported still not knowing where to go for help in the school. We have heard our partners who lead parent advocacy in DC lament about this too - even parents who are deeply engaged in advocating for their children don’t know where to turn or what resources are available at their own schools. This is clearly not due to a lack of involvement on their part, so why is this happening?

Let me share a counterintuitive guess with you - I don’t think the problem is that there is nowhere for them to turn. I think the problem is there are too many places for them to turn.

This is a theme we heard repeatedly in community input gathering to inform the Fairfax Children's Behavioral Health Blueprint.

Imagine that you’re Kira - a mom with two elementary school aged kids, one of whom is in need of mental health supports. You reach out to various folks within the school and community for suggestions, and each person hands you a list of resources available for kids with mental health needs. There are so many resources that you’re overwhelmed about where to start and how to choose one. But you decide to just pick one at random and call them. Turns out they are no longer in business. You try another number. They don’t have any spots available. You move to the next number on the list. They do have availability starting next month but your income is too high for you to be eligible. The next place doesn’t have supports for the kind of mental health issue your child is struggling with. And on, and on, and on.

While the idea of "no wrong door" is great in theory, in practice, it often involves someone behind every door being equipped with a list of other places and people to point someone to. This would be fine if the lists were kept updated, limited to services that were currently available, categorized by eligibility, and tailored to specific needs - but they are rarely any of those things, much less all four.

What people most need is not a laundry list of generic resources that may or may not be available to or appropriate for them. What they need is a way to navigate to the right solution for them - whether that is by way of a person (like a navigator or case manager), an interactive database (imagine being Kira and having a website where you could type in your child’s age, their mental health needs, your family income, your insurance, etc. and receive a list of organizations that currently offer services that meet your specific needs and eligibility), or some other solution (Have an example or ideas? Email me!)

What people often need is one right door - someone or something to help them navigate through all that's available to find the right fit for them.

This is true for mental health support, for childcare, for any number of other needs people are seeking services for.

As anyone who’s ever been handed a laundry list of resources can vouch for, sometimes too many doors can actually leave us feeling lost. If we can shift more systems to create one right door, maybe we can connect far more people with the services and supports they need - not just in theory, but in reality.

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Just do it. Then iterate.

Whatever idea you’ve been mulling over, considering, planning for…just do it.

Now, I know it’s not that simple (in most cases).

Maybe you can’t "just do it” because you don’t have the authority. Or because you need to assess the potential consequences. Or any one of a dozen other perfectly valid reasons.

But there are also many cases when we could "just do it" and we let something stop us. Sometimes it's perfectionism. Sometimes it's fear.

Whatever the reason, it's getting in the way of the magic of just doing it, and then iterating.

As an engineering major in college, I was trained to "fail fast". Now, I don't love thinking about it as failure per se, but it's true that the first attempt is rarely going to be a home run. So just do it. Get it out of the way. Learn as much as you can from the experience and then revise, making it better each time.

Last year, as part of a volunteer team under the umbrella of the Partnership for a Healthier Fairfax, I helped organize the very first Healthy Together Fairfax, a fun, free, interactive community event focused on healthy and active living, with hands-on activities, fitness classes, access to community services and resources, etc.

The event was set to take place at an amazing county park that has a beautiful trail walk, amphitheater, treehouse, playground, carousel, and tons of green space. My co-volunteer who is a whiz at these things put together a thoughtful, color-coded layout for how all our exhibitors would be spread out throughout the park, organized into groups based on the health topics they addressed.

Then Hurricane Ian brought a storm our way and we had to move everything indoors. We were locked out of the iPads we planned to use for exit surveys. Someone whose proposal to participate we had not accepted showed up to exhibit anyway. The list goes on.

But you know what? Despite it all, we had a WONDERFUL event - exhibitors and community members were engaged and learning from one another, we had a number of local agency heads and policymakers come read children’s story books focused on social and emotional health, we had a steady stream of fitness classes and other interactive, community health-focused activities, and everyone - organizers, exhibitors, and attendees alike - expressed excitement about doing it again next year.

But that's not all. We recently held a community meeting to plan for this year's event and we had so many people show up with so many great ideas. When we tried to do something similar last year, we had almost no one show up.

What changed? We've done it once! That means…

• We got a broader coalition on board through partners that participated in the event last year.

• People saw it in action and understood our vision, so they got more excited about it themselves and shared it with others.

• We got some systems and templates built out, meaning we could start our planning earlier and stronger this year, all while putting in fewer hours.

• We learned from last year - this year, we have a rain date set that we’re publicizing from the start, we’ve moved our timeline up so we’ll have exhibitors identified early enough to be actively included in event promotion efforts, we’ll set the exit survey ipads up differently, and so on and so forth.

So my point is - if you can, just do it. Don’t worry about getting it all right or what might go wrong - you won't get everything right, things will go wrong, AND it will still be wonderful (or at the very least, you’ll get your “first pancake” out of the way - as a firstborn child, I feel like I get a pass to share this meme). Most importantly, you’ll learn from it, and be able to do something even better in the next iteration.
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What have you been thinking about or planning for that you're feeling ready to just do? Or, if something's stopping you, what is it? Let me know!

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A fish, an elephant, and an iceberg: Orienting community towards root causes and systems

When a community is trying to address a public health problem, the immediate causes are often the most apparent.

Too many youth aren't physically active. Why? They don't understand the value of physical activity or the consequences of not being active. What should we do? An education and mass communication campaign to help them understand this value and these consequences, so that they are motivated to be more active.

Not only are immediate causes often the most apparent, the solutions required to address them are often (relatively) non-controversial and don't require the upheaval of established systems.

But to truly transform health in communities, we need to move beyond the immediate. We need to 1) drill down to root causes and 2) fly up for a systems wide view.

On the first point -

WHY are too many youth not physically active? Do they have safe spaces to run and play in their neighborhood, and do their schedules allow them to do so? Are the costs of joining recreational sports leagues prohibitive? Are the apps on their phones designed to be addictive, so they have less time for everything else?

To get community members thinking about root causes, one exercise I have found quite helpful is a fishbone diagram (where you start with the problem, which is the "head" of the fish, and then brainstorm multiple causes, as well as causes of causes). This diagramming is often paired with the "5 whys" facilitation strategy (where you keep asking "why" five times to drill down to deeper root causes). The idea here is that this process can help identify countermeasures (things that prevent root causes) instead of merely solutions (things that might just put a bandaid on the problem by treating a symptom instead of a root cause).

On the second point -

HOW might systems be transformed to encourage more physical activity among youth?

First, we need to be able to take a step back and see the system as a whole. I find the elephant analogy an incredibly helpful way to remind ourselves and our communities to do this. It’s an ancient parable you may have heard before about blind/blindfolded individuals encountering an elephant for the first time. Each person feels only one part of the elephant and comes to a conclusion about what they are encountering based on that. It leads to a lot of misconceptions and no single person who has the full and accurate picture.

To take community thinking a step further, from recognizing there is a broader system to understanding how we can improve that system, I love using the iceberg model of systems thinking. It's a great way to reminder ourselves that what we can see of a problem is usually only the tip of the iceberg. "We know that an iceberg has only 10 percent of its total mass above the water while 90 percent is underwater. But that 90 percent is what the ocean currents act on, and what creates the iceberg’s behavior at its tip." Most public health issues are like this as well! I especially appreciate the way this model helps community members walk through the process of identifying trends, underlying structures, and ultimately mental models.

I've often had clients point to a fairly surface-level approach or solution and say, "This is what our community said they want to see." This may be true, and I'm 100% on board with community-driven approaches. However, we also need to ask ourselves if we've walked ourselves and our communities through the kind of tools above to make sure that the solutions we're brainstorming are oriented towards root causes and systems.

Have you had success with setting the stage to approach problems in a way that is focused on root causes or systems? Or have you tried using any of the tools mentioned above? Please share your experience with me!

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Simplify your messaging with the "Kindergartener test"

Have you ever struggled to explain what you do or what public health is?

One of my colleagues has a "grandma test" for anything he communicates to a general audience - if his grandma will understand, then he can share the message. Today, I want to share another twist on that, the "Kindergartener test". Will a Kindergartener understand and stay interested and engaged in what you're saying? This requires a simple, relatable, creative, and - where possible - interactive messaging approach.

Let me share an example.

A couple weeks ago, I participated in my daughter's elementary school career fair.
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Public health is pretty abstract (preventing something before it happens means there's nothing to show!) and I needed to explain it to Kindergarteners-3rd graders. Yikes.
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I was momentarily stumped and walking around the house looking for a good prop to illustrate the upstream/downstream story when I came across my daughter's marble maze.
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It was fun and colorful enough to draw in the kids AND - with the addition of a small round paint sponge I found - had all the elements I needed to illustrate the story.

I had the kids drop a marble in at the top and tell them to pretend it's a person going along for a walk when all of a sudden, they fall into a river. Without anything to protect them, they'd fall all the way down the river and (as the marble drops down the last ramp and off the maze) might get hurt or even drown.
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BUT if there was something to protect them (enter round sponge), where might they put it to protect the person?
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Some kids suggested putting the sponge on the first ramp to prevent the person from going downstream, or at the entrance to the maze to prevent the person from falling in at all. These are the ideas I originally had as well - and when kids said this, we got to do it, see how the marble stopped at the sponge, and talk about how "that protects the person BEFORE they get hurt or sick, which is exactly what we do in public health!".
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But the best part were the other ideas kids came up with that hadn't occurred to me at all.

• Some kids suggested putting the sponge on the floor below where the last ramp ended to cushion the person's fall. So I said, "That's such an interesting idea, and you're absolutely right, that would cushion the person's fall, but they might not land right on it or they might get hurt anyway. But where else could we put the sponge if we didn't want them to fall at all?" This would prompt them to suggest putting the sponge somewhere further upstream.

• Others suggested putting an extra marble on the opposite side of the green entrance to the maze, which meant even if the marble person in question began the maze, they would never get tilted down into the blue "stream", because the extra marble acted as a counterweight - a true systems solution!

• A few kids got so excited about the marble maze, they dropped several marbles in at once - the sponge stopped all of them, and I explained how that's how public health solutions work too, once you put them in place, they protect MANY people at once.

None of these ideas had occurred to me beforehand and they all allowed me to have a meaningful conversation with these smart and thoughtful young kids about public health. I loved every minute of it.

The thing is, simple, relatable, creative, and interactive messaging isn't just helpful for Kindergarteners and grandmothers, it's helpful for everyone.

When you're trying to get an entire community on board with pursuing prevention and public health, you're communicating to a wide range of people with a wide range of existing experiences and understanding - this kind of messaging can help you reach more of them.

Also important to consider is that policy changes that support public health are rarely possible without widespread community support - and community support for public health requires an understanding of what public health is and why it works. This was the motiviation behind my talk on the topic a couple years ago, and I hope we see a true understanding of public health spread more widely in the years to come.

Have you had success with simple, relatable, creative, interactive messaging in your work to transform health in communities? Or is there a message you're struggling to communicate in this way? Tell me all about it!

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Too many partners, too little time, one nifty tool

Public health problems live at the intersection of many different sectors and issues.

You can’t help kids in schools do and feel better without also making sure their teachers are well, that school policies don’t kick them out of class, that their communities are safe, and so on.

So any community health improvement effort worth its salt is going to involve multiple components led by multiple partners.

But it can be really hard for those involved in a joint effort to truly understand the work of other partners. Heck, as anyone who has worked at a large corporation or agency can attest to, it's really hard to understand the work of different departments and teams within the same organization, let alone partner organizations!

Yes, we have logic models and summary descriptions and annual reports, but we often don't have the time to read those things and even when we do, they often fail to give us a true understanding of how the work looks, sounds, and feels on the ground where it's happening.
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We were grappling with just this problem as part of a multi-partner effort to help kids in DC schools thrive. We were bringing various partners together for an in-person convening and many of them had expressed a desire to know more about the activities others were leading. How could we create the space for this without taking up the entire day and while keeping things engaging and interesting?
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One of my colleagues on the project suggested using the Ignite Talks format - “20 slides, 15 seconds a slide, 5 minutes on stage, just you and the audience”. The emphasis in this format is on highly visual slides with interesting imagery. It’s similar to the PechaKucha format, which originated in Japan, and involves 20 slides, each for 20 seconds.

We were a little worried about asking our partners to put together a new presentation just for this convening, but decided it was worth the risk.

And it definitely was! We used these talks to open our convening and it was lively, engaging, interesting, and everyone learned a lot about the different elements of this joint effort we were engaging in.

• By emphasizing visuals, we got to see what the work looked like in action.

• By forcing everyone into a new presentation format, we escaped the boilerplate slides and explanations we otherwise would have gotten.

• Perhaps most surprisingly, by providing a tiny bit of extra structure (“20 slides, 15 seconds each” - instead of just saying “no more than 5 minutes, please”), we actually had everyone stay within the time limit - every single person. (Who else has tried the “no more than X minutes, please” route before, only to find that no one listened to you? Turns out, a little extra structure is the answer!)

All in all, it was a wonderful experience, and one I’ll be looking for opportunities to replicate in other settings and with other groups! I think it’s a great tool for community coalitions and collaboratives to have in their pocket - if you use it, please share how it goes, and if you have questions about how we used it, please reach out.

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Hearing vs. Listening to community

You want to transform health in your community. And you recognize that can’t be done without communities in the center and in the lead.

But how do we actually DO that?

We’ve talked about meeting community where they literally, physically are and these strategies are great to hear what they have to say, but today, I want to push us a little further. Because there is a HUGE difference between hearing and truly listening.

Merriam-Webster defines hearing as “the process, function, or power of perceiving sound, specifically: the special sense by which noises and tones are received as stimuli”.

On the other hand, the definition of listening reads, “to pay attention to sound; to hear something with thoughtful attention: give consideration”.

There’s a lot of lip service being paid to community voice these days, as well as genuine efforts to elevate community voice. But either way, community voice isn’t enough if we merely hear it, but don’t listen to and act on it.

The “act on it” piece is vital - I’d take the definition of “listening” and argue for us to take it one step further than paying thoughtful attention and giving consideration to actually internalizing and acting on what community has to say.

I’ve had the pleasure of working with the Allegheny County infant health equity coalition over the last couple years, and we’ve been incredibly intentional about trying to do this. What does this look like in practice?

• The coalition is composed of moms, doulas and other birth workers, nutrition advocates, community leaders, as well as nonprofit, healthcare, and government leaders;

• We used strategies like focus groups in a box that put community members and leaders in the driver’s seat of leading discussions with community members;

• As we continue to gather community input (as we just did a couple months ago during a community kick off event for implementation of the action plan), we reflect back what we’re hearing to community in ways that are easily digestible (you can see our summary of input from the kick off here);

• We directly link the input we receive through these strategies to our action, implementation, and learning/evaluation plans and we make these connections explicit (for example, you’ll see we quoted community members directly throughout our action plan to demonstrate the connections between what we heard from community and what ended up in the action plan);

• We’ll be capturing community feedback in learning and evaluation activities that directly ask them whether they felt listened to and their input acted upon - and we’ll modify our approach to reflect what we learn.

How are you and your coalitions/organizations working to go beyond hearing from community members to actually listening to them? Drop me a line and let me know!

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How to meet community where they (literally) are

One of my favorite parts of my work with community coalitions and collaboratives is working with them to meet the community where they are.

As a recovering academic, let me tell you why communities don’t trust academics and researchers - even when academics are trying to get community input, the typical model is that they bring folks together in a new space where the researcher has all the power and then ask community members to answer a bunch of questions to serve their own research needs and then the community never hears from them again.

Harsh, right?

I’m not trying to throw academics under the bus, I used to be right there with them, and their hearts are often in the right place. But we’re generally not trained in academia to share power with community members and meet them where they are.

You know who does that well? Community coalitions and collaboratives!

Working hand in hand with these groups over the last several years, here are some of my favorite strategies we’ve employed to meet community members where they are:

• Listen where community is already gathering. I’m part of a coalition where I live in Fairfax, Virginia, and last year, we launched our very first community-wide event called Healthy Together Fairfax. We knew we wanted this to be an event by the community, for the community, so we started by…listening. Just listening. Sounds simple, but it’s a step many skip! We knew there were dozens of community groups already gathering regularly to talk about health, so we simply reached out to them, attended meetings, and listened. We took notes, drew out key themes from what we were hearing, and let those themes drive the planning process.

• Focus the conversation through Focus Groups in a Box. In the first phase of my work with the Allegheny County Infant Health Equity Coalition, our top priority was crafting a community-driven action plan. The Coalition awarded small research grants to community partners that were already gathering places for community members, so that they could lead their own focus groups. I helped develop a standard focus group guide and reporting template that was then shared with these partners, and they shared back insights gathered through the conversations they led to inform the development of the plan. This is an approach that checked a bunch of boxes: we put the power in the hands of community members (they led the groups and were compensated for their time), we met community members where they already were, we heard from dozens of additional marginalized community members that we wouldn’t have reached otherwise, and we got meaningful feedback that could be incorporated directly into the plan. So many wins.

• Widen your reach with Street Stalls. There’s a problem with the two approaches I just shared - there’s a certain type of community member that’s already part of existing groups and community organizations. There’s another type - actually many types - of community members that aren’t part of those groups. And sometimes - scratch that, most of the time - those are the folks we most need to hear from. Knocking door to door isn’t typically an option, but what we can do is gather community input on-site at community locations and events (think community centers, recreation centers, festivals, farmer’s markets). We used this approach last year to gather input to inform the Children’s Behavioral Health Blueprint led by Healthy Minds Fairfax. I designed and set up a tri-fold poster board (don’t underestimate the low-tech options!) with various categories of resources and had teens/children use green dots and caregivers/parents use pink dots to vote on the community resources they find most helpful. Another section the board had an open-ended question about what they’d most like to add/change in their community to support children’s mental health, with blank post-it-notes and markers available for passers-by to add their responses. End result: we got helpful input from a wider range of community members and not just those that would self-select into completing a survey or participating in a focus group.

These strategies are great to meet community where they literally, physically are and hear what they have to say. But there is a difference between hearing and truly listening - find that in our next post!

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