Using Prevention Strategies to Help Families Thrive

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson. On this episode, taking the initiative to put children and their families at the center of efforts intended to help them thrive.

DR. MICHAEL FRASER:
So, if you ask Americans what's the most important to them, it's children. And so, I think that brings us altogether and it gets everybody excited because we all do care about the future. And we all do care about children.

TRACY WAREING EVANS:
We can make all sorts of fiscal arguments about what it saves us—you know, for every dollar spent on prevention, $25 is saved in future costs in other systems—but ultimately, it's really about the heart of what we all want for our own kids, right—for them to be healthy and well. And that's really what we're talking about here.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, pushing for a transformation, reforming America's child welfare system, aiming for one that's focused on family well-being and prevention.

Every time the system fails a child, we rightly ask why. There is nothing worse than missing the signs of trouble or not knowing about a problem in time to save a life. The system is well-intentioned, but too often it falls short. Swift action can change all of that.

A prevention-focused child welfare model is the critical opportunity to bring public health and human services agencies and organizations together, delivering at-risk children and their families the promise of a better future.

Talking with us today are two people helping lead these reforms. Mike Fraser is CEO of the Association of State and Territorial Health Officials. Tracy Wareing Evans is president and CEO of the American Public Human Services Association.

WAREING EVANS:
We all want children and their families to thrive. And if we focus on a system that creates conditions for parents and children to build well-being together, that's really at the heart of the goal. And it's interesting, because I think we say child prosperity and thriving families—they're really one and the same, and that's really what the goal aims to be.

FRASER:
You know, there's a cliché that it takes a village, but it's really true. If you look at a shared goal like child prosperity and thriving families, that's not the responsibility of one entity of government or one sector of the system. And in fact, you know, prosperity, as we're seeing with COVID, is related to health, not just economics.

And so, child prosperity is one of these cross cutting themes that brings us all together in the work we do, both in public health but in child welfare and human services.

JOHNSON:
You are both thinking about this. Does that mean we are not doing a very good job right now in this country serving children, helping them have better lives?

FRASER:
Well, I think there's tremendous room for improvement, you know, and that's always the case. We're a big country, we're a diverse country. And there's, you know—if you look state by state and within state, you're going to see tremendous variation for lots of reasons.

I think we can always do better and we should always be aspiring to do better. There's lots of reasons why we have the system and the outcomes that we have today, and a lot of those are really due to the way that agencies are structured and the way funding works, and really some of the acute priorities that agencies have to address versus some of the systems building work they have to do.

And so, it's really, I think, a matter of alignment more than anybody's doing a bad job or not doing the right thing. It's really about aligning and bringing together.

WAREING EVANS
There's a sense that, I think, we have to start with that the solutions are within our reach. And we know so much more now across both of the sectors, the things that help us move to the conditions that allow any of us to live our lives more effectively and really prevent maltreatment to children and promote strong families.

But there is a really important piece that I think we haven't tackled enough, which is how deeply embedded some systemic and structural inequities and racism is in our systems. And I think we are committed together to really bringing a public health approach and what we know about family-led supported coaching in more concrete interventions with a family, so those universal approaches and those more specific approaches together that will really amplify what's already happening in both our fields.

FRASER:
The one thing that I think we can do better, honestly, that we don't do well is focusing upstream. And I think again, to us, that means focusing really on primary prevention and systems change. And again, I think that's because we're so focused on the downstream outcomes and the things we have to do today to really deal with some of the acute cases of neglect or abuse and those take all our resources.

It's really the same thing in health care. We spend so much time dealing with the effects of a system that doesn't work for folks, and we don't treat them until they're really, really sick. And moving upstream and really thinking about the conditions that create prosperity and thriving families, and those, you know, we should be investing way, way, way more upstream than we are today. And I think that's one area where we can do a lot better.

JOHNSON:
How do you accomplish the upstream objective? What steps need to be taken and who needs to be taking them?

FRASER:
Well, I think we're taking the first step together by working together and kind of sharing our points of view. Even within public health, we have a lot of family-serving, client-focused kinds of work that is not always, you know, "Make sure you're eating your apple and go for a walk," kind of work. It's primary prevention. And so, I think it's really about working together to share our perspectives.

And then, I think the other piece is really an advocacy piece, which is, y'know, policy makers want to see results, and it's really hard to show what didn't happen. So, focusing on prevention is really about preventing something from happening, and getting buy-in on that is really tough. So, I think we've got to take some steps in our advocacy messaging to show why that's important in this case and a little different from what we might expect with some other kinds of programs.

WAREING EVANS:
Yeah. And if I can just amplify Mike's point, I think it requires a shift in mindset. You have to approach building child and family well-being or a prevention frame looking at the assets—the assets of a family, the assets of a community—and shifting our policies and practices to align.

And, again, I think really understanding some of the structural inequities and institutional bias that have been baked into our systems and what that has meant for particularly communities of color, and how do we really pull the right levers to create a more equitable and inclusive system in supporting, really, families on the ground.

And I think also recognizing that this is a bit of relationship building with each other. Again, amplifying Mike's point that we have to, you know—part of it is our two organizations committed to coming together—bringing leaders in public health, bringing leaders in child welfare and human services—and helping kind of create the knowledge together. And bringing a little bit of humility to our work—to say, "What can we borrow from each other and really have a better impact than we have in the past?"

JOHNSON:
What are some of the challenges to this goal of moving our thinking to an upstream perspective?

WAREING EVANS:
Well, I think, you know, again, I'm going to start with—while there are challenges, I think that the opportunities are really before us right now. And the pandemic itself has, I think, been a positive disrupter to seeing what's possible.

So, you know, it's multi-faceted in its nature and we need the collective effort of so many folks to move lots of different levers—policy levers, practice and culture, and organizations' fiscal, really, how do we drive investments further upstream? So, the challenges are there are a lot of moving pieces in and, you know, to really gain the movement and have the real systems change that we're trying to achieve.

You know, you need states, you need federal government, you need community, and you really need to put families in the driver's seat, which is, you know, a real shift in a way that we, at least from the child welfare perspective, that we've really built the systems. And so it, again, kind of comes back to relationships and leadership being really important to driving those changes.

FRASER:
Relationships and leadership are absolutely key. I think some of the other challenges interrelated would be agency culture and how folks have approached the work in the past. And again, I think, as Tracy mentioned, is that positive disruption of COVID gives us a chance to kind of really think differently, maybe to think more efficiently, think about how we can all work together in a different, a new way.

You mentioned earlier in terms of challenges—to me, the funding streams. And there's a lot of myths about, you know, the funding programs and what federal dollars can be used for in states and what state dollars can be used for locally.

And really thinking creatively is another way to address some of this and getting to know some of the nuances and ways that folks can span boundaries with existing resources versus using that the story we tell about the use of those dollars may or may not be correct, actually.

JOHNSON:
Are you worried that people think maybe this problem is being solved? They don't see the need, or it's already been taken care of?

FRASER:
I wish. I don't, you know—I think, certainly prior to COVID, when you look at the opioid epidemic, this was an issue that was top of mind for many people. And families which, you know, again, it's just a more recent example, have lots of cases where we have children in settings that aren't healthy. We have, you know, people in families that aren't thriving.

And coming together to address those problems, I think, is the solution to this. It's not that people aren't working on it. It's that it's a big problem. And it's a problem that's going to take everybody rowing in the same direction.

WAREING EVANS:
Yeah, And I think that if there's any kind of default thinking, it's not that the problem is solved. It's that people tend to think it's too big to solve or not my problem.

And we call it in the child welfare field, like this fundamental attribution error, that if we can just fix an issue that a parent has—substance misuse—or providing additional skills, that we'll program our way out of it. We'll put all of these programs together and somehow that'll solve the problem when, in fact, we've ignored the environmental context.

You know, we often talk about in our fields as the social determinants of health and well-being, all the different things can impact how it is that you can assure your children are well and you are able to provide both as a caregiver and a breadwinner.

And I think the more we come at it from public health prevention orientations and understand kind of a universal lifting up of all boats, if you will, when we equal the playing field a bit more, that's really the lift. And I think, again, the solutions are within our reach. It's really about building on the knowledge of both fields together.

JOHNSON:
So, let's talk about the prevention-led model, because I think that's what you're referring to when you refer to upstream solutions. How does that look and what can be done in those areas, say in the next year to five years, bouncing out of this pandemic that we're in right now?

FRASER:
I think this issue of working together, obviously, but also getting started with public health and human services as a base. I think putting families at the center of everything that is being done in a community to help folks makes a lot of sense.

When you take that approach, you realize, well, maybe a public health home visitor that's doing first time parenting counseling and a case manager from the human service agency and someone going to WIC clinic to get their nutrition supplement may not be the most efficient for that family. Maybe there's another way to organize our services and different kinds of opportunities for prevention in that model.

So, I think it starts with putting those pieces together from the point of view of the people that we're serving versus the agencies that were created to serve them.

WAREING EVANS:
I think Mike said that really well. And when you think about it from that perspective of it, you know, we are trying to bring leaders together across public health and child welfare alongside, or really with, families in the driver's seat. And we know that part of this journey.

So, if I played out a few more years, it's to say, you know, who are we working alongside? Well, we have to work alongside education systems, and health systems, and housing, and transportation, and justice.

And so, you know, this is an effort that will—I think we can make a great deal of impact over the next 5-10 years, but requires us bringing along other partners that are key, again, to how any of us kind of live our lives where we live, learn, work, and play. That's a shift that I think could have very longstanding and positive impacts for communities across the country.

JOHNSON:
Are these partnership discussions is already underway, that you know of?

WAREING EVANS:
Absolutely. In fact, the funder that is helping the work that we're doing across ASTHO and APHSA is Casey Family Programs, who's a long time investor in supporting the foster care system. And there are many others that are, you know, alongside on this journey. The prevention lens, if you will—bringing and trying to think about how we move our systems upstream—has commitment at the federal level as well.

Certainly, there was legislation passed a couple of years ago that really started to move some of the funding streams that flow from the federal government to states and local communities in the child welfare side to more prevention.

We see a lot of support for looking at the dollars that exist for public health and child welfare being leveraged as much as possible in investments early on. Now, that isn't to say that there's a lot more to do on that front, but there are a lot of synergies and this is not new.

Although I think the awakening, if you will, for so many folks in realizing how important it is that we put investments up-front to strengthen the resiliency of families and communities that as we experience it in this global pandemic, I think, has lifted it up a way that, for leaders on the front line, we really want to make sure that we can continue to stand together in solidarity and really move it forward at this moment.

FRASER:
Yeah, I think the work has been done for a while.

But the momentum that we now have for lots of reasons—you know, not the least of which is the pandemic; but prior to that, the opioid epidemic; prior to that, really a renewed focus on equity and social determinants and moving that out of the healthcare and public health space into other sectors—that's been happening for a while.

And I think this is just a natural result of that, with the leadership of philanthropy and families and communities, as well as government, working together.

So, I think we're at this really interesting moment where we want to begin to say, "Okay, look, we've done the assessment, we've done the data. We know what the problems are. We don't need to spend a lot more time, you know, on the research, necessarily. Let's start seeing what does this really look like in the states and communities, and where have they done this well, and how do we build on that to share that nationally?"

And that's what our organizations do so much of. We get leaders together to share a success. And that's what we bring that is different from some of these other groups that worked together, which is, you know, our folks have some of those levers and some of those influence opportunities with policymakers and governors and, you know, members of Congress, to really talk about this in a way that heightens interest and can demonstrate results. And I think that's what makes this such a great opportunity.

JOHNSON:
You're both leading this effort from the association side of the equation, but does the overall initiative need a point person or a point organization? Is that the federal government, is it more dispersed? How does that part of this issue, this solution, look?

FRASER:
You know, I think leadership is something that can be shared, and I think people have different responsibilities. What's needed is more of a strategy where we all see ourselves and a vision and a goal that we all see ourselves and the pieces we can own in this so that folks can take that ownership and move it forward. And, you know, I think the federal role has been to invest, and support, and create an environment that encourages a perspective that focuses on systems that are supportive of families regardless of the agency. I think the state role is, in many ways, similar, and states can innovate.

You know, I don't think it's going to be a big centralized new program as much as people thinking together, "What does this really look like in the jurisdictions we serve and what is gonna work for our community?"

We know how to approach this in Alaska is very different from how to approach this in Manhattan and you know, everybody in between. So, you know, one model never works in our country. And in some ways that's just wonderful because it gives us these opportunities for shared leadership and to let leadership emerge, you know, where it's strong versus because it's a grant requirement.

WAREING EVANS:
Yeah. And I think there are a common frameworks—we use them at APHSA, I know Mike in public health uses them as well—and what we're actually seeing, and this is just in the very early design phase, but we're seeing a lot of synergy actually in different frameworks that we all bring to the table.

And they're not models, right? They're not a one-size-fits-all approach, but there are some questions—a roadmap, if you will—to try to ask the right questions, to make decisions.

And I get really excited when I think about our leaders coming together and bringing some of those frameworks that have worked for the fields respectively, and really mapping them together.

And then, you can see how you might layer in overtime—kind of thinking about, like, concentric circles going out—how you can start to bring a lot of other systems together that are all people-serving systems, right, and have leaders marching towards goals that fit local context, and ultimately are going to benefit the nation as a whole.

FRASER:
The issue here that's so encouraging is if you ask Americans—and I forgot what survey this was, but I'm sure it's still true today—if you ask Americans what's the most important to them, it's children. And so, I think that brings us all together and gets everybody excited because we all do care about the future, and we all do care about children.

And so, the opportunity then is to, as Tracy mentioned, get those people-serving organizations together to really think upstream about what we need to do to create the systems that create prosperity, that enable families to thrive. Nobody's opposed to that. You know, I think the debate is about how, but I think, at our core, we all have the same goal.

JOHNSON:
Let's talk a little bit about frameworks. What's out there right now? What's working?

WAREING EVANS:
Well, we have certainly adapted a model—or a framework, rather—of something called the human services value curve coming out of leadership for A Networked World at Harvard.

And, longer than our podcast to explain the frame as a whole, but it is essentially a lens that gets applied to ask questions about how are we implementing policy and practice and are we focused on—is it really family led? Do we really understand root causes? Or, as I mentioned earlier, or are we simply, you know, trying to design and fix a single issue?

The lens of this value curve really helps us ask those questions. So, that's something we are using.

Public health has its own frames as well. And I think that Mike can share a lot of what has happened in the public health field that we feel has huge implications in child welfare. And in many ways, it's remarkable that, as a nation, we really haven't applied that approach.

But I think maybe hearing from Mike on a couple of other areas outside of our field where, you know—public health has totally changed how we interact in our communities and what we do to assure kind of safety and well-being.

FRASER:
Well, I think there's a couple of different frameworks we use.

Most recently, we've adapted a technique for organizations working together called boundary-spanning leadership, and it's been a way to convene folks from different sectors around a shared goal, to do the tough work of saying, "Alright, why don't we work together? You know, what's getting in our way, what are some of the boundaries that we need, and what are some of the boundaries we don't need, and how do we more effectively coordinate, collaborate, and, you know, again, get to that shared goal?"

That's been fun to watch. It's been something that we've started over the last couple of years—public health agencies—and one of the first places that folks have applied that has been child welfare and human services.

The value curve has actually been really instructive for us as well. You know, again, real traditional kind of public health work and social determinants of health and looking at, you know, what factors have impact on health and moving well out of the clinical setting into communities. And, you know, that's when public health starts really needing to work with education, and housing, and economic development.

And again, historically, that's been the role of public health. And as a public health evolved, and as medicine evolved, we've really been moving towards a more medical approach, more of a healthcare approach. But this is really going back to the reason public health agencies were founded in the first place, which was to promote maternal and child health in every state and have a locus for that activity in every state.

That's the foundation of every single modern public health department. So, it's kind of this back-to-the-future moment, you know, in doing it in a new and different way.

Another model that we've used is this thinking around adverse childhood events and the factors that predict future health. So many of those are the result of what we call adverse childhood events, or basically bad things that happen when we're kids.

And those traumas, and how they're dealt with it, and the number of those—just the sheer number of those in a family setting that a child experiences, whether it's abuse, neglect, all of those things—actually are very predictive of future health outcomes—things like chronic disease, things like addiction. And so, you know, we kind of bring all of that, all those tools to the table when we were speaking about this because we need to use all of them to move forward.

JOHNSON:
Is anyone doing this now? Anybody worth a shout out here on the podcast that you can think of?

FRASER:
Yeah. I mean, I mentioned boundary-spanning leadership. That was, most recently, something that we were working on in New Hampshire. And I know that's a agency that really has spent a lot of time thinking about working within their human services and health components as one agency. I think Washington State has a Healthiest Next Generation project that's really been a model for early childhood and parents support programs aligning in states. There are several—Tracy probably has some others, too.

WAREING EVANS:
Probably what I was going to say is, actually, I think there's a lot more bright spots than maybe the general public would actually recognize. And I think part of our organizations coming together is also to be able to continue to lift some of those up and create additional opportunities for others to learn from what certain communities have done.

JOHNSON:
And those examples give people something to model after, to point to as a reason for getting engaged themselves.

WAREING EVANS:
Right. And believing that there's the possibility of having impact.

FRASER:
Yeah. And, you know, we work at ASTHO with state governments and territorial governments, but a lot of it is happening in places well outside of the government—whether it's, you know, community-led, whether it's other nonprofits, whether it's state-based philanthropies, there's a lot of work in education that I probably need to catch up on. So, I think there's lots of bright spots, as Tracy said.

JOHNSON:
How do listeners engage if they are interested in taking this on here and now?

WAREING EVANS:
I think reaching out to either of our organizations or engaging with their own leadership in public health and human services and child welfare, you know, finding out how that works in their state and their community is a great place to start. They're always looking for folks to be stewards of the change because this really has to happen from community leaders, neighbors. There's a role for everybody in child well-being. There are many ways people can connect in their own communities.

FRASER:
There's lots of ways to engage it. One of them is by going to our website, as well, and contacting state and territorial health departments. Within health departments, there are individuals responsible for family health that are working on this, whether it's what we call the Title V Maternal and Child Health Block Grant, which is a program in every state that brings together public health activities that serve children and families. I think there's lots of opportunities there.

Especially because, with their state Title V programs, they do have a community engagement component, so there's opportunities to get directly involved with advising the state on how it programs a lot of the work in public health that is part of the child-serving and family-supporting work that happens in public health.

JOHNSON:
Everyone agrees that children ought to be the priority, but make the argument for us as we wrap up. Why is this so important?

WAREING EVANS:
I think what I would say is if you think about the paradigm shift, if you will, that we're talking about here, in which families really lead and we have children, and families, and communities essentially building their own well being together, that in turn creates stronger and more resilient communities, and that creates the conditions for more families to thrive. So, I think this is a win-win in many ways.

And, you know, ultimately we can make all sorts of fiscal arguments about what it saves us. You know, for every dollar spent on prevention, $25 is saved in future costs and other systems. But ultimately, it's really about the heart of what we all want for our own kids, right—for them to be healthy and well. And that's really what we're talking about here.

FRASER:
Absolutely. I couldn't have said it better myself.

I mean, it's about the future. It's about doing better. And you know, there's the economic argument, there's the moral argument, and then there's really this values argument. And I think that's where all of us agree, and why this is so important, and why we've never had anybody say, "No, I don't want to work on this."

JOHNSON:
You can find links to resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And, if you have comments or questions we'd like to hear from you. Email us at pr@astho.org. That's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.