Community Participation, Civic Capacity & Neighborhood Identity Findings from Focus Groups and Written Elicitations

1. Community Participation, Civic Capacity & Neighborhood Identity Findings from Focus Groups and Written Elicitations April 3, 2008 Commissioned by The Center for Health Equity, Louisville Metro Department of Public Health & Wellness

2. PURPOSE OF COMMISSION • A social marketing campaign • Increase the community participation of west Louisville residents by ………….. • Reducing the barriers and, • Highlighting the benefits according to • The specific needs, values, beliefs, practices and interests of the residents.

3. Investigative Framework • To improve health and reduce health inequities requires changes in public policy and the arrangements in society that support inequality. • If residents of the City [State, Nation] understand and support policy goals, change and progress are more likely. • To change policies and societal arrangements that support inequality communities must have the capacity to engage civically. • We currently have group differences in the civic capacity of some communities and sectors, i.e., corporations, high income vs. low income communities, etc. • How do we rectify imbalances in civic participation and civic power?

4. Civic Engagement • Participation • Formal and informal • Social and Political • Organized community life • The capacity of people to organize in ways that bring about dialogue with and/or challenge a system. • May include individual or group acts • Attending public meetings • Writing a letter to the paper or government official • Signing a petition, etc. • Voting • Civic engagement and participation • Confront & organize to address community issues • Lead to the ultimate goal of community practices for social justice.

5. Civic Capacity Building • Strengthens the ability of community organizations and groups • Build their knowledge, structures, systems, people and skills so they are better able to define and achieve their objectives • Training, education, resource identification and resource building, organizational and personal development • Promotes sustainability and strengthens internal and external or bridging and linking social capital

6. Goals Civic Engagement • Mobilize residents to become civically engaged • Identify issues • Examine issues • Ask questions • Organize • Take action • Be responsible for what they can control

7. MEASURING CIVIC CAPACITY • Political Efficacy • Social Cohesion • Social Capital • Collective Self Efficacy

8. How Does this Affect Health?

9. Policies that Reduce Availability of Affordable Quality Housing Policies that Reduce Availability of Financial Resources Government Policies Stress Associated With Income and Housing Insecurity Direct Material Effects of Income Direct Material Effects of Poor Quality Housing Health Status: Increased Morbidity and Mortality

10. Strategy and Research • Part One • Exploring current “landscape” of public understanding (focus groups, written elicitations) • Part Two • Message development (new “lenses” on the issue - explanations in particular) • Message testing - evaluating effectiveness (online, and in-person

11. Research Questions • How do Louisvillians currently think about community participation? • What role does neighborhood identity play? • What are the key obstacles to increasing participation? • Are there promising directions for moving forward?

12. Methods • Focus groups • Recorded, transcribed • Written elicitations • Looking for shared thinking patterns, e.g.: • Links between topics • Topics that aren’t thought about • Ideas that seem important • Differences between how we want people to think and what they think

13. Subjects • Louisville residents • Non-experts, non-activists • 13 women and 7 men • 9 conservative, 10 liberal, 1 moderate • 12 White, 6 Black, 1 Hisp, 1 Nat.Am. • Mix of ages, educational backgrounds • From lifetime residents to newcomers

14. Focus groups Six groups 2 hours Incentive $50 Videotaped, audio taped, transcript Pre-Screened Focus Group questionnaire Homeowners 8 Low Income 7 N.E. Christian 6 Portland 5 St. Stephen’s 6 Youth 18-24 3 FORMAT & SUBJECTS

15. Ages 18-24 three 30-50 fourteen > 50 eighteen Gender Female 19 Male 16 Home ownership Own 19 Homeless 1 Rent 13 Unknown 2 Race African American 25 White 9 Hispanic 1 SUBJECTS

16. Education Levels College graduate 6 Graduate degree 5 High school 15 Professional degree 1 Some college 6 Unknown 2 Income > $75 3 $50-75 4 $35-50 6 $10-15 2 $15-20 2 $20-25 4 $25-35 6 SUBJECTS

18. GROUPS • 1 group of young adults • Ages 18-24 African American • 1 group from Northeast Christian • Adults • 1 group from St. Stephen’s • Adults • 1 group of adults from Portland • White • 2 groups of adults from W. Louisville • African American • Low income • Middle income

19. Expert View: External Factors External Factors Health Outcomes Social determinants play a key role in determining health.

20. Expert View: External Factors External Factors Housing Economic opportunity Education Work status … Health Outcomes Diabetes Cancer Blood pressure Obesity … Social determinants play a key role in determining health.

21. GROUP A GROUP B GROUP C Actual Interpretation: Right Choices Healthier Less Healthy CHOICES Character, Knowledge, Culture, Priorities, Values Public assumes a different causal story: RIGHT CHOICES

22. Actual Interpretation: Right Choices CHOICES HEALTH OUTCOMES A “User-friendly” Conceptual Model: simple, easy to understand – seems like the whole story A Moral Model: Not just how things do work, but how they should work – outcomes seem fair

23. A Limiting, Distorting Lens HEALTH OUTCOMES Q: Some people say the city of Louisville should do more to close the gap between those who are in good health and those in ill health. What do you think? A: I think people need to eat better, exercise more, I think that’s a big issue here in Kentucky. The way we live. The way we eat. The way we don’t exercise, a lot of it is [contributing] to being overweight. Conservative African-American woman, age 64

24. A Limiting, Distorting Lens HEALTH OUTCOMES [You] need to choose a different outlook and then from that different outlook that will perhaps guide you towards a healthier life ... If people understood they actually do have some amount of power – some amount of control in their lives, then that would be a healthier place to start – a healthier viewpoint. Liberal white man, age 31 Note: Choices matter, but they’re not the whole story.

25. A Limiting, Distorting Lens HEALTH OUTCOMES Q: If you had to take a guess on what groups of people in Louisville would be healthier and what groups would be less healthy, what do you think? A: The couch potatoes would be less healthy. Conservative white woman, age 71

26. A Limiting, Distorting Lens HEALTH OUTCOMES • Blacks don’t take care of themselves right. That’s why there’s more health problems with Blacks than Whites, because they just don’t take care of themselves right. They don’t eat right. They don’t exercise. They don’t go to the doctor like they should. That’s the problem with Blacks. • Conservative African-American woman, age 44

27. A Limiting, Distorting Lens HEALTH OUTCOMES • Eating habits is one of the biggest things that’s causing most of the diabetes and stuff like that, because unfortunately the Black race has a rich diet. It’s got a bunch of grease in it and that’s causing cholesterol and all those stuff. Once we get educated on it we will be able to do better. • Conservative African-American man, age 60

28. A Limiting, Distorting Lens HEALTH OUTCOMES • I think it has a lot to do with [African-American] culture. I’m being stereotypical, but based on what I know, they are OK with the bodies that they have. Some Black people have great bodies. Other Black people are bigger … but they’re okay with themselves, and I think White people have a harder image of what they need to live up to. There’s more of a pressure on White people, because we’re the dominant race. • Liberal White woman, age 22

29. A Moral Lens Q: Do you think we as a society owe every person some kind of help for being healthy? Is something like that a right to have? A: No. Not as a society, because see a lot of times people cause their health problems by the way they live. Conservative African-American man, age 60 It’s your own personal responsibility to do what you can to improve your health and keep yourself healthy ... If I’m going out, [if] I smoke a lot, if I’m carrying on excess weight or if I have four or five alcoholic drinks every day – I’m making that decision. That’s my choice, so I’m hurting myself. I think there’s too much of people not taking responsibility for their actions and just letting it go and thinking, well, you know, let somebody else take care of me. Moderate White woman, age 75

30. Response to Causal Claims External Factors Housing Economic opportunity Education Work status … Health Outcomes Diabetes Cancer Blood pressure Obesity …

31. External Factors Housing Economic opportunity Education Work status … Health Outcomes Diabetes Cancer Blood pressure Obesity … Response to Causal Claims • External factors as outcomes, not causes(people create their own poverty, racial isolation) A lot of discrimination is self-imposed ... [Blacks] get 25 years old and they don’t have an education, they don’t know how to speak properly. Mainstream isn’t going to take them in, because they’re not mainstream. Conservative White man, age 29

32. External Factors Housing Economic opportunity Education Work status … Health Outcomes Diabetes Cancer Blood pressure Obesity … Response to Causal Claims • External factors as obstacles that should be overcome(many examples of people doing fine) You can still make a way if you try. I’ve seen people do it . . . It’s all based on your choices. Liberal White woman, age 30

33. RIGHT CHOICES Summary • Comfort with disparities • Resistance to Causal Claims • Right Choices as a powerful lens with no real competition

34. Where “Right Choices” Comes From • Natural tendency to think “Little Picture” • American emphasis on Individualism, Personal Responsibility (to exclusion of other views) • Reinforcement in the media

35. “Right Choices” in the News • Media “tells the story” through choice of stories, language, images, etc • Right Choices as a natural reading, even when it’s not stated directly Troutman, who is nationally known for his work fighting racial health disparities, said there are complex factors behind the problem such as poverty, access problems and discrimination. Jesse Penick, a 41-year-old African American getting a checkup at the Portland clinic this week . . . cannot resist eating such foods as pork chops and fried chicken. "It's kind of hard to eat right," he said. Courier-Journal, 12/24/05

36. Opportunities This report has so far focused on the “bad news.” The research also suggested very promising ways of moving forward.

37. Opportunities Approaches with the potential to bring about a shift in thinking • Health gradient • It’s about everyone – avoids traps about groups • Potentially a clear and concrete idea • A totally new idea - potential for “aha!” effect? • Very clear causal stories • i.e. that can “compete” with Right Choices

38. Opportunities • Frame social determinants as Opportunities for health • Convey a “Positive Vision” • Clear, practical image of interventions that can succeed

39. Opportunities • Familiar case studies • where it’s impossible to pin blame on individuals • E.g. lack of green space? lack of full service grocery stores? Rubbertown?

40. Recommendations So Far • Ask the following question about every communication: Does it allow people to focus on individual choices/behaviors? • Don’t bother focusing on disparities per se. • Talk about practical and effective changes/interventions

41. Recommendations So Far • Make causal stories as concrete and irresistible as possible

42. CL@culturallogic.com www.cullturallogic.com

43. Building Civic Capacity, Engagement, and Action

45. What are We Dealing With? • Many of the inequalities in health- are due to inequalities in the social conditions in which people live and work. • Valentine, et. al, PloS Medicine 2006; 3(6): e106. TH commission on the Social Determinants of Health • Tackling these conditions- social determinants health- underlying causes of poor health can contribute to improving health and health equity.

46. Central Questions? • Why are you civically active? • Why are you not civically active? • What is your view of west Louisville? • What issues concern you? • Parameters for this discussion • Local economy • Neighborhoods • Your family • Jobs, wages • Educational opportunities

47. What Ideas or Theories Do We Want To Explore? What are their views of West Louisville? What Issues concern them? Why do they participate or not participate?

48. Why Do Individuals Elect Not To Participate? • Because They Can’t…… • Legal restrictions • Intimidation, fear, road blocks • System makes participation/voting difficult • Internalized powerlessness or racism • Because They Don’t Want to… • Will this do any good? • Is this effective in achieving economic or non-economic benefits? • Self-interest • Is there a perceived benefit? • Can I trust the people in power? • Attitude influences participation • Because Nobody Asked • Mobilization Theory- participation is based on contextual cues and political opportunities in the environment of the individual- media messages, campaign spending, conversations with friends/neighbors, etc. • Participation influences political attitude, efficacy, and sophistication • Mobilization mediates the effects of SES and attitudes on participation. • Mobilization accounts for approximately half of the decline in voter turnout since 1960. Sidney Verba, Kay L. Schlozman, Henry Brady and Norman Nie, “Resources and Political Participation,” paper prepared for the 1991 annual meetings of the American Political Science Association

49. Expected Outcomes • A report: • How people in west Louisville think about civic participation [in comparison to…..] • A look at the issues that concern them • How they think about west Louisville • Recommended messages and activities • Preliminary ideas for a communication strategy • Preliminary ideas for evaluation • Be prepared to grow, change, and make midcourse corrections based on our observations. 

50. RecruitmentHow & Who? • 1 group of young adults • Ages 18-24 African American • 1 group of adults from Portland • White • 2 groups of adults from W. Louisville • African American • Low income • Middle income