November 6, 2017 Liz Borkowski, MPH 1Comment

Regular readers know the past several months have been full of bad news for public health, so I’m happy to be able to highlight something positive: Policy findings from five different communities that took very different approaches to tackling gender health disparities. Articles about their experiences were recently published in a supplement to the journal Women’s Health Issues, where I’m the managing editor. Their experiences show how changing policies at the organizational, local, and state levels to address gender disparities can help reduce barriers to health for everyone.

Articles in the supplement address creating a trauma-informed workforce in Baltimore; assuring safe walking and biking paths in Billings, Montana; using findings on mental health and diaper need to advocate for policies that improve diaper access in New Haven and beyond; updating high school and medical school curricula in Philadelphia; and making it possible for community health workers in Utah to play greater roles in healthcare.

Identifying needs and solutions

The coalitions highlighted in the supplement all received funding from the U.S. Department of Health and Human Services Office on Women’s Health (OWH) as part of OWH’s Coalition for a Healthier Community (CHC) initiative. In a commentary introducing the supplement, OWH’s Stephanie Alexander and Stephen Hayes explain:

The CHC initiative provided long-term support to 10 organizations operating in six regions in the United States. Grantee communities varied in catchment area, nature of interventions, diversity of coalition members, and coalition membership size. Grantee organizations were members of existing community coalitions. Coalitions were composed of local, regional, and national organizations; academic institutions; and public health departments. All coalitions were required to develop a gender-based approach designed to address the roles, behaviors, activities, and biological and psychological attributes society assigns to women and/or men. Coalitions then determined how these factors impacted treatment, access, and overall health (Alexander & Walker, 2015).

The grantees conducted community needs assessments and gender-based analyses to identify gender constraints that affected the health of women and girls, and then developed evidence-based plans to address the health issues they identified. A report from the CHC evaluators summarizes and analyzes the policy changes that all 10 grantees undertook as part of their work – which wasn’t necessarily policy-focused from the start, but often expanded to include policy as the coalitions discovered ways in which policy changes could make their local environments more conducive to public-health improvements.

A wide range of policy approaches

Several of the coalitions focused on interventions to help women improve their diets and become more physically active, and recognized that their local environments can make it hard to adopt such healthy behavior changes. So, in addition to encouraging healthier eating and exercise, they also worked to improve those conditions:

  • B’More Fit for Healthy Babies recognized that obesity and trauma both contribute to poor birth outcomes in Baltimore, so they launched a weight-loss intervention using a trauma-informed care approach. The coalition’s trauma-informed approach served as a model that helped Baltimore city agencies improve their capacity to provide services in ways that are sensitive to the needs of city residents who have experienced trauma, with more than 1,000 employees eventually getting trained in trauma-informed care. When Freddie Gray’s death at the hands of the police and the resulting uprising drew national attention and resources to Baltimore, the city was able to build on its trauma-informed progress to offer more coordinated mental health and substance use services to residents.
  • The Healthy by Design coalition in Billings, Montana identified unsafe streets and trails and inadequate sidewalks as barriers to physical activity that disproportionately affected women, girls, and residents who rely on mobility devices. They used findings from focus groups of local residents to advocate for a Complete Streets policy “to ensure all roadway users traveling by automobile, bicycle, public transit, foot, or mobility assistive device are considered during the planning and design of roadway projects.” The Billings City Council adopted a Complete Streets resolution in 2011 and passed a stronger version in 2016 after the earlier version faced a repeal threat. Physical activity rates have increased in Billings, and the gap between the percentage of women and men reporting no leisure-time physical activity has narrowed.
  • The Philadelphia Ujima coalition focused on several different organizations that influence public health. They worked with a high school and medical school that revamped their curricula to better address gender issues, and with community-based organizations to adopt healthier policies on topics like the nutritional quality of food served at events. One of the churches involved in the coalition recognized through its participation that leadership lacked a sufficient understanding of the gender norms and stereotypes contributing to sexual and relationship violence, and they developed a policy to include relationship and sexual violence in future leadership trainings.

Two of the coalitions are working to change state laws in order to remove barriers:

  • The Coalition for a Healthier Community for Utah Women and Girls (CHC-UWAG) developed an intervention that relies on community health workers to help racial and ethnic minority women in Utah adopt healthier lifestyles. Forthcoming trial results suggest the intervention is successful, but training and paying CHWs is challenging when the state lacks mechanisms for certifying them and most insurers don’t reimburse for their services. The coalition’s work has contributed to the creation of a CHW Special Interest Group in the Utah Public Health Association; winning support for CHWs from the Utah Medical Association; and proposed state legislation to promote and support CHWs.
  • The New Haven Mental Health Outreach for Mothers (MOMS) Partnership conducted a survey that found mothers with diaper need – that is, struggling to secure enough diapers to send their children to daycare – are more likely to also report mental health need. They reported these findings in a 2013 Pediatrics article that has since been cited in several local, state, and national efforts to improve mothers’ access to diapers. Among the achievements are San Francisco’s distribution of free diapers for those under the age of three in CalWORKs (California’s version of TANF); Connecticut’s exemption of diapers and feminine hygiene products from sales tax starting in 2018; and a Community Diaper Program championed by the Obama administration that helps provide free diapers to low-income families.

These communities’ achievements don’t only help the women who live there. Improvements like safer walking paths and a trauma-informed city workforce can benefit all local residents, and the articles in this supplement (which are free to read for a limited time) can provide useful lessons for other communities interested in developing their own local solutions.


Liz Borkowski, MPH is the managing editor of Women’s Health Issues and a researcher at the George Washington University Milken Institute School of Public Health.

One thought on “From Baltimore to Billings, local solutions to women’s health concerns

  1. Blog Post- Response to “From Baltimore to Billings, local solutions to women’s health concerns”- By: Loren M. Hampton, MPH(C)

    I think its wonderful that cities in need have taken it upon them selves to get policy change that may make a difference in their overall health. Research has showed that health disparities among genders is vast, especially when it comes to child bearing women. Women often have more stress on their emotions and more stress on their bodies from bearing children, and less time and autonomy to take care of them selves due to having to take care of everyone else. In the article by Liz Borkowski, cities across the United States are pushing for policy reform to help improve the overall health of women. Some of these issues include neighborhood safety, gender based curricula in schools, recruiting Community Health Workers, etc. Instead of each city attempting to tackle a grand systemic issue via policy change or implementation (such as Baltimore City’s safety concerns about a safe and healthy environment that promotes outdoor exercise), I wonder if these women’s health problems might be addressed in another way; using Conditional Cash Transfers (CCT).

    A conditional cash transfer scheme is a method of reducing poverty by which government subsidies are given to participants in cash rather than by way of another subsidy. Though it has only been done once in the United States to date (Opportunity-NYC), CCTs have been used in many developing countries successfully including in rural Mexico. Researchers such as UC Berkeley’s Stefano Bertozzi, spent a decade studying and implementing CCT’s for desired behaviors such as sending children (mostly young girls) to school. At each stage of completion for desired behaviors, a sum of money was given to the female heads of households in rural Mexico. In addition to the desired behavior of education, the study found that women were spending 75% of the additional money received from CCT on food for their families. This showed that not only were participants willing to perform desired behaviors that were good for them selves and good for their family, but they were taking additional steps on their own volition to continue that trend.

    Traditionally, CCT programs operate such that participants receive money at various stages of completing desired behaviors. For the women in Baltimore, Billings, New Haven, Philadelphia and Utah, some of these behaviors might look like incentives for shopping for healthier foods, purchasing a gym membership, attending classes on sexual violence, or obtaining preventative health screenings. Of course none of these suggestions address the more systemic issues of schools not addressing women’s health issues or unsafe streets to exercise. This program would still rely heavily on the omen them selves to prioritize what is important to them and make sure that they are completing the desired health behaviors regardless of structural barriers. With that being said, I also understand the importance of policy change and the great restrictions that women in these vulnerable populations face. I also understand that many of these systemic issues have taken and will continue to take years to implement and effective policy makers to make that happen. Issues of dangerous neighborhoods and parks is not new information, these issues have been present and shown to be harmful or decades and yet, still little has been done to institute real change. In the mean time, there are many women, children and families who are suffering and need a more immediate solution, and I think conditional cash transfers could prove to be a valid solution.

    The idea that I am proposing also has the added benefit of reducing domestic violence and abuse. It is often the case that a women stays with an abusive partner due to lack of funds and due to lack support (be it financial, familial, etc). By offering women cash for desired heath behaviors, we increase the chances for their financial stability and therefor reduce the risk of their entrapment in an abusive relationship. If one of the desired behaviors is also to attend meetings with others in the program, about leading a healthy lifestyle or having a healthy relationship for example, then emotional support could also be created in this way.

    Professor Will Dow at the University of California Berkeley, did an additional study looking at CCT’s with sex workers in Tanzania. What he found was that many of the women engaged in sex for profit out of desperation, and many were trying to gain enough money for food and for rent for their children. While his study focused on reducing the number of STDs that these women obtained, it did so by allowing women to decide who and when they want to have sex. An analogous situation in my program would give women money for breastfeeding for example, and we might find that they use the additional money to decide where they are going to live or where they are going to shop, possibly even whether or not they need to have a second job that prevents them from getting a healthy amount of sleep each night. The possibility of improving health outcomes in women are endless!

    The question of when, where, and most importantly how much still remains and to that, I currently have no answer. Sadly it is a very un-American thing to do, to give “handouts”. However, the evidence of the cost effectiveness of preventative health is insurmountable. And when we are talking about mothers in particular and their offspring, we are talking about the health of the next generation; which I believe you cannot put a price on.

    Poverty, cash transfers, and risk behaviours
    Bertozzi, Stefano M et al.
    The Lancet Global Health , Volume 1 , Issue 6 , e315 – e316

    de Walque D, Dow WH, Nathan R, et alIncentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural TanzaniaBMJ Open 2012;2:e000747. doi: 10.1136/bmjopen-2011-000747

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