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Root Cause Analysis: A Community Engagement Process for Identifying Social Determinants of HIV


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This presentation serves as a training of trainers for the root cause analysis process, where participants will be able to train their organizational staff and community members on the process. In addition, it shows how it can be used for community engagement, coalition building, and to identify the root causes of HIV.

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Root Cause Analysis: A Community Engagement Process for Identifying Social Determinants of HIV

  1. 1. As you come in, take a character card, find your character group and sit together at a table. Welcome!
  2. 2. Introductions Please share: - Your name - Your organization - Your role - Your reflection of your character card
  3. 3. Root Cause Analysis: A Community Engagement Process for Identifying Social Determinants of HIV Hannabah Blue & Laura Gerard JSI Research & Training Institute, Inc. March 26, 2019
  4. 4. Workshop Goal This presentation will serve as a training of trainers for the root cause analysis process, where participants will be able to train their organizational staff and community members on the process, and how it can be used for community engagement, coalition building and to identify root causes of HIV.
  5. 5. Workshop Objectives By the end of this workshop, participants will be able to: ● Describe social determinants of health (SDOH) ● Describe how to conduct a root cause analysis (RCA) of social determinants of HIV ● Describe how RCA can be used as a community engagement strategy ● Identify strategies for addressing the root causes of HIV
  6. 6. Agenda Overview Introductions/ Overview 1:30pm Value & Power of Partnerships 1:50pm Revisiting SDOH 2:00pm Root Cause Analysis process 2:30pm Break 3:00pm Report Back & Discuss 3:15pm Prioritization of Root Causes 3:45pm Action Planning & Next Steps 4:15pm
  7. 7. The Value and Power of Partnerships
  8. 8. Early Phase Middle Phase Late Phase What they do -Take baby steps -Launch pilots -Convene non-traditional partners -Commit joint resources -Develop multiple simultaneously running programs -Expand networks -Alter existing business models - Change core practices -Design incentives to allocate resources differently Momentum Builders -Engaging a wide range of stakeholders -Defining a vision around shared values -Cultivating relationships with local leaders -Attending to basic operations, including staff capacity and long-term financial planning -Experimenting -Fostering trust among partners and with the community -Gaining support from local and state policymakers -Sustainable financing -Engaging constructively around controversy -Committing to continuous learning and adaptation -Greater alignment with government policies around payment and regulation -Creating a forum for leaders to work together Pitfalls -Inadequate infrastructure -Lack of shared leadership -Political resistance -Sagging infrastructure -Competing interests -Difficulty measuring progress PhasesofHealth-RelatedMulti-SectorPartnerships
  9. 9. Everyone’s Contribution to the Solution 15% Solutions – Focus on things that we can change – Everyone has 15% of the solution – Will take only 6-7 people to make a 100% change! – “Where do I have the discretion and freedom to act right now so that I can contribute to addressing our challenge?” – “What can I contribute to help address our issue or opportunity that does not require any additional resources or authority?” – “What is my 15% contribution to our solution?”
  10. 10. Collective Impact ● Large-scale social change requires broad cross-sector coordination, yet the social sector remains focused on the isolated intervention of individual organizations. ● Abandon individual agendas in favor of a collective approach. ● Fixing one point on the continuum doesn’t make much difference unless all parts of the continuum improved at the same time. ● No single organization, however innovative or powerful, could accomplish this alone.
  11. 11. Honoring Our Past, Valuing Our Future Journey Map:
  12. 12. Making an Impact – Root causes of health inequality – Two main clusters of root causes of health inequity: – The intrapersonal, interpersonal, institutional, and systemic mechanisms that organize the distribution of power and resources differentially across lines of race, gender, class, sexual orientation, gender expression, and other dimensions of individual and group identity – The unequal allocation of power and resources—including goods, services, and societal attention—which manifest in unequal social, economic, and environmental conditions, also called the social determinants of health.
  13. 13. Revisiting Social Determinants of Health
  14. 14. Source: http://biggest-loser-where-are-they-now
  15. 15. Determinants of Health Exercise Adapted from CDC. Physical environment (where a person lives) Discrimination, income, gender Access, quality, insurance status Sex, age Substance use, unprotected sex, smoking Social/Societal Characteristics Total Ecology Genes & Biology Health Behaviors Health Services
  16. 16. Interpersonal Community SocietalIndividual Health Begins Where We Live, Learn, Work and PlayIndividual ● Individual Behavior ● Personal history (e.g., history of abuse, substance use, etc.) ● Biological Community •Schools •Workplaces •Neighborhoods Interpersonal ● Relationships (Parents, family, intimate partners, peers) System ● Societal factors (health, economic, educational and social policies) The Social Ecological Model: A Framework for Prevention. ecologicalmodel.html
  17. 17. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity Nov 04, 2015 | Harry J. Heima and Samantha Artiga
  18. 18. HIV in Native Communities Data Review
  19. 19. HIV Diagnoses Among AI/AN in the US by Transmission Category and Sex, 2016
  20. 20. New Cases of HIV, AI/AN • AI/AN comprise 2% of the total U.S. population, yet ranked fourth in the rate of HIV diagnoses in 2016 among reported groups • HIV has disproportionately affected AI/AN Communities • HIV incidence among AI/AN patients has increased from 174 cases (7.9/100,000) in 2010 to 222 in 2014 (9.5/100,000) • This rate is paradoxically HIGHER in the highly active antiretroviral (HAART) era than the pre-HAART era ( 1990-1999) Centers for Disease Control and Prevention. HIV Surveillance Report, 2014; vol. 26. Published November 2015. Accessed March 28, 2016 (Reilly et al. Am J Public Health 2014)
  21. 21. Native Women Transmission • Roughly 31% of new HIV diagnoses among AI/AN women in 2016 was through injection drug use, compared to 12% among all women • AI/AN women have 3x the HIV diagnosis rate of White women • There is a 1.5x higher risk of acquiring HIV if a woman has experienced intimate partner violence • Roughly 80% of AI/AN women and men were reported to experience violence in her lifetime, and nearly 40% of Native women reported experiencing violence within the past year Centers for Disease Control and Prevention. (2018). HIV Among American Indians and Alaska Natives in the United States. Retrieved from ttps:// Centers for Disease Control and Prevention. (2013). National Health Interview Survey Retrieved from: WHO, UNAIDS (2010) Addressing violence against women and HIV/ AIDS: What works? National Institute of Justice. (2016). Violence Against American Indian and Alaska Native Women and Men – 2010 Findings from the National Intimate Partner and Sexual Violence Survey. Retrieved from
  22. 22. MSM/GBTQ/Two Spirit • 54% increase in HIV diagnoses among gay and bisexual AI/AN men from 2011 to 2015 —highest increase in the country among reported groups • 56% of Native transgender and gender nonconforming respondents in a national survey had attempted suicide, as compared with 41% of all other transgender groups • 36% of Native American transgender respondents reported losing a job because they are transgender Centers for Disease Control and Prevention. (2018). HIV Among American Indians and Alaska Natives in the United States. Retrieved from ttps:// (Harrison-Quintana et al., 2012, p. 1); (Center for American Progress and Movement Advancement Project, 2015, p. 10). publications/A_Spotlight_on_Native_LGBT.pdf; (Gates, 2014, p. 2)
  23. 23. Death Rates • AI/AN persons living with HIV/AIDS (PLWHA) have the lowest proportion of survival after 12, 24, and 36 months when compared to other age-matched groups • In 2014, AI/AN and Native Hawaiians/Pacific Islanders were reported to have the highest percentage (25.4%) of Stage 3 (AIDS) at the time of diagnosis compared with other racial groups. Death Rates From Human Immunodeficiency Virus and Tuberculosis Among American Indians/Alaska Natives in the United States, 1990–2009 Reilley, B., Bloss, E., Byrd, K. K., Iralu, J., Neel, L., & Cheek, J. (2014). Death rates from human immunodeficiency virus and tuberculosis among American Indians/Alaska Natives in the United States, 1990–2009. American journal of public health, 104(S3), S453-S459.
  24. 24. Adverse Childhood Experiences (ACEs); erican_IndianAlaska_Native_Children_The_2011-2012_National_Survey_of_Children's_Health # of ACES AI/AN Children Non-Hispanic White Children 2+ 40.3% 21% 3+ 26.8% 11.5% 4+ 16.8% 6.2% 5+ 9.9% 3.3% ACES are associated with high HIV risk behaviors and HIV acquisition
  25. 25. Mental Health • People with severe mental illness at higher risk for HIV • In 2014, suicide was 2nd leading cause of death for AI/ANs between the ages 10 and 34 • AI/AN children and adolescents have the highest rates of lifetime major depressive episodes and highest self-reported depression rates than any other ethnic/racial group • In 2014, AI/ANs ages 18+ had co-occurring mental illness and substance use disorder almost 3x that of the general population in the past year infected.aspx Office of Minority Health. Mental Health and American Indians/Alaska Natives, Whitesell NR, Beals J, Crow CB, Mitchell CM, Novins DK. Epidemiology and etiology of substance use among American Indians and Alaska Natives: risk, protection, and implications for prevention. Am J Drug Alcohol Abuse. 2012;38(5):376-82. Substance Abuse and Mental Health Services Administration, The TEDS Report: American Indian and Alaska Native Substance Abuse Treatment Admissions Are More Likely Than Other Admissions to Report Alcohol Abuse,. Rockville, MD: 2014.
  26. 26. Poverty and Inadequate Housing • AI/AN have the highest poverty rate of any race and ethnicity, with 1 in 4 living in poverty in 2012, nearly double the national average • 33.8% of Native American children lived in poverty in 2016, at 1.7 times higher than the national average • 40% of on-reservation housing is considered substandard (compared to 6% outside of Indian Country) • Nearly 1/3 of homes on reservations are overcrowded • Less than half of the homes on reservations are connected to public sewer systems, and 16% lack indoor plumbing living-in-poverty/ degrees-of-economic-well-being-for-asian-ethnic-groups/
  27. 27. Health Insurance Access and Quality • In 2016, 19.2% of AI/AN lacked health insurance coverage, compared to 8.6% nationally. • Limited access to health services can increase risk for an undiagnosed or untreated HIV infection • State and local health departments and programs often do not have HIV programs that focus specifically on working with Natives with culturally competent services United States Census Bureau. (2017). American Indian and Alaska Native Facts for Features. Retrieved from
  28. 28. Sexual Risk • Teen pregnancy rates – AI/AN had third highest teen pregnancy rate between 2007 and 2015, behind African Americans and Hispanics – Had smallest decline between 2014 and 2015 of all races and ethnicities at 6% • Unintended pregnancies – Urban AI/AN had higher rates of unintended pregnancies and higher rates of mistimed pregnancies than NH-whites
  29. 29. AI/AN Disparities in Sexually Transmitted Infections and Viral Hepatitis Rates per 100,000 Disease AI/AN White, Non- Hispanic Year Chlamydia 749.8 199.8 2016 Gonorrhea 242.9 55.7 2016 Syphilis 8 4.9 2016 Hepatitis C 1.8 0.9 2015
  30. 30. Substance Use • In 2013, among persons aged 12 or older, the rate of substance dependence or abuse was higher among AI/AN than any other population group • From 2003-2011, AI/AN youth were more likely to need alcohol or illicit drug use treatment than persons of other groups by age, gender, poverty level, and rural/urban residence.
  31. 31. From the Data… ○ What is one thing that surprised you? ○ What data do you think might be missing or should be included? ○ What questions did the data raise for you?
  32. 32. Root Cause Analysis: the What & Why? Symptoms of the problem Underlying causes More efficient and effective than addressing a symptom of the cause - Used to identify the underlying cause(s), or root cause(s), of a problem or event, such as a health issue. - Used as one strategy for identifying social determinants.
  33. 33. Twigs Second Why? Branches Third Why? Trunk Fourth Why? Roots Fifth why? Risk Factors (-) Protective Factors (+) Leaves First Why?First Why?
  34. 34. SocietalCommunityIndividual Public Policy/Societal Comprehensive social programs (+) Accessible reproductive health care (+) Integration of cross-sectoral programs & policies (+) Interpersonal Supportive family structure (+) Risk Factors (-) Protective Factors (+) Health Begins Where We Live, Learn, Work and Play Community/Organizational Violence (-) Strong social networks (+) Individual Behavior Sex without contraception (-) Multiple sexual partners (-) Feeling of power and control over life decisions (+) Participation in civic activities and social engagement (+) Positive self-esteem (+) Interpersonal
  35. 35. Root Cause Analysis (RCA) ● Reflect on what you’ve learned today & ask: “Why do Native people have low survival rate of HIV/AIDS in the U.S.?” *One root cause per post-it, including protective factors and risk factors. At least 4 root causes per group and at least 2 levels of the Social Ecological Model.
  36. 36. Root Cause Analysis (RCA) ● Reflect on what you’ve heard this morning & ask: “Why do many Native people with HIV/AIDS live for many years?” *One root cause per post-it, including protective factors and risk factors. At least 4 root causes per group and at least 2 levels of the Social Ecological Model.
  37. 37. Sample RCA Pathway First Why: Why do Native people have low survival rate of HIV/AIDS in the US? Second Why: Why are Native people dying from opportunitistic infections in the US? Third Why: Why are Native people not taking medication? Fourth Why: Why do Native people have difficulties accessing HIV treatment? Fifth Why: Why are there few HIV specialist at Native clinics and programs? Root Cause: Lack of adequate funding for IHS Risk factor (-) at the societal level
  38. 38. Break
  39. 39. Report Back from Root Cause Analysis: SEM
  40. 40. Prioritization of Root Causes 1. Consider leverage points a. The factors that are most directly connected to each other suggest points of intervention or “leverage points” that will be more likely to have an impact on prevent infant mortality
  41. 41. Prioritization of Root Causes 2. Prioritize feasible determinants a. Priority Needs Filter b. Determine which factors i. Are being addressed elsewhere ii. You lack the resources to address iii. Cannot be changed (e.g., biological factors including age, race/ ethnicity, gender) iv. Are not linked to HIV
  42. 42. Prioritization of Root Causes 3. Plan for Action a. Root Causes of Infant Mortality Action Plan b. For each priority factor listed: i. Consider potential strategies (Column 2) that could be implemented to address it ii. List the resources available (Column 3) to help implement the strategies iii. Specify additional resources (Column 4) & information (Column 5) that may be needed to implement the strategies iv. List next steps (column 6) to move strategies forward.
  43. 43. Values Pledge statements: I CAN • Commit to what you can • Allow others to lead ○ Be there when you CAN ○ Pass on what you CAN • Nurture yourself
  44. 44. Workgroup Report Back ● Root cause: ● Potential intervention strategies: ● Resources available: ● What do we need to know more about? ● Immediate next steps:
  45. 45. Additional Strategies and Considerations for Engagement ● Rotating leadership/coordinators ● Process is as important as the product ○ Allowing time and space for both the doers and the thinkers ● Keep your mission, values and goals centered in your work ○ Revisit your values during each meeting- pick one to reflect on during each meeting ● Celebrate small wins! ● Transform conflict ○ Opportunity to focus on common ground and explore challenges
  46. 46. Additional Strategies and Considerations for Engagement ● Integrate quick activities along with longer ones ○ Quick, fun videos; policy changes ● Think about equity of voices for input ○ Processes that allow for full participation- TOP facilitation ● Create regular processes for appreciation ○ Gratitude mailboxes ● Provide document of participation in Coalition activities- ○ Letters of accomplishment, participation ● Buddy system! ○ Pair people up- new members with seasoned member
  47. 47. See Yourself First – Define your strengths, areas for collaboration, purpose and values as an organization – Partnerships Values Statement – Who you are, what you bring, what you stand for, how you view the partnership, what you commit to do in the partnership
  48. 48. See Yourself First – Define your strengths, areas for collaboration, purpose and values individually. – Being a collaborative leader means that a person is skilled at both understanding what’s happening in a group, and successfully intervening to assist a group in moving towards its goal. – Collaborative Leadership – Assess the Environment – Create Clarity: Visioning and Mobilizing – Build Trust – Share Power & Influence – Develop People – Regularly Engage in Self-Reflection – Assessment: Assessment-Tools.pdf
  49. 49. Thank you! Ahe’hee! Hannabah Blue Laura Gerard