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.

1. As you come in,
take a character
card, find your
character group
and sit together at
a table.
Welcome!

2. Introductions
Please share:
- Your name
- Your organization
- Your role
- Your reflection of your
character card

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. 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. 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. 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. The Value and Power of Partnerships

9. 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

10. 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?”

11. 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.

12. Honoring Our Past, Valuing Our Future
Journey Map: https://markholmgren.files.wordpress.com/2017/04/using-journey-maps-final.pdf

14. 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.

15. Revisiting
Social
Determinants
of Health

17. Source: http://biggest-loser-where-are-they-now

18. Determinants of Health Exercise
Adapted from CDC. http://www.cdc.gov/socialdeterminants/FAQ.html
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

19. 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. http://www.cdc.gov/ViolencePrevention/overview/social-
ecologicalmodel.html

20. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity
Nov 04, 2015 | Harry J. Heima and Samantha Artiga

21. HIV in Native
Communities
Data Review

22. HIV Diagnoses Among AI/AN in the
US by Transmission Category and
Sex, 2016
https://www.cdc.gov/hiv/group/racialethnic/aian/index.html

23. 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.
http://www.cdc.gov/hiv/library/reports/surveillance/. Published November 2015. Accessed March
28, 2016
(Reilly et al. Am J Public Health 2014)

24. 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://www.cdc.gov/hiv/group/racialethnic/aian/index.html
Centers for Disease Control and Prevention. (2013). National Health Interview Survey Retrieved from:
https://www.cdc.gov/nchs/fastats/american-indian-health.htm
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
https://nij.gov/publications/pages/publication-detail.aspx?ncjnumber=249736

25. 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://www.cdc.gov/hiv/group/racialethnic/aian/index.html
(Harrison-Quintana et al., 2012, p. 1); (Center for American Progress and Movement Advancement
Project, 2015, p. 10). http://www.ncai.org/policy-research-center/research-data/prc-
publications/A_Spotlight_on_Native_LGBT.pdf; (Gates, 2014, p. 2)

26. 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.

27. Adverse Childhood Experiences
(ACEs)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762720/;
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4929123/
https://www.researchgate.net/publication/305670595_Adverse_Childhood_Experiences_among_Am
erican_IndianAlaska_Native_Children_The_2011-2012_National_Survey_of_Children's_Health
https://www.ncbi.nlm.nih.gov/pubmed/29176114
# 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

28. 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
https://www.news-medical.net/news/20140214/Persons-with-severe-symptoms-of-mental-illness-are-at-higher-risk-for-being-HIV-
infected.aspx
Office of Minority Health. Mental Health and American Indians/Alaska Natives,
https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=39
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.

29. 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
http://www.pewresearch.org/fact-tank/2014/06/13/1-in-4-native-americans-and-alaska-natives-are-
living-in-poverty/
https://www.epi.org/blog/2016-acs-shows-stubbornly-high-native-american-poverty-and-different-
degrees-of-economic-well-being-for-asian-ethnic-groups/

30. 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 https://www.census.gov/newsroom/facts-for-features/2017/aian-month.html

31. 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
https://mchb.hrsa.gov/research/documents/finalreports/forquera_r40_mc_08954_final_report.pdf
https://www.cdc.gov/teenpregnancy/about/index.htm

32. 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
https://www.cdc.gov/std/stats16/chlamydia.htm
https://www.cdc.gov/hepatitis/statistics/2015surveillance/index.htm#tabs-6-9

34. 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.
https://www.samhsa.gov/sites/default/files/topics/tribal_affairs/ai-an-data-handout.pdf
https://www.cdc.gov/hiv/pdf/group/racialethnic/aian/cdc-hiv-natives.pdf

35. 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?

36. 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.

37. Twigs Second Why?
Branches Third Why?
Trunk Fourth Why?
Roots Fifth why?
Risk Factors (-)
Protective Factors (+)
Leaves First Why?First Why?

38. 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

39. 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.

40. 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.

41. 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

42. Break

43. Report Back from
Root Cause Analysis:
SEM

44. 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

45. 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

46. 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.

47. 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

48. Workgroup Report Back
● Root cause:
● Potential intervention strategies:
● Resources available:
● What do we need to know more about?
● Immediate next steps:

49. 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

50. 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

51. 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

52. 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: https://northwoodscoalition.org/wp-content/uploads/2016/10/Chapter-7-Collaborative-Leadership-Self-
Assessment-Tools.pdf

53. Thank you!
Ahe’hee!
Hannabah Blue
hannabah_blue@jsi.com
Laura Gerard
laura_gerard@jsi.com