Texas Health Institute was one of seven national finalists to receive a grant from Robert Wood Johnson Foundation’s (RWJF) to test their Aligning Sectors Theory of Change. Over the course of two years, THI examined 20 cross-sector initiatives, varying in geography, scope, and size, from across Texas. We share our findings on the new Align Texas website, which includes our blueprint report and full length report.
Cross-sector collaborations have become an increasingly popular approach to address social challenges and inequities. These collaborations often involve organizations from health care, public health, and social service sectors, with each organization contributing unique strengths and perspectives. Cross-sector collaboration can lead to stronger, more sustainable improvements to population and community health.
“In Texas, we have a unique learning opportunity,” says Ankit Sanghavi, MPH, BDS, executive director of Texas Health Institute. “Given the breadth and scale of collaborative efforts operating here, and the variety in places, populations, and health statuses combined with political and other contexts, our team was able to study several cross-sector alignment efforts for achieving health equity.”
The RWJF Aligning Sectors Theory of Change describes this process of cross-sector collaboration, including the areas in which change occurs and the elements involved in the process (see below). When we started, the RWJF theory of cross-sector alignment had yet to be evaluated to understand in more detail how alignment works and under what circumstances.
THI applied a “realist” evaluation framework in order to understand the specific ways in which cross-sector collaboration progressed for these coalitions under various conditions. A realist evaluation framework seeks to identify the specific changes that happen because of an activity, as well as contexts in which change occurs and the means by which it happens.
Emily Peterson Johnson, LMSW, senior health research analyst on the project reflects that “realist evaluation theory offers an exciting way to make evaluation findings more meaningful, actionable, and generalizable.” A realist evaluation can give us a more nuanced understanding of how, why, and in what contexts cross-sector collaborations happen.
Guided by a statewide steering committee representing various organizations, THI conducted:
Site Selection of Twenty Health Equity Focused Cross-Sector Alignment Efforts Across Texas
“This project has illuminated the truly amazing work well underway by outstanding community organizations,” says Cody Price, MPH, health policy research analyst at Texas Health Institute. “The coalitions and community organizers we spoke with consistently referenced the value of trust with their community members. There’s a lot of work left to be done, but working together is the best path forward. And in our digital age, we may have better tools to connect various stakeholders.”
This project spanned over two years and involved input from a variety of THI staff, external consultants, advisors, and partners. As our team looks back on this undertaking, we found many points of learning and growth throughout the process.
We learned about the value of realist evaluation theory. While many traditional evaluation frameworks can describe program activities or outcomes at a basic level, the realist evaluation approach provides a greater insight into why things work. This can help us understand how to replicate similar outcomes.
We learned about how to adapt the project to changing needs of participants. As with many projects that launched at the beginning of the COVID-19 pandemic, we had to adapt our plans. We learned about being flexible and sensitive to the needs of participating organizations, many of whom were often on the frontlines of pandemic response.
We learned about the value of these findings. To our knowledge, a large-scale assessment of cross-sector alignment efforts has not previously been conducted within Texas or nationwide. Our findings offer valuable information for initiatives that want to learn about the processes by which alignment happens, best practices for alignment, and common barriers.
“This evaluation taught us about the foundational role that trust and community voice play in effectively bringing together communities,” says Afrida Faria, MPH, manager of health equity programs at Texas Health Institute. Without uplifting the voice of the community, especially those historically marginalized, communities cannot work towards meeting the true needs of its members.”
THI looks forward to working with RWJF and the Georgia Health Policy Center to disseminate these findings and apply them in ongoing work aimed at leveraging cross-sector collaboration to address health inequities.
DIRECTOR OF COMMUNICATIONS
For the first time since 2019, the National Network of Public Health Institutes held its annual conference in New Orleans, LA, May 17-19. Texas Health Institute had one of the largest contingents present, with 11 staff and associates attending: an organizational record for THI. With nearly every attendee masked, and vaccine or testing requirements met beforehand, the conference was safe and accessible to the hundreds of public health professionals who came from across the United States and its territories.
The THI team presented multiple breakout sessions:
Katie Bradley, convenings production manager, co-presented a breakout about using Project ECHO to address the 2020 double-disaster of hurricane season during the COVID-19 pandemic in Texas. The Project ECHO model was also the topic of a pre-conference event she attended with other THI staff. “I appreciated the opportunities NNPHI provided to enhance my knowledge and skills with Project ECHO and learn how others implement Project ECHO to improve public health in their areas.”
The conference also provided ample opportunities for cross-state collaboration and learning. “The team was fully engaged in sessions that spoke to best practices and effective communication tools and tactics in public health. We left both energized and inspired to do more to improve the health of Texans,” said Stephanie Ondrias, chief convening and education officer, who also co-presented a breakout.
Andy Miller, chief strategy and impact officer, found it beneficial to hear from professionals at other public health institutes. “I liked learning how they are approaching public health challenges in their states. It was interesting to see how we might apply those approaches to Texas' challenges, especially those related to health equity and social determinates of health.” Miller presented on THI’s COVID-19 work.
In addition to a variety of breakout presenters from different backgrounds, different ethnicities, and lived experience as part of minoritized communities, NNPHI selected a stellar set of plenary speakers who helped reframe the paradigm of public health, with stark attention to the racism still inherent in public health research practices, community health, health education, and epidemiology today.
“Abigail Echo-Hawk pointedly opened the conference with the words: ‘I don't need your evidence-based practice without my evidence.’" John Oeffinger, director of e-learning and training—also a breakout presenter—recalled that “this theme was echoed throughout many of the conference breakout sessions and networking opportunities. This aligns with so much of the work we do at THI which reinforces our leadership role in several NNPHI projects.”
“From the plenaries to the poster presentations, I was inspired by how the conference centered the experiences of people of color, particularly Indigenous people and researchers,” said Kanaka Sathasivan, director of communications. “Hearing from so many amazing speakers really shifted my own views and helped me learn to be more critical about how public health methods can be inclusive and respectful.”
Beyond sharing experiences and gaining new perspectives, the team also enjoyed networking in person after such a long gap. “I’m always blown away when I’m in a room with other public health professionals,” says Nishi Singhal, primary care program officer. “The level of passion and commitment to making a difference was palpable. I came back to Texas with a renewed sense of agency of improving the health and well-being of communities!”
The variety of work and drive for health equity was evident throughout the conference. “It was amazing to see the breadth of initiatives that PHIs are leading and supporting, and the innovations that are taking place in a variety of areas,” said Rachelle Johnsson Chiang, chief research and evaluation officer.
Cody Price, health policy research analyst, shared that “the conference was an invaluable reminder of what matters in public health practice—bringing everyone closer, inch by inch, to their best possible health. This year’s conference was packed with great speakers, great people, and great work. I look forward to attending again.”
In summation, Ankit Sanghavi, executive director, celebrated that “this year’s conference was a valuable opportunity for all of our staff. The convening gave us a unique opportunity to come together to champion systems change, engage in best practices, and make human connections that underscore why we are in public health: to improve the health and lives of all.”
Sandy Tovar, DNP, APRN, PPCNP-BC, AE-C
EXECUTIVE BOARD MEMBER
Why South Texas?
Historically, border areas have been neglected in many, if not all, aspects of health care and public health. Even prior to the COVID-19 pandemic, communities along the southern border of Texas experienced disproportionately higher rates of chronic illnesses, such as diabetes, obesity, and cardiovascular disease, which adversely affected the approximately 93% Hispanic community, leading to devastating health outcomes and higher treatment costs.
Decades of research have demonstrated that these health outcomes are often a reflection of the social, economic, and environmental factors of each community. For South Texas, food deserts, a nursing shortage, health literacy, limited job opportunities, an inadequate public transportation system throughout the region, and a desperate need for a skilled and educated workforce are just some of the factors that contribute. In addition, high rates of poverty combined with a large population of uninsured people necessitates urgent attention and collective action.
While data and numbers show the scope of the issue, the human impact is harder to convey. Caring for children and their families throughout my professional career in South Texas has been a privilege and an honor. I have been rewarded on many levels as I continue to work towards equity and health care for all people regardless of their background. However, witnessing the obstacles, struggles, and hardships my local community endures can be overwhelming and sometimes deeply disheartening.
Despite impressive regional achievements and admirable efforts by various entities within the last ten years, there remains much work to be done. It is evident that no one individual organization or entity can be responsible or capable of meeting the demands of this unique part of South Texas. As members and representatives of our communities, we are all charged with not only being the consumer and patient advocates, but also the problem solvers and advocates for health equity.
Advancing Collective Action
As a health equity advocate and as a THI board member, I seek to leverage our role and expertise as an independent public health institute in Texas to understand, listen, and capture the most pressing needs of the region. THI works closely with communities all over Texas and across the nation to design, plan, implement, and evaluate population health improvement efforts. I am both encouraged and inspired by the community interest and buy-in at a series of meetings in late March 2022 with members of the THI leadership team and active Hidalgo County community leaders.
I look forward to follow-up discussions with stakeholders and hope to be able to strategically execute solutions by identifying opportunities that exist in our South Texas region and demonstrate the leadership to create pivotal, significant, and sustainable change within the region. This includes collaborating with representatives from academic centers, rural and urban areas, city, county, state, and federal officials, for-profit and nonprofit organizations, and key community stakeholders.
These efforts in turn will help foster the connections and infrastructure necessary to create the systems and environments that advance health and opportunity for all. Partnerships and alliances with those who can bring needed resources and knowledge to South Texas can make a difference in the lives of those in most need and help pave the road to a more prosperous and healthier South Texas.
DIRECTOR, ELEARNING AND TRAINING
Last year, TransFORWARD: Improving Transgender Lives—a collaboration between Texas Health Institute and Equality Texas Foundation with Transgender Education Network of Texas—successfully completed its first Patient-Centered Outcomes Research Institute (PCORI) project! The goal was to connect transgender people with clinicians and researchers, ensuring medical care for transgender people is informed by evidence-based data.
We started work in November 2018 to create a clinical research collaborative. Meaningful engagement of patients and other stakeholders comes with challenges, as does any innovation in the research process. We found that engagement challenges are most often described in three domains: (1) infrastructure to support engagement, (2) building relationships, and (3) maintaining relationships.
Key findings include:
We applied Project ECHO’s 3-part methodology to 18 topic sessions grouped in 3 series of 6-sessions each. The three series consisted of six sessions on mental health, housing, and employment. Fifty people attended one or more of the mental health sessions; 33 attended the housing sessions; and 22 attended the employment sessions.
Together, we successfully created a 28-person Research Engagement Advisory Council (REAC) to lead collaborative network development. The network spans all eight Texas regions, and trained 226 transgender people family members, clinicians, and researchers on terminology and projects to expand research capacity. REAC also includes a volunteer member and a staff person from Texas Medical Association, Texas Nurses Association, and Texas Hospital Association.
We increased collaboration with The PRIDE Study through shared community engagement efforts. We were able to raise enrollments from 100 transgender and gender diverse enrollments to 381.
In addition, we built a multi-sectoral network bringing together hospitals (children’s, public, nonprofit, Veterans Administration), clinics (LGBTQ+ health, AIDS Resource, Endocrinology), FQHCs, private practices (MDs, PAs, NPs), a county jail, and a clinic serving homeless transgender people. We also collected an email contact list of 300 people interested in PCORI research and proposal development.
Expansion and Future
PCORI further funded TransFORWARD for an add-on to study the impact of the COVID-19 pandemic on the transgender and gender-diverse communities. The Project ECHO COVID-19 Leadership Team of thirteen people included three transgender people and three cis people from the LGBQ+ community. The COVID-19 Enhancement enabled additional opportunities to bring in new stakeholders including elected officials or their staff. However, the pandemic also exposed stigma, discrimination, racial, and structured economic differences.
We submitted two ancillary research studies to the PRIDE Study, which are now moving through the review process:
PCORI Work Continues
PCORI’s goal is to reduce the 17 years the Institute of Medicine describes as the time from a patient identifying a research topic to when evidence-based data is put into clinical practice. In addition to this first successful project, we started our second PCORI Engagement Award in October. Our colleagues at the UT Southwestern Medical Center lead a new PCORI Research Award on Suicide Intervention. Our colleagues at UT Dell Medical School lead a Merck Long-Acting PrEP clinical study. Together, we are building a transgender and gender diverse research collaborative in Texas. The collaborative is bridging into the larger LGBQ+ community with several new awards.
DIRECTOR, ELEARNING AND TRAINING
November is Transgender Awareness Month, a time to celebrate and honor the trans (transgender and gender diverse) community and bring awareness to issues facing trans people. We interviewed several people involved with TransFORWARD: Texas Transgender Health, a collaboration between Texas Health Institute and Equality Texas Foundation, about barriers to health care for trans adults and how to improve the system for future generations. TransFORWARD aims to improve the lives of trans adults through research, evaluation, education, and dissemination of resources to foster growth in transgender health care and research.
Emmett Schelling serves as the current executive director for Transgender Education Network of Texas (TENT), the statewide trans led and focused policy org in Texas. Madeleine Croll is pursuing a masters in political science while working as graduate teaching assistant and currently serves as vice president of GENTex, Gender Equality Network of Texas. Rocky Lane is a regional co-lead at TransFORWARD and a creative entrepreneur specializing in media and consulting services. Justine Price is completing her doctorate in health sciences and is a former deputy director of a local health department.
Why do you invest time in TF?
Emmett | I’m trans, so I want to see trans health improve. I want to see it improve in Texas, the state with the second largest population of transgender adults. I believe we can not only affect the state, but the rest of the nation, in building a better, more inclusive and healthier world for all of us. The pandemic has opened our eyes, that the most vulnerable people are experiencing greater health concerns.
Madeleine | TransFORWARD allows me to be a conduit for the community, the medical research community, and clinicians. It’s important for them to hear from us directly. I try to compile what the community tells me to say “This is our experience. Now that you are aware of it, what can we do to make it better?” We can understand different cultures and form the bonds we need to move forward. We must collaborate as equals because as much as we appreciate clinicians’ skills, they need to recognize the fact that we have our dignity.
Rocky | I invest my time in TransFORWARD because people I trust invest their time in TransFORWARD: people that I have followed for a long time to understand how things work, how change happens, how advocacy can help build better partnerships to get us to the next level for our community. I was brought here by my mentor, Emmett Schelling from Trans Texas [Transgender Education Network of Texas]. I think Emmett thought because I used to be a health worker that I'd be a great member of this team.
Justine | Because it's really important work for people. The thread that underlies all of the challenges in the transgender community is the unknown. It's a lack of understanding, of data points, of familiarity and being able to relate to people. We don't even really know how many people are trans, how many people identify and on which point of the spectrum. Biology is just starting to join hands with sociology and psychology to understand the spectrum of sex in the same way. A lot more needs to be done to understand the nuances of the transgender population and how we can best tailor treatment.
What are some of the barriers to care for trans people in Texas?
Madeleine | A lot of our barriers [in the Rio Grande Valley] are economic. Our region has severe poverty, including the poorest U.S. county: Starr County. Labs are expensive; insurance is a major barrier. And many people are not competent to provide gender-affirming care, even basic medicine. I’ve heard of providers laughing at patients who “come out” to them. Some clinicians gleefully use their positions of power to render moral judgments against us. Accessibility and transportation are issues, and we are hyper-policed, so if you're undocumented, you're afraid to go out during the day. If you need advanced care, like gender affirmation surgery, there's no place to get it done. Do you go to Monterrey and take your chances trying to come back? And language becomes a barrier. Even within the Latinx community transgender is “transgénero” in Spanish, but across the river, the term is “transexual,” meaning I am taking the step to medically transition, which is a distinctive difference in Spanish.
Rocky | The three buckets identified in our talks with the community were: navigation to affirming resources or clarity of what resources are; access based issues, like cost or access to more complex care; and cisgender people. A lot of the things that we hear from community directly result from cisgender people being a major barrier or the people that trans adults have to get through to get to their services.
Justine | Again, I think it's the unknown. My primary care physician had a hard time understanding my estrogen therapy. She felt it was not safe to be on such a high dose of estrogen, because her medical knowledge was on using hormone replacement therapy for postmenopausal cis women. But that amount would have been ineffectual for trans women. Is our comfort level as a marginalized population such that we can honestly and openly talk about differences between trans people and cis people? I don't think that there's anything wrong or shameful in saying there's a difference. It comes on the basis of fact. If we don't talk about it, we're not going to be able to find the evidence and educate providers so that they even know what to look for or know to make the distinction.
Emmett | First and foremost is the lack of knowledge, information, education. I think 50% of Texans said they had never even met a transgender person. Which, I giggled a little bit, because there's a very good chance you've met a transgender person and not realized it. The second thing is bias. When you don't know about people, then whatever bias or whatever you've been reading is going to play a part in your understanding or opinions or purview. Texas is a tough state to be trans in, with a limited pool of knowledgeable, informed, and educated health care professionals, and in rural areas, it could be a 3- to 6-hour drive for an appointment. Plus issues of employment and housing, the components along with health that foundationally set up people to be secure and successful. And then we get into other disparities that span across race, ethnicity, ability, and in health care, there is discrimination that can happen.
How do we change the system to ensure future generations don’t face these barriers?
Rocky | One solution is to build something specifically for ourselves and not try to adapt cis systems. So, build trans health care centers, for instance, to take over all training, research and treatments. We need to have community members be a liaison or ambassador, such as a patient navigator. The fact that we have cisgender doctors is not the issue, but that we don't have trans health care workers in any abundance. When I talk about cisgender people as a barrier, it's not something that cisgender people can solve or get out of without trans people. Trans adults want to talk to each other, to have access to each other. Dedicated centers could eliminate variable outcomes and also allow us to outline medical direction and accountability systems in a full regional level.
Justine | First create an environment that's embracing, friendly, and inclusive of trans people so that we can hear from the people that these issues are affecting. Second, with those people as vital stakeholders at the table, continue to build that evidence base and shape projects by identifying priorities and needs, starting with the most critical working towards the ones that are less of an immediate impact on people's lives. And then, combining those two things, we continue to educate providers and build this as a cornerstone, just like any other aspect of medical training, into curricula, something that falls under that umbrella of general care pluralism.
Emmett | Education is a big piece of any change: real permanence and a real shift that helps future generations. One of the things about TransFORWARD that I so appreciated is everyone participating is committed to learning from one another, our collaborative work, research, and different studies. We got honest feedback from the community that has not been heard from, the good, bad, ugly, everything in between. If we don't have that information, and we're not talking to researchers, providers, and community members, then we're not going to effect change for the next generation. We have so many trans adults in this nation that need care, and we need people that are educated and understand from every aspect how to help make them well and make sure they can have successful, happy, healthy lives.
Madeleine | Protective legislation is always a good thing to strive for. It's not something, though, that I expect from my state. A lot of people here, if they have the privilege to do so, will go somewhere else that's more accepting. But a lot of us have talents and skills, and we deprive people of those skills and talents. So, the community has experienced that loss through geography just as much as suicide. We need to address education and the fact that there are queer people, queer families, and you share this state with us. We're not a threat to anybody's way of life. People are going to be themselves, regardless of whatever barriers you put. The only thing you're doing is criminalizing us and putting us in greater danger.