Promoting Well-Being and Reducing Risk Post-COVID-19

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode:

DR. JEWEL MULLEN:
One of the reasons that the Shared Risk and Protective Factors framework is very helpful is that it moves us from siloed thinking to systems thinking. It moves us from siloed thinking when we think about what we can do or who needs to be at the table.

DR. SARAH BACON:
It's about achieving better and more efficient outcomes. So, there are a lot of benefits for our state and territorial partners and for their partners to use this framework and apply it.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we examine the case for using the Shared Risk and Protective Factors framework when working to reduce adverse childhood experiences, suicide, and opioid misuse. It promises to help busy public health teams better organize their thinking about the connections between risk, preventive actions, and health outcomes and behaviors. The framework is scalable, supported by science, and can even be used in times of crisis—pandemics included.

We have two conversations about it.

Dr. Jewel Mullen is a former commissioner of the Connecticut Department of Public Health and the former principal deputy assistant secretary for health at the US Department of Health and Human Services. Today, she's the associate dean for health equity at the Dell Medical School—that's at the University of Texas at Austin. She's along in a bit.

First, we catch up with Dr. Sarah Bacon. She's the senior advisor for adverse childhood experience prevention within the Office of Strategy and Innovation at the Centers for Disease Control and Prevention.

BACON:
So, I'll start with just defining risk factors, which are really just anything that increase the likelihood that someone could experience an adverse outcome, like violence, or engage in risky behavior, like substance use. So, examples of risk factors are things like family conflict, or a lack of economic or housing security.

Protective factors, on the other hand, can have direct benefits or help buffer against that risk. So, examples here are things like close connections with a caring adult or access to mental health services, to name just a very few.

Risk and protective factors span every level—from the individual and family to institutional settings, and communities, and relationships, and society levels—and they interact in really complex ways. So, some of them—some risk and protective factors—are associated with multiple types of violence and with other health outcomes, like opioid overdose or misuse, or with suicide.

So, a Shared Risk and Protective Factor framework really just gives us a way to organize our thinking about which risk and protective factors influence a broader range of health outcomes or health behaviors. It lets us sort of figure out which are most operational in driving that broader range of outcomes that we want to prevent, and which are most important for reducing risk and for enhancing protective factors. So, it gives us a way to think systematically and strategically about where those opportunities for crosscutting prevention can occur and where we can most effectively intervene.

So, to illustrate, take an example of a child who has experienced physical abuse or neglect. That child is then at greater risk for committing violence against their peers, for bullying, for teen dating violence, for other forms of violence, as well as for substance use and suicidal ideation and behavior. They're also at risk for perpetrating child abuse, elder abuse, intimate partner violence.

And we can see that, across these multiple forms of violence and these multiple health risk behaviors, child abuse and neglect was that shared risk that precipitated all of those.

So, this gives us really powerful and actionable information about where to focus our prevention efforts.

JOHNSON:
The framework allows a practitioner to see how the risks and the protective factors are related, and then maybe how to apply the interactions for a better outcome?

BACON:
That's right.

It really is about achieving better and more efficient outcomes. So, there are a lot of benefits for our state and territorial partners and for their partners to use this framework and apply it.

And first is, exactly as you said, that working from a shared risk and protective factor perspective helps us make those prevention and health promotion efforts much more efficient. So, by focusing on those risk and protective factors that have implications for multiple outcomes of violence and injury, our impact can be even greater.

It's also a constant reality for all of us that we have limited resources to invest in prevention and health promotion work. So, the Shared Risk and Protective Factor framework gives us a roadmap to invest in ways that are going to be more impactful and in ways that are more sustainable, and that's really important.

Another benefit for us is that it sort of invites us to consider a much broader range of partners than we might typically do otherwise. So ACEs [Ed. note: adverse childhood experiences], and opioid misuse, and suicide all have risk and protective factors in common; but those factors are also relevant to other considerations—like other chronic health conditions, mental health more broadly, educational and economic attainment and security—and each of those domains brings with it a host of partners and their resources and their expertise that we can bring to bear on the problems that we're trying to address in public health.

In addition to those additional partners, the Shared Risk and Protective Factor framework allows us to also consider a broader range of programs, of policies and practices, and the experience that those other fields or domains bring to us to consider what may be the most effective solution for a given community.

JOHNSON:
Would you say this framework makes it easier for someone in the field to come up with a solution faster?

BACON:
It absolutely does allow for more—not only more efficient program implementation, but more efficient identification of which programs may have the best chances for success in a given community.

By understanding which risk and protective factors are going to be most active in influencing the outcomes that we want to achieve, and using the programs that have been identified as effective for reducing risk and increasing protective factors, then, yes, using the Shared Risk and Protective Factor framework absolutely allows for faster, more efficient, and, really, more scientifically-driven identification of programs that will bring about the outcomes we want.

JOHNSON:
Does that work in any situation on any scale—in other words, at the very micro level involving one child, or at the macro level involving an entire community?

How does it scale?

BACON:
As long as we are attending to the risk and protective factors that we want to have impact on, it can work at any scale.

We have a long history and significant body of science that has identified risk and protective factors at each level. So, we know what the risk factors are at the individual level. We know what the risk factors are at the school level, and the family level, and the community level, and even at the policy and sort of cultural and society level.

And so, our partners, in working with us, have to think about which factors they want to influence; but then, yes, there is absolutely a body of science to support intervention at any level that is needed or appropriate.

JOHNSON:
How does it help people in the field during a crisis?

BACON:
During a crisis, folks are all experiencing some more shared risks that's a bit more universal.

So, during a crisis, for example, we see risk factors that everyone is experiencing, like lack of social support, increased stress on individuals and families and on businesses. We may be seeing increases in substance abuse, new or worsening depression or anxiety, mental and behavioral health problems, unemployment, of course, and food and housing insecurity.

Once we've identified those shared risk factors, it really gives us that roadmap or sort of a guide to figure out what strategies we can bring to bear to mitigate their impact and ameliorate the consequences that they're having for our families and communities.

So, we want to be looking at strategies that focus on reducing financial stress for families and supporting economic stability; so, that seems like childcare subsidies, a livable wage, paid sick leave, unemployment benefits.

We want to make sure that we're providing safe means for social connections; so, online chats, video messaging, and video meetings and things like that.

We want to make sure that we're promoting physical and mental health; so, access to physical exercise programs through some sort of non-traditional or creative modes than what we are otherwise used to. We want to make sure that there's access to online counseling services, safe outdoor spaces.

And we want to ensure the continuation of critical social services; so, things like child protective services, crisis intervention, and violence and suicide prevention hotlines.

JOHNSON:
Do you have to load all of those extra factors into the framework when an event occurs that maybe is a little bit out of the norm for a community or a region?

BACON:
One of the great things about this Shared Risk and Protective Factors is that those things are already identified. During times of crisis, we're just able to see which ones are more active or which ones have really been cast in an unforgiving spotlight for this critical time.

But these are the things that we already know are related to some of the outcomes that we want to prevent.

JOHNSON:
As far as teams are concerned, at the implementation level, who should be involved working through this framework if they want to use this to help solve a problem?

BACON:
Well, this is really an everyone problem, meaning that we are all affected by the presence of some of these stressors in that violence, opioid overdose, suicide, and risk factors associated with those—there's downstream consequences from all of the risk that we're experiencing.

JOHNSON:
How does the CDC support states and territories on this issue of the framework?

BACON:
Well, the prevention of ACEs, and suicide, and opioid overdose are the three strategic priority areas for the Injury Center. So, these public health challenges and their intersectionality pose a really heavy burden on the health and the wellbeing of the populations that we serve, and our state and territorial partners serve those same populations and they're really well positioned to partner with us in our prevention efforts. So, we really value those relationships and take the responsibility of supporting them very seriously.

Happily, we already have a number of existing resources that are available now to support those efforts. So, I've already mentioned the Preventing Adverse Childhood Experiences resource—and I encourage folks to look into that—and that's really there to help states and communities use the best available evidence to prevent ACEs from happening in the first place.

We also have the strategic vision from the division of violence prevention within the Injury Center, and that provides a really useful and actionable framework for connecting the dots—and those resources will also have prevention benefits for opioids and suicide, as well.

As I mentioned, we also have the existing funded cooperative agreements that are supporting health departments to bring CDC and other evidence-based resources to bear on preventing ACEs, opioid overdose, and suicide.

So, these are a really great way for us to engage in real exchange and dialogue with our funded partners and have a more dynamic conversation so that we can learn from them about the realities that they're confronting within their states, in their communities, and when we can be responsive to their needs and build resources based on what we're hearing from them. And we'll, of course, continue to do that.

And, finally, we'll continue to partner with our great colleagues at ASTHO who bring a very high level of expertise and a depth of relationships with other partners, and those are critical for our continuing success in the prevention of ACEs, and opioid overdose, and suicide.

JOHNSON:
Wrapping up, what's the strongest argument you can make for using the Shared Risk Protective Factor framework in addressing these issues in a state or territory?

BACON:
The strongest argument to me is that the work is already done, in large part. The science is there to support the robust relationships between these shared risk and protective factors and the outcomes that we want to either prevent, in the case of risk, or achieve, in the case of protective factors.

So, we're in a position to draw on a long-standing evidence base and a really well-developed body of science that tells us what to do. There's still a lot of work to be done in actually implementing the programs that we know to be successful, so it's certainly not still an easy lift; but we're starting from a place of great insight and great information, and we have the resources available to tell us what is going to work if we can implement it correctly.

JOHNSON:
Dr. Jewel Mullen is thinking about the framework as a tool that could help in the response to COVID-19, the virus that's responsible for several developing public health emergencies.

MULLEN:
As many of my medical and public health colleagues have been talking about the threats that COVID-19 poses for communities and the people in them, we readily start to drill down to who's most impacted and what work we have to do to care for them.

That makes COVID-19 a case study, because so many of us who want to help us realize that we're trying to address an acute crisis in the context of ongoing social inequities that many people experience.

JOHNSON:
What you're saying is, then, that we've got new problems on top of old ones?

MULLEN:
Yes.

The way I have described talking about vulnerable communities or people who are at risk during this pandemic: the more that we hear about the excess mortality among people with underlying chronic conditions, I try to get people to step back—not just peel back layers, but to step back—and think about what has happened and what has happened in communities.

Many times, what we get to is an understanding that those chronic conditions and difficult circumstances didn't just start, and they sometimes reflect what I call some peoples having to live in situations that go from bad to worse.

JOHNSON:
Those people are the ones who seem to be suffering the most during this pandemic.

MULLEN:
Exactly.

So, if you have people who are already—on what they might consider a good day—struggling with paying for their housing, purchasing their food, making sure that their children have all they need to go to school ready to learn, hoping that they don't get sick because they don't have any paid sick leave or health insurance, then that version of a good day for some people already starts out very hard.

The social health, economic, and psychological disruption that comes with the pandemic then takes what is really not so good or bad to a situation that's even worse, and that's playing out over and over.

JOHNSON:
If you're in a public health team somewhere around the country or in one of the territories dealing with everything that COVID has brought into the equation, how easy is it to back up and look at the more institutional issues—the problems that were there before the virus arrived—and deal with those in this context?

It would seem to be difficult, but is it?

MULLEN:
Being able to back up and see the big picture is what I call both the benefit of public health thinking, but also sometimes the challenge of a governmental public health official—the kind of person that some will refer to as a bureaucrat.

And here's why: we're taught to understand risk factors; we're taught to understand or seek for the causes of disease; we're taught to try to look for solutions. At the same time, as we work inside health agencies, we're also taught how to administer programs, make sure they're adhered to, make sure there's fidelity. And to do that, we are also trained to determine who's worthy of our support.

So, that's what makes it both easy but not so easy. And I've started thinking that part of what we can do as state and territorial health officials is really ask ourselves how we continue to develop more empathy for the communities that we want to serve. And when we're so far away from them, the pathway to that empathy might be through learning how to work even more with the community organizations that serve the people.

JOHNSON:
How would you go about doing that in the process of addressing the pandemic in your population?

MULLEN:
The pandemic gives us many opportunities to build and demonstrate that empathy—one of which is to just give ourselves a chance to do what we're asking the rest of society to do, which is to acknowledge, to own, and to wrestle with our own emotions about what's going on, to be vulnerable. I think it takes us one step closer to remembering that other people are doing the same thing.

Then, the next part of that is saying, "Okay, I'm too far removed to actually do the hands on caring and providing. So, this is a great time for us to learn how to be even more meaningfully community-engaged and health-promoting." In my view, that calls for strengthening our relationships with and support for local public health because they are many steps closer to communities.

And I have spent several days now reminding people that the public health workforce has been decimated over the past decade and is being challenged more than any time I know in my lifetime. So, if we partner with local public health, we actually can help them more effectively engage with the community organizations who are actually the agents for the work that needs to be done with individuals.

JOHNSON:
You've been a state health official.

How would you go about following your own advice, given the situation we're in right now?

MULLEN:
So, I have to start answering that question with this statement, which is I have been a state health official; but I think many of my colleagues who are ASTHO alums would admit that there's a part of you that never gives up being a state health official, even when you acknowledge you're not doing the work anymore.

So, from that perspective, what I ask myself now is how can I best communicate to people that we care? I have a tremendous appreciation for how much being able to serve community is dependent on peoples being able to trust what we say, what we do, and what our motives are. That starts with meaningfully being able to communicate in ways that people understand.

I try to use plain language. I have learned how to say to people, "Is there something you know of that I can help you with?" as opposed to going to people and telling them what I can do for them. And then, if I have an idea of something I might do, I say, "Does that even make sense?" Because I only want us to think about how we can be value added.

The next thing that I think we can do as public health officials is to keep the conversation about communities at risk focused on, not that people did things to develop underlying conditions, but that the root causes of diseases really are embedded in social factors and policies that people didn't create. Doing that helps us communicate, as public health officials, in a way that doesn't stigmatize, that that doesn't stereotype people, and that doesn't shift the burden of finding solutions to the people who are suffering.

JOHNSON:
What does the Shared Risk and Protective Factors framework help you accomplish those objectives?

MULLEN:
One of the reasons that the Shared Risk and Protective Factors framework is very helpful is that it moves us from siloed thinking to systems thinking: it moves us from siloed thinking when we think about what we can do or who needs to be at the table; and it moves us to systems thinking as we consider that, even as public health officials, the approaches to shared risk and protective factors call on the disciplines that include but go beyond public health.

JOHNSON:
We're hearing now that the numbers or the projections might be higher because a lot of the states are reopening to some degree.

Is there going to be time to do this kind of work if we're still in reaction mode?

MULLEN:
If we let there be—if we engage in a fallacy that we're too quick to get something done, to take the time to do what needs to happen—then there won't be time.

But that's why it's so important for us to be able to step back and also say, "We know we have programs we wanted to administer. We know that we have to report to our grantors—to the CDC, for example, or the Department of Education—what we've accomplished."

This is where it's important for us all to move beyond thinking about how our fidelity to specific programs has been and how compliant we have been, to also think about how we have innovated and adapted them to best purpose the resources that we have. That's how we make the time.

We talk in different circumstances, in health and related to the economy, what's the new normal going to be? This is a great time for us to think about what the next normal, and hopefully a more health-promoting normal, can be in education.

JOHNSON:
Wrapping up, what's the best argument for including the Shared Risk and Protective Factors framework in your toolbox right now?

MULLEN:
Right in the midst of this pandemic, it is so easy to get overwhelmed with a public health response that some people see as a medical response. We talk so much about hospitals, and bed capacities, and numbers of ventilators, and mobilizing nurses and doctors.

And what people don't necessarily see behind the scenes is how much of that work is: one, is still being done by public health; and two, how much public health holds a key, not just by itself, but a key to the solutions that people are asking for beyond the pandemic. When we're talking about undoing inequities, improving the built environment and the environmental ecology, creating safer communities—that's all core public health.

As people are reopening the economy, they are also starting to ask questions about what's going to happen with the most vulnerable who will still be at higher risk, and they're calling for tools that are key public health tools.

This is where I encourage my colleagues to speak boldly: contact tracing, we do that; connections to community organizations, we know how to get there; the right policies to support families' economic mobility, the data about the benefits of paid sick leave, of our minimum wage, we've been working on that.

So, at the same time that we respond, we should be very ready to respond to help change the policy environment because that's what's going to make the long-term difference—changing the policy environment to assure that we move into a place where protective factors emerge and to start to swap some of what, now, are too many risks for people.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.