System Fragmentation and Service Silos: Leveraging Provider Perspectives to Support Health Equity Among Families Living in Poverty

Background. Service providers in community-based organizations are often the first and only point of contact for many under-resourced families seeking or receiving services to support child development, caregiver/child behavioral health and have invaluable perspectives on child and family health and wellbeing. Their knowledge is central to improving services for children and families, however they are often not included in discussions on how to move health equity forward. We used an ecological framework to explore service providers’ perspectives of what system level changes are necessary to promote health equity among children and families in economically underserved communities. The overarching aim of the current study is to better understand the determinants of equity or disparity in service delivery and uptake among child and family-serving community-based organizations. Research questions: 1) What are the major barriers to health and mental health for children and families? 2) What are the major strengths that help promote health and mental health within families and organizations? 3) What are the major facilitators to health and mental health utilized by families and organizations?

Methods. Qualitative in-depth interviews were conducted with 21 service providers from community-based agencies from one city. Purposive sampling was used to recruit providers in behavioral health, food assistance, maternal and child health, and child welfare programs. A semi-structured interview guide was designed based on ecological and strengths-based frameworks to elicit participants’ perceptions of major strengths, challenges, and supports experienced by children and families. Probes were constructed to extract detailed examples from providers’ experiences related to (1) the home environment, (2) child development, (3) trauma and poverty, (4) supports/services. Interviews were transcribed and analyzed using MaxQDA v.20.

Results. Major themes were organized according to the four primary levels of the child’s social ecology: 1) macro, 2) community, 3) organization, and 4) family. Macro-themes included rights-based policy and programming, and racism/oppression as broader common underlying factors that interact with other levels of the family’s ecology to influence wellbeing. Community-level themes included impacts of the physical environment and building social cohesion on child and family outcomes. Secondary stress, system fragmentation, resources, and system and provider supports were identified as organizational factors influencing health and wellbeing. Finally, family-level factors identified by administrators and providers centered on unmet family needs (e.g., income, housing, food) and improving supports related to financial stability, parenting support, and facilitating access to services.

Conclusion. Including perspectives of direct practice providers helped to uncover common, multi-level strengths-based determinants related to addressing basic human rights and improving rights-based policies. Focusing efforts on building community cohesion and organizational capacity for strengths-based, equity-oriented service delivery may help organizations advance health equity in economically underserved communities.