Elevating Social Determinants of Health to Transform Child Welfare Systems into Child and Family Well-being Systems

By: Jody Levison-Johnson and Amy Templeman

All families need help sometimes, and to deliver that help, we must understand the external conditions that impact their lives. The human and social services sector is at the forefront of an evolutionary change, one that aims to realign social services to be more preventative with greater upstream resources that focus more directly on addressing the social determinants of health (SDoH) to achieve better outcomes.

While we have increased our understanding of the importance of addressing external conditions, including social and economic opportunities, access to community-based resources and supports, greater health equity and more, our nation’s investment in place-based supports has not kept pace.

For example, the COVID-19 pandemic has shed a harsh light on the public health disparities in our nation. Communities of color are more at risk of getting sick and dying from COVID-19 (Centers for Disease Control and Prevention, 2022), demonstrating that ZIP codes are still the top determinant of how we live, work, and play (Ducharme & Wolfson, 2019). The opportunities lie in examining the discriminatory practices that undermine well-being so that systems can better address root causes.

The potential to improve health outcomes and more fully address SDoH through greater investments in human services could transform a range of systems, including health, education, welfare, and criminal justice systems and ultimately result in greater well-being for all families.

To achieve this will require a tremendous shift in resources, both at the federal funding level to redirect funding to more front-end resources, through policies that adapt to a more preventative approach, and in the way that place-based services are delivered by community-based organizations. Too many of our social systems were structured to respond only after harm occurs; by realigning our nation’s social service delivery systems and reimagining the power and impact of the social sector, we can deliver on the promise of equitable access to health and well-being for all people.

Our Nation Under Invests in Social Services

The Commonwealth Fund recently released a report that ranks the United States last in health care systems among 11 of the wealthiest countries in the world, despite having the highest percentage spending of its GDP on health care. The United States spends twice as much on health care as other developed nations and yet, fares the worst in key health metrics, such as life expectancy and maternal and infant mortality. In fact, a recent report from the CDC found that the United States has the highest rate of maternal death of any developed nation (Kekatos, 2022).

How can that be? According to data from the Bassett Healthcare Network and University of Wisconsin Population Health Institute, only 20% of health outcomes are attributable to actual health care while 80% are attributable to SDoH, including environmental, behavioral, and socioeconomic factors (Bassett Healthcare Network, n.d.).

It’s telling that our nation’s investment in human services that address SDoH is among the lowest in developed nations (Alliance for Strong Families and Communities, 2018). Researchers have begun to draw a direct linkage between that investment disparity and health outcomes, noting that “states with higher ratios of social to health spending had better health outcomes one and two years later” (Bradley et al., 2016).

The pandemic helped us all understand that no family is immune to stress or challenges. Stress can overload families and contribute to greater risk of adversity. Times of turmoil often pave the way for key societal shifts. Today, we have the opportunity to shift our focus more toward addressing social determinants and realign our systems to better support all families.

Supporting the Shift from Child Welfare Systems to Child and Family Well-being Systems

A blueprint for this can be found in the shift from child welfare systems to child and family well-being systems that offer families the support they need to prevent harm before it occurs. The transformation that we see today is moving away from the idea that it is solely the function of the child protection agency to keep kids safe. Instead, CPS is one component in a shared, community-wide responsibility for child and family well-being with an emphasis on prevention and a public health approach that addresses SDoH.

For our child welfare system to truly move to a preventive approach, upstream resources must be rooted in community and not tied to intervention by a government system to access them. This would require communities working in partnership with funders (often governmental entities) to identify their specific needs and design supports that effectively respond to them.

In fact, in December 2021 researchers from Tufts Medical Center found that incidents of child abuse actually dropped during the pandemic at the start of the lockdown, despite many pundits suggesting that incidents would rise due to children being isolated at home (Sege & Stephens, 2021). Evidence suggests that while the pandemic increased familial stress for many, it also afforded families access to additional financial supports and increased time at home contributing to enhanced parent-child attachment. These factors, the researchers believe, potentially account for this drop in abuse and maltreatment.

We are at a unique moment in history. Our deepening understanding of what it takes to weather the storms of a global pandemic is resulting in a shift in the way we think about supporting families. In fact, we are more primed than ever before to think about economic and family supports and to tackle child welfare in a way that emphasizes supporting families over penalizing them.

And that thinking is supported by an ever-growing body of research. Chapin Hall at the University of Chicago recently released a brief on the impact of concrete economic supports for families and its correlations to reducing involvement with the child welfare system (Wiener et al., 2021). Their research identified poverty as a key driver of child welfare system involvement and suggested that even modest economic supports could help stabilize families and prevent the need for removing children from the home.

Systems Transformation is Complex but Achievable

Reshaping child welfare systems into child and family well-being systems that can address SDoH will require a broad focus on system transformation. With shared values focused on equity, diversity, and inclusion, we must modernize child welfare systems through redesign with parent and youth partners, drive cross-system integration and operations, provide sustainable financing, and remove systemic and structural barriers upholding racist practices and policies that contribute to poor health outcomes.

In 2021, with those goals in mind, key leaders in the social service sector and Social Current convened a group of human service sector leaders to develop guiding policy principles for the social sector’s work through the lens of SDoH. The group identified seven guiding principles that are critical to addressing SDoH across the child welfare sector. They are:

Partnering with the Entire Health Ecosystem

• The collective health and well-being ecosystem must be at the table and engaged. We are not in it alone. We must co-identify barriers to care and solutions. We want to mobilize and support the field in any identified workforce development needs.

Changing Power Dynamics

• Health and well-being systems must seek to balance power among all key stakeholders. Policymakers should promote and require that health care systems and the social sector, including community-based organizations (CBOs), work together to improve individual health outcomes, and provide reimbursement strategies that incentivize and further collaboration that shares power with parents, youth, and community members.

People-centered Focus

• Health and well-being systems must provide individualized care. These systems will commit to identifying barriers and co-creating solutions with the community and those with lived experience to address systemic trends that negatively impact individuals.

Addressing Root Causes

• Throughout history our culture, economy, and policies have created both intended and unintended consequences that drive disparities in opportunity and outcomes. These systems and practices are deeply rooted in who we are and inform the decisions we make. All solutions must address these assumptions.

Anti-racist Approaches

• Racism is embedded in all sectors of our society. It must be called out and confronted. We must name communities who are damaged by discrimination which include but are not limited to Black, Latino/a/x, Indigenous, Asian Americans, and LGBTQ+ populations. We also must call out inequitable policies that contribute to poor health outcomes.

Forming and Scaling Solutions

• Together, the systems must explore evidence-based interventions designed to eliminate health disparities, while also being mindful of opportunities to implement and scale new innovations and promising practices.

Prevention and Early Detection

• Health and well-being systems, with the engagement of CBOs, must commit to moving further upstream when developing solutions. Identifying protective factors makes a difference for individuals to enhance their resilience and well-being. Strengthening individuals and families before they come upon difficulty leads to greater population well-being and health care savings overall.

System transformation is never easy, but these guiding principles can be applied as a roadmap for change and help transform a broad range of social sector systems in a way that is responsive where it needs to be and fair in its treatment and decision-making for children and families. And these lessons are applicable across the entire social and human-serving ecosystem, including child welfare, health care systems, juvenile justice, education, and more.

Jody Levison-Johnson is the President and CEO of Social Current, an organization focused on advancing the work of the social sector through collaboration, innovation, policy, and practice excellence. Jody is a longstanding champion for systems change that helps individuals and communities thrive. Over several decades, her career has crossed a variety of settings including private providers and state and local governments. Jody holds a MSW degree from Syracuse University and a MA and PhD in Leadership and Change from Antioch University.

Amy Templeman, a kinship and adoptive parent, is the director of Within Our Reach and director of practice excellence at Social Current. In these roles, she works to support families and promote equity. Before joining Social Current, Amy served as executive director of the federal Commission to Eliminate Child Abuse and Neglect Fatalities, leading the effort to produce a report to the president and Congress. Amy helped to establish the Office of Well Being at the District of Columbia’s child welfare agency. She gained research experience at The Urban Institute and Johns Hopkins University.

References

• Alliance for Strong Families and Communities. (2018). A National Imperative: Joining Forces to Strengthen Human Services in America. Author. https://www.alliance1.org/web/resources/pubs/national-imperative-joining-forces-strengthen-human-servicesamerica.aspx
• The Annie E. Casey Foundation. (2021). States Spending Little on Prevention Services, Survey Finds. Author. https://www.aecf.org/blog/states-spending-little-on-prevention-services-survey-finds
• Bassett Healthcare Network. (n.d.) Center for Population Health. Author. https://www.bassett.org/research-institute/centerpopulation-health
• Bradley, E.H., Canavan, M., Rogan, E., et al. (2016). Variation In Health Outcomes: The Role Of Spending On Social Services, Public Health, And Health Care, 2000–09. Health Affairs, 35(5). https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.0814
• Centers for Disease Control and Prevention. (2022). What is health equity? Author. https://www.cdc.gov/healthequity/whatis/
• Ducharme, J., & Wolfson, E. (2019). Your ZIP Code Might Determine How Long You Live—and the Difference Could Be Decades. TIME. https://time.com/5608268/zip-code-health/
• Kekatos, M. (2022). Maternal mortality rates increased during 1st year of COVID pandemic: CDC. ABCNews. https://abcnews.go.com/Health/maternal-mortality-rates-increased1st-year-covid-pandemic/story?id=83061990
• Sege, R. & Stephens, A. (2021). Child Physical Abuse Did Not Increase During the Pandemic. JAMA Pediatrics, 176(4),338–340. doi:10.1001/jamapediatrics.2021.5476 Weiner, D., Anderson, C., & Thomas, K. (2021). System
• Transformation to Support Child & Family Well-Being: The Central Role of Economic & Concrete Supports. Chapin Hall at the University of Chicago. https://www.chapinhall.org/wp-content/uploads/Economic-and-Concrete-Supports.pdf

This article was originally posted in CWLA’s Children’s Voice Magazine – Vol. 32 #1, 2023. To read through the entirety of Vol, 32, purchase the issue on the Child Welfare READ of America’s website.