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Moving a State Division of Public Health Toward Statewide Leadership in Child Maltreatment Prevention

A PREVENT Case Study in Raleigh, NC

Strong leadership is a key ingredient in creating change in society. Is great leadership innate or is it something that can be taught and learned? Either way, widespread child abuse and neglect in our society is a reality in need of change. In 2005, the North Carolina Institute of Medicine convened a Task Force on Child Abuse Prevention in North Carolina. This Task Force found that “Lack of leadership for child maltreatment prevention is a significant barrier to advancing prevention efforts statewide”, with leadership as the first of 6 main areas for improvement in the state. Further, the task force recommended that the NC Division of Public Health (DPH) develop a Child Maltreatment Prevention Leadership Team to coordinate statewide efforts to implement the recommendations of the Task Force.

The Division of Public Health created a new position to direct the overall child maltreatment (CM) prevention initiative. They also partnered with Prevent Child Abuse North Carolina to co- chair the Child Maltreatment Leadership Team, a public-private partnership with members representing public agencies, state-level and community-based nonprofit agencies, parents, and university faculty. Unfortunately, the leadership team as assigned did not prove to be as successful as hoped; it was supposed to be part of a legislative study commission, but there was no legislative authority and thus no clear role. In addition, many saw it as being duplicative with the Child Fatality Taskforce. The state health director recognized overlap between three groups within DPH (child maltreatment prevention group in the maternal and child health section, child fatality prevention team, and the early childhood comprehensive system) and charged these three groups with figuring out how to work together without duplicating efforts. This new group knew about the PREVENT Institute from a previous NC DPH team who had attended and spoken highly of the experience. The group invited three other partners, the injury and violence prevention branch (DPH), the Office of the Chief Medical Examiner (DPH), and the Children’s Trust Fund (then located in the Department of Public Instruction), to join; they applied and were accepted to attend PREVENT in November 2008.
In their application, the team proposed developing a division-wide plan for assuming leadership in child maltreatment prevention and for coordinating efforts between the DPH and the Children’s Trust Fund in the Department of Public Instruction (DPI). Several factors external to and within the team necessitated a modification of their goals. One change came as a result of legislation introduced to move the Children’s Trust Fund out of DPI, so the goal around building organizational ties between DPH and DPI via the Trust Fund needed to wait. Also, the November 2008 election brought a change in NC’s governor, secretary of health and human services, and state health director, along with a dramatically reduced budget. The team needed to wait for the fallout of these political changes to settle before fully diving into their plan. Internally, the training received at the PREVENT Institute encouraged the team to focus on the more basic steps of their proposal. They intensified their focus on building capacity on child maltreatment prevention within the DPH before trying to plan ways in which the DPH would collaborate with external partners and assume leadership on this issue statewide. They recognized the inherent weakness in the IOM design for leadership in CM prevention. DHP had been assigned a leadership role; now they needed to go back and create the capacity and focus to assume that leadership.
The PREVENT Institute emphasizes using data and evidence to make decisions whenever possible. When the team returned to Raleigh after the first part of the PREVENT Institute, they had a new goal: to understand current conditions within DPH that would affect their ability to become the state leader in child maltreatment prevention. Over the next six months, they worked on three main tasks. The first was to gather more information. They completed literature reviews of child maltreatment rates, consequences of abuse, and evidence from other efforts to build organizational capacity and influence policy affecting child maltreatment. The second task was to do an “environmental scan” of the Division of Public Health to identify current activities that prevent child maltreatment, whether it was the program’s intention or not. They found that many people working in traditional public health services like immunizations and nutrition were building protective factors and reducing risk factors related to child maltreatment even if they didn’t identify it as such:
If you walked the halls in Public Health and asked people if they worked on primary prevention of maltreatment they’d say Huh? But the truth is when you ask them what they do, it is. (Team member interview October 2009)
The third main task was to develop a survey of DPH staff to identify what people in the division understand about the problem and what they perceive their role is in preventing child maltreatment. The team developed their survey with input from several focus groups of DPH staff and support from the State Center for Health Statistics. The final survey was put through official channels so that it could be sent by the health director, a move intended to improve their response rates. People are much more likely to pay attention to a survey in their inbox if it came from their boss! The team also received permission to send the survey to all the local health departments in the state. Creating the ability for the DPH to effectively lead statewide efforts on child maltreatment prevention would be greatly enhanced by being able to connect with all the different levels of public health across the state.
Changing an organization as a step in the long term process of creating social change around child maltreatment prevention is not a quick or easy task. As one team member from the Raleigh PREVENT team pointed out, “Changing an organizational identity is a much slower process than anyone might admit to.” The team’s experience at PREVENT helped them see that starting with changing their organizational identity was an important first step in reaching their overall leadership goal. The three main efforts within their team project are laying a solid foundation for the creation of the leadership identity necessary to direct statewide efforts in child maltreatment prevention. In addition, the PREVENT experience has started some other ripples that are moving in the same direction. One is that the creation of the team itself has strengthened the relationship between the child maltreatment initiative (which is housed in the Maternal and Child Health Section), the Injury and Violence Prevention Branch (which hasn’t made child maltreatment one of its priorities, but which works on other types of violence prevention), and the Office of the Chief Medical Examiner (which houses the State Child Fatality Prevention Team). Another ripple effect from PREVENT is that the state child fatality prevention team started to incorporate discussions of protective factors in addition to risk factors in their reviews of a child death (from child maltreatment and all other causes). The board now includes discussions of what support the family would have needed to avoid this death (like child care, mental health care etc) rather than just what are problems they had that lead to it (substance abuse, poor parenting skills, etc). This group, which focuses exclusively on cases after the fatal violence has occurred, expanded their self perception to include more of a prevention perspective. It is an example of the small shifts that the PREVENT team aims to foster across the DPH en route to creating the unified understanding of child maltreatment prevention necessary within the agency for strong and effective leadership by the agency.

PREVENT Institute 2008 North Carolina Team
  • Studied examples of successful organizational change within the field of child maltreatment prevention
  • Completed an environmental scan of all activities from all branches of the NC Division of Public Health that relate to child maltreatment prevention
  • Developed a survey to be implemented with staff of NC Division of Public Health and local health departments to assess understanding of child maltreatment and perception of their role in its prevention
  • Built the capacity of the Division of Public Health to address child maltreatment by strengthening relationships among branches and between DPH and other agencies working on child maltreatment prevention

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