Women's Health Issues 27-S1 (2017) S6–S13

www.whijournal.com

Original article

Community Coalitions’ Gender-Aware Policy and Systems

Changes to Improve the Health of Women and Girls
Shelly Kowalczyk, MSPH, CHES a,*, Suzanne M. Randolph, PhD a, Linda Oravecz, PhD b
a
The MayaTech Corporation, Center for Community Prevention and Treatment Research, Silver Spring, Maryland
b
Family Studies and Community Development, Towson University, College of Liberal Arts, Towson, Maryland

Article history: Received 1 February 2017; Received in revised form 25 July 2017; Accepted 1 September 2017

a b s t r a c t
Background: Addressing environmental barriers and community conditions through policy and systems change provides
the foundation for creating sustainable public health change at the population level. In an effort to influence population-
level change that is gender aware, the United States Department of Health and Human Services Office on Women’s
Health funded the Coalition for a Healthier Community initiative supporting 10 grantees in the implementation of
gender-based, public health systems approaches to improve women and girls’ health.
Methods: A national evaluation assessed the extent to which these gender-aware public health systems approaches
result in programs and policies that are sustainable and cost effective in addressing health disparities in women and
girls. For this paper, a review of policies reported on in grantees’ quarterly progress reports was conducted, and policies
were categorized based on each policy’s status, level, sector affected, and whether it was gender aware.
Results: The review revealed 77 policies at varying stages of development or implementation intended to facilitate
systems-level change at the coalition, school, organizational, local, or state level. Fifty-one percent of these policies were
identified as being gender aware, because they were intended to reduce barriers to or increase facilitators of gender equity.
Conclusions: Community coalitions, like the Coalition for a Healthier Community coalitions, can be valuable channels for
promoting policy change, as demonstrated by the many policies developed and/or supported by the Coalition for a
Healthier Community grantees in their attempt to meet the needs of women and girls.
Ó 2017 Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health.

The World Health Organization (2009, 2016) and the Inter-
agency Gender Working Group (Greene & Levack, 2010) have urged
researchers, policy makers, and program staff to consider gender
(vs. “sex”) as an important social determinant of women’s and girls’
health. Sex refers to the biological (anatomical and physiological)
characteristics that define males and females; gender refers to the
socially constructed roles, behaviors, activities, and attributes that a
given society considers appropriate for men and women. The
World Health Organization recognizes that addressing gender
norms and roles leads to a better understanding of how the social
constructs and unbalanced power and opportunities between
women and men affect their health risks, health-seeking behaviors,
and health outcomes (Faricy, 2012). As such, it is unreasonable to
expect that people will change their behaviors easily, when so
many social, cultural, and environmental influences are working
against such change (Faricy, 2012).

Funding Statement: This project is made possible with funding from grant
no. WH-CCE-11-001 from the U.S. Department of Health and Human Services
Office on Women’s Health. Its contents are solely the responsibility of the au-
thors and do not necessarily represent the official views of the Office on
Women’s Health, the Office of the Assistant Secretary for Health, or the U.S.
Department of Health and Human Services.
Data Access and Responsibility.
Shelly Kowalczyk had full access to all the data in the study and takes re-
sponsibility for the integrity of the data and the accuracy of the data analysis.
Shelly Kowalczyk and Suzanne M. Randolph are employees of The MayaTech
Corporation, the organization that conducted this research under contract to the
U.S. Department of Health and Human Services, Office on Women’s Health
(OWH) to provide national evaluation services for the OWH’s Coalition for a
Healthier Community Initiative. These individuals serve as Deputy Project Di-
rector and Project Director, respectively, of the national evaluation.
The evaluation study on which this paper is based was reviewed and approved
by the U.S. Office of Management and Budget (OMB). The OMB control number is
0990-0443 and approval expires on 02/28/2019. The study also was reviewed by
the Institutional Review Board (IRB) of The MayaTech Corporation (Federalwide
Assurance No. FWA00012366) and approval expires on September 30, 2017.
* Correspondence to: Shelly Kowalczyk, MSPH, CHES, The MayaTech Corpo-
ration, Center for Community Prevention and Treatment Research, 8401
Colesville Road, Suite 430, Silver Spring, MD 20910. Phone: 301-587-1600;
fax: 301-587-1524.
E-mail address: skowalczyk@mayatech.com (S. Kowalczyk).

1049-3867/$ - see front matter Ó 2017 Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health.
https://doi.org/10.1016/j.whi.2017.09.004
 S. Kowalczyk et al. / Women's Health Issues 27-S1 (2017) S6–S13 S7

For decades, health programs have focused on individual
behavior change to improve health outcomes. However, address-
ing environmental barriers and community conditionsdincluding
socially constructed gender roles, norms, and behaviorsdthrough
policy and systems change provides the foundation for creating
sustainable public health change at the population level (National
Association of City and County Health Officials, 2016). Where you
live, work, learn, play, worship, and receive health care affects how
you live (Faricy, 2012). Consequently, changing the context or
environment of a community enables widespread behavior
change with an intent to improve health outcomes. The use of
community coalitions is one approach to engaging communities
in creating and sustaining conditions that promote and maintain
behaviors associated with widespread health and well-being
(Choy, Maddock, Brody, Richards, & Braun, 2015). Coalitions,
characteristically representing diverse sectors of a community
such as schools, health care systems, community service pro-
viders, government offices, and businesses, are ideal conduits for
engaging the necessary stakeholders to effect population-level
change. Coalitions can help to build local knowledge and capac-
ity, focus and coordinate efforts, reduce resistance to change
amongst community members, and enhance communication
(Brown, Feinberg, Shapiro, & Greenberg, 2015), allowing them to
successfully promote policy change within communities aimed at
improving health outcomes.
Background
The U.S. Department of Health and Human Services Office on
Women’s Health (OWH) Coalition for a Healthier Community
(CHC) initiative supported 10 grantees across the United States in
the implementation of gender-based, public health systems
approaches to improve women and girls’ health (Alexander &
Walker, 2015). A national evaluation of the CHC initiative
assessed the extent to which these approaches are sustainable
and cost effective in addressing health disparities in women and
girls. In planning the national evaluation, a systematic review of
gender-based interventions was conducted (Kowalczyk,
Randolph, Stokes, & Winston, 2015) and revealed that,
although rigor is increasing in evaluations of gender-based in-
terventions, most outcomes are assessed at the individual level,
to the neglect of results of systems-level strategies such as policy
changes. This paper focuses on policy changes that were the
focus of or resulted from efforts of CHC grant-supported activ-
ities, and the extent to which these policies are gender based or
gender aware (Table 1). Policy change was not always initiated by
the coalitions; however, the impetus for the policies often
evolved from the gender-based work conducted by the co-
alitions. In addition, coalition members and partner organiza-
tions contributed to various aspects of the conception, planning,
and/or development of the policies as well as education of the
public about the gender-based policy issues.
Methodology
During an annual grantee meeting that included the project
directors, project coordinators, and evaluators from the grantee
sites, the evaluation team trained grantees on what constituted
“policy, systems, and environmental changes” using the Centers
for Disease Control and Prevention’s (CDC) policy definition and
concepts (CDC, 2010). Grantees submitted quarterly progress
reports that included a list of the policies that were developed or
influenced by the coalition as a result of CHC grant-supported
efforts. Grantees provided an inventory of actions they

Table 1
Definition of Terms

Term Definition

Policy change The passing of “laws, [ordinances, resolutions, mandates,] regulations, rules, protocols, and procedures designed to guide or
influence behavior” (e.g., legislative or organizational; adapted from Centers for Disease Control and Prevention [CDC], 2010, p. 5).
Systems change/systems- Involves “change that impacts all elementsdincluding social normsdof an organization, institution, or system” (may include
level change environmental change; CDC, 2010. p. 5).
Gender-based/gender- Policies that take into account the different social roles of men and women that lead to women and men having different needs
aware policies (Kabeer & Subrahmanian, 1996).
Influence (policy) Any attempt by individuals and groups to shape policy through education, advocacy, political pressure, or mobilization of interest
groups (Kilpatrick, n.d.).
Trauma-informed care Trauma-informed care is an approach to “engaging people with histories of trauma that recognizes the presence of trauma
symptoms and acknowledges the role that trauma has played in their lives. A trauma-informed approach:
Realizes the widespread impact of trauma and understands potential paths for recovery;
Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
Integrates knowledge about trauma into policies, procedures, and practices; and
Seeks to actively resist re-traumatization” (Substance Abuse and Mental Health Services Administration, 2015).
Policy Status
Proposed Set objectives, identify the cost, and estimate the effect of solutions (Cairney, 2013).
Developed Draft a proposed solution to address the identified problem, at any level (Cairney, 2013).
Introduced Raise awareness of formulated policies and educate the audience (Kilpatrick, n.d.). For the introduction of legislation, the term refers
to formally presenting proposed legislation to a governing body for a vote.
Enacted Practice or procedure, regulation, ordinance, or law, including more broadly defined provisions or changes in an organization’s
policies and procedures (Kilpatrick, n.d.).
Rejected A proposed practice or procedure, regulation, ordinance, or law that has been denied by the governing authority (Kilpatrick, n.d.).
Policy sector impacted (CDC, 2010)
Community-at-large Community-wide efforts that impact the social and built environments, including improving food access, walkability, tobacco use
and exposure, or personal safety.
Community institution/ Entities within the community that provide a broad range of human services and access to facilities such as faith-based
organization organizations, senior centers, boys and girls clubs, and colleges or universities.
Health care Places where people go to receive preventive care or treatment, or emergency health care services such as hospitals, doctor’s offices,
and community clinics.
School Primary and secondary learning institutions, whether public, private, or parochial.
Worksite Places of employment, including business offices, restaurants, retail establishments, and government offices.
S8 S. Kowalczyk et al. / Women's Health Issues 27-S1 (2017) S6–S13
perceived as “policies” and provided information about three
dimensions of each policy (Table 1): 1) whether the policy was
gender aware (i.e., whether the policy was focused on reducing
barriers to or facilitating improvements in women and girls’
health), 2) the level at which the policy was developeddstate,
local, school, organization, or coalition, 3) and the status of the
policy, namely, proposed, developed, introduced, enacted/
passed, or rejected.
For this paper, qualitative approaches were used to identify
and code policies. The most recent data available were abstracted
from grantees’ year 4 quarterly progress reports (September
2014–December 2015). Policies compiled by OWH for the CHC
annual policy inventory were also reviewed and abstracted to
ensure that all policies were accounted for through 2015. The
resulting list included 90 unduplicated policies as identified by
the grantees. However, during coding we determined that of the
90 policies, only 77 met criteria for systems-level policy change
as defined for this initiative. The 13 excluded from this paper
tended to be activities that were more programmatic or outreach
oriented, often focused on raising awareness of the health issue.
In addition to coding the dimensions (i.e., variables) as
described, the evaluation team coded the 77 policies for the
sector the policy was intended to impact. The team used the
CDC’s CHAnGE data collection tool for this purpose (CDC, 2010).
The five sectors of the CHAnGE tool are defined in Table 1.
Each of these variablesdgender awareness, level, status, and
sectordwas coded separately by two researchers. Results of
coding were tabulated to check for percent agreement (i.e., inter-
rater reliability). Inter-rater reliability was achieved at 94% across
all variables, and ranged from 86% to 97% for the specific vari-
ables: 97% for gender awareness, 96% for level, 95% for status, and
86% for sector. In addition to coding policies for the variables
described, policies were also categorized into three cluster areas
based on the Healthy People 2020 Objectives (HP2020) that were
the focus of coalitions’ programming and systems-level changes
(Table 2).
Results
Description of the CHC Grantees
A list of the 10 OWH-funded CHC granteesdincluding infor-
mation about their coalition, target population, HP2020 focus
areas, broader programmatic approach clusters, the CDC CHAnGE
sectors, and a summary of policy changesdis included in Table 3.
Number, Level, Gender-Aware Classification, and Sector of Policies
Number of policies
As of December 31, 2015, the 10 CHC coalitions contributed to
the development of 77 policies that were the focus of or the
Table 2
Cluster Areas
Cluster Area HP2020 Topic Areas Addressed in Cluster
Areas
Violence against women/ Injury and violence prevention, substance
trauma-informed care abuse, and mental health
Wellness/obesity/nutrition General prevention and wellness, nutrition
and weight status, and physical activity
Managing chronic conditions Diabetes self-management and heart disease
and stroke prevention or self-management
result of their OWH grant-supported activities. The number of
policies reported ranged from 2 to 17 per coalition.
Status of policies
Sixty-one policies (79%) were passed or enacted; the status of
the remaining 16 policies included 11 that were developed, 4
that were introduced, and 1 that was rejected.
Number of gender-aware policies
Of the 77 policies, 39 (51%) were determined to be gender-
aware policiesdthose that proactively addressed the social
constructs that characterize differences between men and
women.
Levels of policy
Policies were proposed and/or instituted at various levels,
including some policies instituted at multiple levelsdfor
example, the establishment of joint user agreements between
organizations and schools to open facilities for physical activity.
Table 4 summarizes the number and percentage of policies at
each level and whether they were classified as gender aware.
The largest percentage of policies were instituted at the or-
ganization level (45%), followed by state-level policies (23%).
Three-quarters of the state-level policies were identified as
gender aware, whereas approximately one-third of the
organization-level policies were identified as gender aware.
Sectors
The sector toward which a policy was focused and where the
impact was expected was also identified for each of the 77 pol-
icies. Table 5 displays the number and percentage of policies by
sector. Most of the policies (40%) were focused toward impacting
the community-at-large, whether statewide, regionally, or
locally. Nearly one-quarter of the policies (23%) were focused on
impacting specific community institutions or organizations. The
remaining 28 policies were focused on impacting change within
worksites (16%), health care organizations/systems (13%), and
primary and secondary schools (8%). All but one of the policies
focused on primary and secondary schools were classified as
gender aware. Nearly three-quarters of the policies focused on
impacting change within health care organizations/systems
(70%) were classified as gender aware. The remaining sectors
with policies identified as gender aware included community
institutions/organizations (50%), community-at-large (48%), and
worksites (25%).
Policy Themes by Cluster Area
Twenty-eight of the policies were in the violence against
women/trauma cluster; 41 were in the wellness, obesity, and
nutrition cluster; and 5 were in the managing chronic conditions
cluster. Three other policies were classified as other; one focused
on saving paper, one focused on car safety, and the last focused
on creating a template to standardize reporting by a grantee’s
subcontractors and partners.
The following is a summary of the policy themes by cluster.
Although some of the policies are expanded upon in other arti-
cles in this supplement, others are notdof note are those that
were the focus of or resulted from CHC grant-supported activ-
ities of the Consortium for Health, Safety and Support (Hawaii)
and the Delaware Coalition for Health and Justice. As such,
additional information about their efforts are included below.
 S. Kowalczyk et al. / Women's Health Issues 27-S1 (2017) S6–S13 S9

Table 3
Summary of Coalition for a Healthier Community Grantees, HP2020 Focus Areas, Clusters, and CDC CHAnGE Sectors

Grantee/Location Coalition Target Population HP2020 Focus Areas/ Clusters Sectors Impacted
Objectives by Policy Change

Brandywine Counseling & The Delaware Coalition for Women engaging in Access to health services Violence against Community-at-
Community Services, Wilmington, Health and Justice prostitution or other HIV women/trauma large
DE behaviors that place them Mental health and mental Health care
at risk of HIV disorders
or who are HIV positive, Substance abuse
with emphasis on
reaching women of color,
especially black women
Summary of Brandywine policy changes: Statewide trauma-informed probation program; trauma-informed staff training requirements within health care
organizations.

Drexel University College of The Philadelphia Ujima Women, men, and youth Heart disease and stroke Wellness/ Community-at-
Medicine, Philadelphia, PA Coalition for a Healthier affiliated with Nutrition and weight status obesity/ large
Community partner sites Physical activity nutrition CI/O
Managing Health care
chronic School
conditions Worksite
Summary of Drexel policy changes: Organizational policies to promote healthy behavior; school wellness and nutrition policies; high school curriculum
requirements addressing gender; medical school requirements specific to women’s health and gender equity.

Domestic Violence Action Center, The Consortium for Health, Women representing Educational and community- Violence against Community-at-
Honolulu, HI Safety and Support diverse based programs women/trauma large
ethnicities, particularly Injury and violence CI/O
Native prevention Health care
Hawaiians and Filipinos School
Summary of DVAC policy changes: State-level legislation (passed and drafted)danti-human trafficking, emergency contraception in emergency rooms, baseline
standards for childcare providers, reduced financial exploitation by abusive partners; bystander training requirement at an institute of higher education; primary
and secondary education curriculum requirements regarding healthy relationships; health care organization policy regarding intimate partner violence screening.

Family League of Baltimore, B’more Fit for Healthy Babies Women residing in Maternal, infant, and child Wellness/ Community-at-
Baltimore, MD Baltimore health obesity/ large
City who have given birth Nutrition and weight status nutrition Health care
within Physical activity Worksite
the last 5 years, are
receiving
public assistance, and are
between
the ages of 18 and 44
Summary of FLB policy changes: Citywide fresh produce distribution; worksite wellness and breastfeeding policies; health care organization policies to incorporate
specific screening and referral processes in postpartum discharge protocols; trauma-informed care training requirements for city employees and B’more Fit
program staff.

National Kidney Foundation of Inkster Partnership for a Adult African American Diabetes Wellness/ Community-at-
Michigan, Ann Arbor, MI Healthier Community women Health communication and obesity/ large
with an existing health information nutrition CI/O
diagnosis of diabetes technology Managing Health care
or those who qualify as Physical activity chronic Worksite
being at conditions
risk for diabetes
Summary of NKFM policy changes: Worksite wellness policies; organizational policies to promote healthy behavior; health care system quality improvement policy
change; garden curriculum at public schools to increase food access and security; “Greenway Project” wellness policy; citywide obesity and Community Health
Worker resolutions.

St. Vincent Healthcare Foundation, Healthy by Design Women age 18 and older Older adults Wellness/ School
Billings, MT in Physical activity obesity/ Worksite
Yellowstone County, nutrition
including an
emphasis on senior
women
Summary of St. Vincent policy changes: Worksite lactation, physical activity, and nutrition policies; school wellness policy; safer streets policy.

Thurston County Public Health & Thurston Coalition for Female residents age 10– Access to health services Violence against Community-at-
Social Services, Thurston County, Women’s Health 14 Injury and violence women/trauma large
WA prevention
Mental health and mental
disorders
Summary of Thurston policy changes: Formed the Child Abuse Prevention Task Force to address and develop policies surrounding violence against children and
childhood trauma.

(continued on next page)

S10 S. Kowalczyk et al. / Women's Health Issues 27-S1 (2017) S6–S13

Table 3 (continued )

Grantee/Location Coalition Target Population HP2020 Focus Areas/ Clusters Sectors Impacted
Objectives by Policy Change

University of Illinois at Chicago, Southern Seven Coalition for Adult women and men Diabetes Wellness/ CI/O
seven southern counties in Illinois Women’s Health Heart disease and stroke obesity/ Worksite
nutrition
Nutrition and weight status
Physical activity Managing
chronic
conditions
Summary of UIC policy changes: Organizational policies to promote healthy behavior; policy toolkit to encourage organizational policy change.

University of Utah, Salt Lake City, UT Utah Women’s Health African, African Nutrition and weight status Wellness/ Community-at-
Coalition American, American Physical activity obesity/ large
Indian, Hispanic/Latina, nutrition CI/O
and Pacific Health care
Islander women in Utah Worksite
Summary of Utah policy changes: Wellness policy within institute of higher education; gender training requirement in local medical school; local chapter of
American Public Health Association changed bylaws to include a special interest group for community health workers.

Yale University School of Medicine, New Haven MOMS Partnership Low-income, racially and Maternal, infant, and child Violence against Community-at-
New Haven, CT ethnically health women/trauma large
diverse pregnant and Mental health and mental CI/O
parenting disorders Health care
women of children ages Substance abuse School
0–7 in
New Haven
Summary of Yale policy changes: Housing vouchers for mothers with mental illness; diapers to mothers in home visiting program; data sharing agreements;
citywide public housing policy to standardize screening for parenting and pregnant women at risk of/who have depression or trauma.

Violence against women and trauma-informed care
Four coalitions advanced programmatic and policy priorities
that addressed violence against women and trauma. A summary
of the types of policies and activities in this cluster area is pre-
sented below.
Government action. Most of the government action in this cluster
occurred at the state level. For instance, state-level legislation
was passed in Hawaii in the following areas: 1) emergency
contraception in hospital emergency rooms, 2) the establish-
ment of baseline standards for childcare providers with respect
to child and partner abuse, 3) releasing domestic violence vic-
tims from shared cell phone plans and housing rental agree-
ments to reduce barriers to escaping abusive partners, and 4) the
establishment of a victim-centered sex trafficking ban. A state-
wide proclamation was issued in Hawaii honoring violence
awareness month, a local ordinance was passed establishing a
domestic violence task force in Honolulu, and the Governor of
Hawaii authorized the establishment of a position within the
Department of Human Services dedicated to strengthening do-
mestic violence and child protective services. Additionally,
Waipahu, Hawaii, high school students and community partners
drafted two resolutions for the Hawaii State Legislature to
mandate addressing healthy relationships in both grade school
and high school curricula. Last, state-level policies in Connecticut
resulted in two governmental agencies providing housing
vouchers and diapers to mothers with mental illness or at risk for
depression who are in home visiting programs. Additional in-
formation about the statewide and national impact of the New
Haven MOMS Partnership’s efforts to increase access to diapers
can be found in the article by Wallace and colleagues (Wallace
et al., 2017).
Local coalition actions for trauma-informed care. Coalitions and
their partners have taken various measures to ensure trauma-
informed approaches to care at the local level to address the
consequences of trauma and to facilitate healing. These local
coalition actions have included 1) the establishment of a trauma-
informed probation program throughout Delaware, 2) trauma-
informed staff training for a health care system in Delaware, 3)
intimate partner violence screening at a health clinic in Hawaii,
4) an organizational policy aimed at integrating intimate partner
violence education into all community projects sponsored by a
coalition partner in Hawaii, and 5) a formal partnership between
the coalition and a community college in New Haven, Con-
necticut, to provide referral services for mental health

Table 4 Table 5
Number and Percentage of Policies by Level and Gender-Aware Classification Number and Percentage of Policies by Sector and Gender-Aware Classification

Level of Policy Number and Percent of Policies (N ¼ 77) Sector Number and Percent of Policies
(N ¼ 77)
Overall, n (%) Gender Aware, n (%)
Overall, n (%) Gender Aware, n (%)
Organization 35 (45) 12 (16)
State 18 (23) 14 (18) Community-at-large 31 (40) 15 (19)
Local 12 (16) 5 (6) Community institution/organization 18 (23) 9 (12)
School 4 (5) 2 (3) Worksite 12 (16) 3 (4)
Coalition 1 (1) 1 (1) Health care 10 (13) 7 (9)
Multilevel 7 (9) 5 (6) School 6 (8) 5(6)
 S. Kowalczyk et al. / Women's Health Issues 27-S1 (2017) S6–S13
counseling. In New Haven, a citywide policy was developed for
implementing standardized screening for pregnant and
parenting women pertaining to depression and trauma in all
public housing. The Thurston Coalition for Women’s Health in
Olympia, Washington, worked to form a Child Abuse Prevention
Task Force to develop policies addressing violence against chil-
dren and related trauma. The Task Force joined with the CHC
coalition and a coalition for women’s health to work on imple-
mentation of health improvement objectives around reducing
adverse childhood experiences. And although not originally
identified as one of their HP2020 objectives, the Family League of
Baltimore has established policies requiring training of city
government personnel and B’more Fit for Healthy Babies pro-
gram staff in trauma-informed care. Further information on their
efforts can be found in the article by Tuck and colleagues (Tuck
et al., 2017).
Data collection and sharing. The New Haven MOMS Partnership
established data sharing agreements with the State Department
of Social Services to share state data from federal programs
(Temporary Assistance for Needy Families and Medicaid) to
support mothers with mental illness and design appropriate
programming. This coalition also developed a data sharing
agreement with the public school system to share data for the
research of two-generation mental health impact and educa-
tional outcomes.
Workforce development and curriculum and class train-
ing. Violence prevention was incorporated into the curriculum
at one institute of higher education through the efforts of the
Consortium for Health, Safety and Support (Honolulu, HI) to help
raise awareness of violence on campus. Gender violence has
become a topic for an ongoing class within the local public school
system in the same city.
The Consortium for Health, Safety and Support led by the
Domestic Violence Action Center accounted for almost one-half
of the state-level policies reported (9, or 43%)dmore than any
other CHC grantee. All of these policies were gender aware;
they were intended to reduce barriers to and increase facilita-
tors of gender equity. The Domestic Violence Action Center and
the Consortium for Health, Safety and Support engaged in
advocacy in partnership with women legislators to strengthen
Hawaii’s domestic violence and sexual assault laws, as
described.
The Delaware Coalition for Health and Justice, led by Bran-
dywine Counseling and Community Services, focused on
meeting the unique health needs of women who engage in sex
workdone of those being treatment and care for psychological
and physical trauma. The coalition, in partnership with the Court
and the Office of Probation and Parole, helped institute a policy
for a Trauma-Informed Probation program throughout Delaware.
The policy allows the Court and the Office of Probation and
Parole to operate as trauma-informed systems of care, by
providing a jail diversion program for women with substance
abuse problems who are engaged in sex work. Trauma-informed
care training has extended to a local health care system in an
effort to reduce barriers to care for women with substance use
disorders.
Wellness, obesity, and nutrition
There were six grantees with programmatic and policy pri-
orities that addressed wellness, obesity, and nutrition, particu-
larly as it related to physical activity and nutritional standards.
S11
A summary of the types of policies and activities in this cluster
area is presented.
Government action. Most of the government action in this cluster
occurred at the local level. For instance, a citywide wellness
policy was enacted with support of the Inkster Partnership for a
Healthier Community in Inkster, Michigan, that spurred the
establishment of a new walking path to promote physical ac-
tivity. In Salt Lake City, Utah, the CHC grantee was instrumental
in the signing of a citywide resolution to educate small busi-
nesses on the importance of providing workplace lactation sta-
tions. An obesity prevention-related resolution was signed by the
mayor in Inkster, Michigan, through efforts of the CHC grantee
and the city. A statewide declaration in Utah established Pacific
Islander Health Week, largely through the efforts of the Utah
Women’s Health coalition, to address Pacific Islander health
disparities. A breastfeeding policy was implemented within the
city government of Baltimore, where the CHC coalition helped to
spearhead the policy initiative. The B’more Fit for Healthy Babies
coalition also supported a bill drafted by a statewide coalition to
eliminate taxing of bottled water to encourage lower-cost,
healthier beverage choices for children.
Local actions to promote wellness and good nutrition. Several
organizations, including faith-based and health care provider
organizations that were coalition partners or supported the
coalition in some manner, implemented wellness policies to
promote healthy behavior among their employees and members.
These policies included providing increased opportunities for
physical activity, encouraging healthy eating and healthy meal
preparation through limiting unhealthy foods at sponsored
events, the implementation of policies to prevent smoking in and
around worksites and at community events, requiring health
screenings and referrals as part of routine health care through
incorporation into electronic discharge tools, and implementing
a lactation policy. In Billings, Montana, members of the Healthy
by Design coalition worked with a school district to revise their
school wellness policy to include healthy snack guidelines,
nutritional standards, and wellness enhancements. Healthy by
Design members also developed and implemented comprehen-
sive worksite nutrition policies by addressing vending machine,
catering, and cafeteria food nutritional standards. One university
developed a specific healthy foods nutrition policy, and another
modified their wellness policy to prohibit serving sugary drinks
and junk food at student events. The Southern Seven Coalition
for Women’s Health in collaboration with the University of Illi-
nois at Chicago developed a policy toolkit to encourage organi-
zational policy changes around health and wellness within
worksites, organizations, and churches.
Workforce development and curriculum and class training. Drexel
University/Hahnemann University Hospital created an office
within the school to elevate issues of gender equity in medical
evaluation by supporting programming for medical students and
physicians. This university also increased curricular hours for
women’s health, resulting in additional lectures for first- and
second-year medical students (see Robertson-James et al., 2017).
The University of Utah instituted gender training via their Women
and Gender Portfolio Program, a 4-year program for training physi-
cians in gender-based care. In secondary education, a garden
curriculum was implemented within a public school district in
Inkster, Michigan, with the collaboration of the National Kidney
Foundation of Michigan, to increase food access and security, as
S12 S. Kowalczyk et al. / Women's Health Issues 27-S1 (2017) S6–S13
well as to supplement the nutritional needs of community resi-
dents. The Philadelphia Ujima Coalition supported a local voca-
tional high school’s efforts to incorporate gender into its
curriculum (see Robertson-James et al., 2017).
Formal partnerships. A faith-based organization in Inkster, Mich-
igan, partnered with a health care service provider and a local
government office to create a joint use agreement to establish
space for community workshops and trainings on health and
wellness. Another organization partnered with schools and faith-
based organizations to create joint use agreements to open facil-
ities for physical activity in Salt Lake City, Utah. In Baltimore,
Maryland, B’more Fit for Healthy Babies coalition partners
collaborated with the local parks department and a volunteer
organization to establish a partnership to distribute fresh produce
at recreation centers throughout the city.
Managing Chronic Conditions
Three grantees adopted programmatic and policy priorities
that addressed managing chronic conditions, specifically in the
areas of diabetes and heart disease and stroke. A summary of the
types of policies and activities in this cluster area is presented.
Wellness policies. In Inkster, Michigan, in collaboration with the
Inkster Partnership for a Healthier Community, a faith-based
organization implemented a policy to improve wellness by
authorizing public access to their facilities for chronic disease
management, fitness classes, and health education; another
partner implemented a policy that established a formal agree-
ment with a medical equipment company to provide free blood
pressure cuffs to eligible patients for monitoring heart health;
and a task force serving as a community collaborative advocacy
group was later established to develop city-wide wellness pol-
icies associated with diabetes.
Workforce development. In Inkster, Michigan, the CHC coalition’s
efforts in working with the board of a local health center resulted
in a patient navigator position. The position was created to
provide diabetes education, improve follow-up, and create link-
ages to community resources for community residents at risk for
poor health outcomes.
Discussion
Community coalitions can be valuable channels for promot-
ing policy change, largely owing to their engagement of a variety
of stakeholders in collaborative planning and community
mobilization efforts at multiple levels and sectors (Roussos &
Fawcett, 2000). This has been demonstrated by coalitions’ suc-
cess in policy and systems change efforts in such areas as tobacco
control and obesity prevention (Faricy, 2012). The CHC coalitions
seemed to benefit from this multilevel, multisectoral approach to
addressing the needs they identified during their gender-based
analyses. Results showed that they successfully supported pol-
icy development and implementation aimed at systems-level
change at the state and local levels, within organizations,
schools, and health care systems. These types of systems changes
are necessary when individual and interpersonal behaviors are
not enough to overcome negative environmental influences
(Gregson et al., 2001). Considering that policy outcomes were
not an intended goal at the outset of the CHC initiative, it is
noteworthy that 77 policies resulted from efforts of the grantees’
work. Furthermore, one-half of the policies supported by the
CHC coalitions were gender aware. In examining the individual
policies, those focused on obesity prevention tended to be pol-
icies focused on specific HP2020 objectives and systems change,
particularly at the organizational or school levels, but were not
necessarily gender aware. This may be due in part to the fact that
obesity is affecting men and women more proportionately than
some of the other focus areas of this initiativedfor instance,
intimate partner violence and mental illness, which generally
affect a much larger proportion of women than men (CDC, 2014;
World Health Organization, n.d.). As such, policies focused on
these topics are inherently gender aware, because they aim to
strengthen gender equality by changing norms, structures, and
experiences, whereas obesity-related policies tended to focus
more on the immediate behavior of increasing physical activity
and/or improving nutrition. With that said, grantees’ progress
reports provided limited information about the policies, so a
policy not deemed gender aware may have been included in that
category had more information been provided about the
conceptualization and development of the policy.
Implications for Practice and/or Policy
Although population-level behavior change is the intended
outcome of systems change, there is a great deal of activity and
action that needs to occur prior to policy implementation. The
policies examined for this study reveal not only policies enacted
as a result of coalition-supported efforts, but developmental
steps that the coalitions have taken that are intended to result in
policy and systems change. For example, several of the coalitions
have convened or have been asked to be a member of a task
force, advisory group, or similar collaborative focused on advo-
cating for a specific policy. These collaboratives are raising
awareness of issues within their communities to garner support
for policies. At the outset of the CHC Initiative, it was important
to educate the coalitions about policy and systems change, as
there are often misperceptions that this type of change includes
only legislation passed at the state or local level. However, upon
review of the policies reported by the CHC coalitions, there were
still several policies that did not meet the CHC’s operational
definition of “policy” and “systems” change. Additional guidance
may have been beneficial to help coalitions distinguish pro-
grammatic changes versus systems change. Future efforts should
include sufficient advance training so that coalition staff and
other stakeholders can master these concepts early in their work.
The list of gender-aware policies generated by this small
sample of coalitions is illustrative of what is possible with
collaborative, gender-based, public health systems approaches to
eliminating gender disparities in women and girls’ health.
However, additional research is needed to examine the impact of
these policies over time. Furthermore, to contribute to the field
of evidence to support policy and systems change, it is necessary
to document and report with more detail on the processes used
to develop, implement, enact, and/or enforce these policies.
Finally, the evolving nature of coalitions can present chal-
lenges when it comes to policy and systems change, which tends
to be a time-consuming process. Changes in administration and
leadership of a coalition, its partner members, or staff within
partner organizations who serve as coalition members can delay
the process while new members get up to speed; in addition, the
coalition may lose some of its key “champions” and see them
replaced by those who may not be as committed or available to
carry out the work that is needed to create the desired change.
 S. Kowalczyk et al. / Women's Health Issues 27-S1 (2017) S6–S13
Conclusions
The data in this report reflect secondary analyses of infor-
mation that were based primarily on grantee project directors’
and local evaluators’ reports on their own coalitions. Data were
analyzed through 2015; therefore, additional policies may be
reported in grantees’ final reports submitted between January
2016 and April 2017. Although sites were located across the
United States, some geographic regions were not represented;
nor did the funded sites represent the full programmatic or
policy contexts in which their programs and policies were
implemented. There were no retrospective comparison data at
the community or organizational levels to determine what
policies existed before CHC funding, even though grantees
conducted needs assessments and gender-based analysis data
collection in phase I of their grants. Despite these limitations,
this study has several strengths that could inform future plan-
ning, implementation, and evaluation of collaborative ap-
proaches to policy and systems changes to improve the health
of women and girls. For instance, this study provides practical
examples of policy and systems changes that can be developed,
implemented, or shaped by partnerships with state and local
organizations to improve women and girls’ healthdchanges
that often have more sustaining potential than individual-level
changes in behavior, attitudes, and knowledge to improve
health and increase equity.
Acknowledgments
This supplement issue was prepared for the U.S. Department
of Health and Human Services Office on Women’s Health
with contract support from NORC at the University of
Chicago. MayaTech performed this work under contract
#HHSP23320095645WC, and want to thank OWH staff Stepha-
nie Alexander, MS, and Stephen Hayes for their contributions,
along with the CHC grantees.
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Author Descriptions
Shelly Kowalczyk, MSPH, CHES, is Senior Technical Vice President and Manager of
MayaTech’s Center for Community Prevention and Treatment Research, with
expertise applying quantitative and qualitative data collection approaches and
analytic strategies in the evaluation of programs, policies, and systems.
Suzanne M. Randolph, PhD, is Chief Science Officer, MayaTech, and Associate Pro-
fessor Emerita, Family Science, University of Maryland, College Park, School of
Public Health, with methodological expertise in survey, experimental, and evalu-
ation research designs applied to studying social/human services, and public health.
Linda Oravecz, PhD, is an Associate Professor in the Department of Family Studies
and Community Development at Towson University. Her research and teaching
interests focus on family policy, poverty, and interpersonal violence.