Health Professionals Organizing for Climate Action: A Novel Community Organizing Fellowship

Abstract

Problem

Climate change is a public health and health equity crisis. Health professionals are well positioned to advance solutions to this crisis but may lack the training and self-efficacy needed to achieve them.

Approach

The Center for Health Equity Education and Advocacy at Cambridge Health Alliance, a Harvard Medical School Teaching Hospital, developed a novel, longitudinal fellowship that taught health professionals about the health and health equity effects of climate change, as well as community organizing practices that may help them mitigate these effects. The fellowship cohort included 40 fellows organized into 12 teams and was conducted from January to June 2022. Each team developed a project to address climate change and received coaching from an experienced community organizer coach. The effects of the fellowship on participants’ knowledge, skills, and attitudes were evaluated using pre- and post-fellowship surveys.

Outcomes

Surveys were analyzed for 38 of 40 (95%) participants who consented to the evaluation and completed both surveys. Surveys used a 7-point Likert scale for item responses. McNemar’s test for paired data was used to assess changes in the proportion of respondents who agreed (“somewhat agree”/“agree”/“strongly agree”) with item statements in pre- vs post-fellowship surveys. Statistically significant improvements were found in 11 of the 17 items assessing knowledge, skills, and attitudes. Participants’ views of the fellowship and its effects were assessed through additional items in the post-fellowship survey. Most respondents agreed that the fellowship increased their knowledge of the connections between climate change and health equity (32/38, 84.2%) and prepared them to effectively participate in a community organizing campaign (37/38, 94.7%). Each of the 12 groups developed climate health projects by the fellowship’s end.

Next Steps

This novel fellowship was well-received and effective in teaching community organizing to health professionals interested in climate change solutions. Future studies are needed to assess longer-term effects of the fellowship.

Problem

Climate change is a public health and health equity crisis.^1,2 Burning fossil fuels and ecological degradation have substantial adverse effects on human health, particularly in historically marginalized communities.³ Health professionals often understand the risks of climate change to human health⁴ and feel a responsibility to educate the public and policy makers.⁴ They are among the most trustworthy voices for climate action⁵ and therefore are well positioned to advance climate solutions. However, health professionals often lack the training and self-efficacy—a belief in their capacity to act to achieve a goal—needed to be effective in this role.⁶

Community organizing is a leadership practice that enables a constituency to mobilize its resources to take collective action through social movement power.⁷ Marshall Ganz (Harvard Kennedy School) developed a pedagogical framework to teach community organizing⁷ that has been taught in the fields of government and business and used effectively to teach health professionals.⁸ A critical component of this pedagogy is public narrative, or purposeful storytelling to share personal values that builds relationships.⁷ Community organizing training has potential to develop valuable leadership skills in health professionals interested in addressing the impacts of climate change on health and health equity and to address the sense of isolation and demoralization among health professionals concerned about climate change.

A fellowship to teach community organizing to combat the health effects of climate change could close this training gap. We piloted a novel, longitudinal climate fellowship for health professionals. Most fellows were already working within an organization on climate projects. Goals for fellows were to (1) improve knowledge connections among climate change, health, and health equity; (2) develop fellows’ community organizing and public narrative skills; (3) improve sense of purpose, community, and self-efficacy, and reduce burnout; and (4) develop the home climate organization’s capacity through conducting a community organizing project.

Approach

Background

The fellowship was offered by the Center for Health Equity Education and Advocacy, an educational initiative at Cambridge Health Alliance, a Harvard Medical School Teaching Hospital. We recruited groups of 3–4 health professionals already working together in their local community on a climate health project. Applicants filled out a group application and had the option of having 1 of their team members be a non-clinician community partner. Applicants were accepted based on the strengths of their organization/team and project proposal. Of the 31 teams and 100 people who applied, we selected 12 teams and 40 fellows. The fellowship ran from January to June 2022 and was limited to U.S.-based health professionals.

Structure

All teaching for the fellowship was conducted virtually. There were 6 2-hour monthly sessions and 3 weekend immersions that lasted 4 hours on both Saturdays and Sundays (Table 1). Although the formal fellowship program concluded after 6 months in June 2022, groups continued to meet with their coach for monthly coaching sessions from July to December 2022 for further project development.

Table 1.

Description of Session Topics, Key Learning Objectives, and Curricula of the Climate Health Organizing Fellowship, Cambridge Health Alliance, Center for Health Equity Education and Advocacy of Harvard Medical School, 2022

Session	Topics covered and key learning objective	Description of curriculum and source
Unit 1: Fellowship Launch (2 hours)	Topics:  • Course orientation  • Introductions from faculty and fellows  • Shared agreements, community norms, ground rules  • Introduction to theory of change framework Key learning objective: Introducing the theory of change framework	In the first meeting as a fellowship cohort, we provided an overview of the fellowship goals and content. We established shared values of the cohort through storytelling, with each fellowship group introducing themselves and their reason for working on climate change. We established community norms with shared learning agreements and introduced the theory of change framework.7
Immersion 1: Becoming Community Organizers (2 days)	Topics:  • Structural competencies  • 5 principles of community organizing  • Public narrative: story of self, story of us, story of now Key learning objective: Develop and practice public narrative: story of self, story of us, story of now	Day 1: We introduced the concept of structural competencies9 as a lens through which to understand how health inequities and the local experience of the climate crisis are co-produced. We defined the 5 principles of community organizing and introduced the practice of public narrative—sharing public stories of leadership to motivate action. We conducted a workshop on 1 component of public narrative—story of self.7 Day 2: We focused on learning and practicing the 2 other components of public narrative: learning and sharing story of us and story of now.7
Unit 2: Pillars of Support (2 hours)	Topics:  • Relationship building, part 1  • Power mapping, part 1  • Structural competencies workshop, part 1 Key learning objectives: Learning the skill of power mapping, understanding how “pillars of power” are upholding the status quo, building lists of people to recruit into team campaigns	This session covered the concept of “pillars of power” and relationship power mapping with people and the teams that could seek to build relationships strategically with them for their campaigns. Additionally, we conducted a structural competency workshop in which 1 team presented their work on improving health equity through expanding tree canopies using a structural competency framework. After the presentation, we had small and large group discussions about the role the practice of redlining played in reducing tree canopies in communities of color.
Unit 3: Relationship Building (2 hours)	Topics:  •Relationship building, part 2  • Power mapping, part 2  • Structural competencies workshop, part 2 Key learning objective: Building relationships through one-to-one meetings	This session focused on learning and practicing the leadership skill of developing values- and interests-based relationships with members of the constituency to organize.7 Additionally, we conducted another structural competency workshop in which 1 team presented their work on persuading a major medical society to incorporate climate action into their statewide policy platform using a structural competency framework. After the presentation, we had small and large group discussions about the roles medical societies have played in both supporting and hindering climate action and environmental justice.
Unit 4: Building and Supporting Leadership Teams (2 hours)	Topics:  • “Snowflake” leadership structure, part 1  • Team purpose, norms, roles Key learning objective: Developing teams and distributed leadership models through a snowflake structure	This session focused on learning the conditions and practices that enable motivated, committed, and stable leadership teams, including refreshing one-to-one relationship building and developing shared purpose, norms, and roles.7
Immersion 2: Campaign Strategy (2 days)	Topics:  • Developing a strategic goal  • Defining a theory of change  • Structural competencies workshop, part 3  • Creating and using tactics  • Developing timelines for campaign  • Snowflake leadership structure, part 2  • Revisiting story of now Key learning objective: Understanding and developing a shared campaign strategy with one’s constituency	Day 1: We covered an overview of strategy development for community organizing campaigns, focusing on developing a theory of change and strategic goal. We also conducted our third structural competency workshop in which 1 group presented their work addressing the impacts of heat and air pollution on reproductive health outcomes using a structural competency framework. After the presentation, we had small and large group discussions on the effects of municipal and federal policy decisions that had contributed to disproportionate impacts of heat and air pollution in immigrant communities. Day 2: We presented the criteria for good tactics and developed a campaign timeline for group projects. Finally, we revisited the concept of the “story of now” and anchored this practice in creating urgency for climate health organizing work.
Unit 5: Leadership Team Structure Revisited (2 hours)	Topics:  • Snowflake leadership structure, part 3  • Developing an organizing campaign Key learning objective: Reviewing the concepts and practices of launching and maintaining structured leadership teams	This session focused on reviewing the skills needed to launch successful leadership teams and practicing developing a snowflake of teams they planned to organize to accomplish the strategic goal.5
Unit 6: Taking Action (2 hours)	Topics:  • Creating actions that support strategic goals and tactics  • Mobilizing people through actions and events  • Phone banking Key learning objective: Planning effective actions and asking for commitments from people to attend and contribute campaign activities	This session focused on how to be effective in driving people to take action. We reviewed the process of gaining commitments from people to step into actions planned in their campaigns.7
Immersion 3: Launching Campaigns (2 days)	Topics:  • Guest keynote speaker: Marshall Ganza  • Group project presentations  • Coaching as a practice  • Reflections Key learning objective: Reflecting and consolidating learning from the fellowship	The closing immersion for the fellowship involved a keynote address and discussion with Marshall Ganz and then short presentations from each of the fellowship teams, summarizing their campaign goals, strategies, and work to date. We held a workshop on effective coaching strategies and presented reflection prompts that fellows discussed in small and large groups.

^aMarshall Ganz (Harvard Kennedy School) developed a framework to teach community organizing.⁷

Content

We used 4 distinct pedagogical and curricular content elements to align with the fellowship goals described above.

Climate change and health equity.

Didactics and discussion sessions focused on historical and structural factors that have created disproportionate impacts of climate change in communities of color and economically disadvantaged communities. Using a structural competency framework,⁹ the curriculum included principles of community partnership and used historical case studies such as the present-day health effects caused by the historical practice of “redlining” (Table 1). Active learning through robust discussion prompted groups to incorporate historical and structural analysis into their climate health community organizing project design.

Community organizing modules.

The curriculum’s community organizing component was developed in collaboration with Ganz and is based on 5 core principles of leadership practices⁷: (1) developing a “public narrative” using storytelling to define values and create a call to collective action; (2) building intentional relationships; (3) developing leadership structures with well-defined purpose, ground rules, and roles; (4) creating a strategy for identifying resources that can build power to achieve clear goals; and (5) securing commitments to generate measurable, motivational, effective action. Table 1 describes how these principles were taught throughout the fellowship. Fellows were assigned 1–2 hours of prework videos and readings per session that introduced community organizing concepts. Each session started with interactive didactic presentations and discussions. Fellows then broke into small groups for community organizing skill-building workshops and extensive coaching.

Coaching of teams and project development.

Each group received coaching from an experienced community organizer coach mentored by Ganz. Coaches assigned to work with 2 fellowship groups supported work on key community organizing practices such as crafting and presenting public narratives; practicing how to hold one-on-one outreach meetings; creating teams with clear purposes, structures, and roles; and developing campaign strategies with goals, tactics, and timelines. Fellows began the fellowship with a proposed project that would address a specific climate-related health problem in their community or clinical practice setting. The groups’ projects (see Supplemental Digital Appendix 1) were the focal points of these skills workshops. Each group also had an additional dedicated hour every month with their coach for further personalized coaching.

Community building exercises.

Another goal was for fellows to develop a sense of purpose, community, and self-efficacy, as well as to reduce a sense of burnout. The effect of community organizing on these domains has been previously described¹⁰ and may increase motivation to attempt solutions-oriented work. We explicitly and repeatedly discussed the overwhelming nature of understanding climate change’s impacts. We also ran self-reflection exercises to give fellows space to articulate the challenges of working on an existential crisis and to create opportunities to find community within the cohort. Nurturing a trusting, egalitarian learning environment was critical to facilitating the safety needed for these discussions in which participants may feel vulnerable.

Evaluation methodology

We obtained fellows’ informed consent to participate in the evaluation. Before the start of the fellowship, we used a 19-item survey (Supplemental Digital Appendix 2) to collect information on fellows’ demographic characteristics and (1) knowledge of climate change and health equity; (2) knowledge of community organizing skills; and (3) sense of community, purpose, self-efficacy, and burnout. After completion of the fellowship, we administered a 57-item survey that contained the same 19 items as the pre-fellowship survey (excluding demographic questions) as well as 38 additional items that assessed the experience of taking the fellowship and its effect on fellows’ future climate work and their home organization. Two of the items included on both the pre- and post-fellowship surveys assessed professional identity formation, a domain not ultimately covered explicitly in the curriculum and therefore not included in this evaluation. A 7-point Likert scale was used for responses to all survey items (1, “strongly disagree,” through 7, “strongly agree”).

We analyzed survey results for 38 of the 40 (95%) participants who completed the pre- and post-fellowship surveys and consented to participate in the evaluation. Likert scale responses were dichotomized by combining “strongly agree,” “agree,” and “somewhat agree” into one category and combining all other responses into another category (“neither agree nor disagree,” “somewhat disagree,” “disagree,” and “strongly disagree”). We used McNemar’s test for paired data in assessing pre- to post-fellowship changes in the proportion of respondents agreeing with statements in each set of paired questions. We considered P values of < .05 to be statistically significant and used descriptive statistics to analyze responses to questions that were only present in the post-fellowship survey. Analyses were performed using Stata version 17.0 (Stata Corp, College Station, Texas).

The Cambridge Health Alliance Review Board Office deemed this project to be exempt from its review.

Outcomes

Demographics

Supplemental Digital Appendix 3, shows the demographic characteristics of the fellowship participants. Of study participants, 31/38 (81.6%) were women, 24/38 (63.2%) were White, 5/38 (13.2%) were Black, 4/38 (10.5%) were Asian, and 3/38 (7.9%) were Hispanic or Latino. Doctors comprised 18/38 (47.4%) of the cohort, 13/38 (34.2%) were nurses, 2/38 (5.3%) were medical students, 2/38 (5.3%) were hospital-based administrators, 1/38 (2.6%) were social workers, 1/38 (2.6%) were respiratory therapists, and 1/38 (2.6%) were nonprofit leaders. Most worked in the Northeast region of the United States (21/38, 55.3%).

Pre- to post-survey changes in knowledge, skills, and attitudes

When assessing pre- to post-fellowship changes, we found improvements in all 17 items, with 11 of 17 achieving statistical significance (Table 2). After the fellowship, a higher proportion of participants reported a good understanding of the historical context of health inequities related to climate change (26/38, 68.4% vs. 37/38, 97.4%; P = .0023), a good understanding of how to put principles of community organizing into practice (12/38, 31.6% vs. 36/38, 94.7%; P < .00), a belief they could make a difference in addressing climate change (32/38, 84.2% vs. 38/38, 100%; P = .01), and an ability to develop effective strategies in their local community to combat climate change (14/38, 36.8% vs. 35/38, 92.1%; P < .00).

Table 2.

Changes in Knowledge, Skills, and Attitudes Pre- to Post-Fellowship in a Survey of Climate Health Organizing Fellowship Study Participants, Center for Health Equity Education and Advocacy at Cambridge Health Alliance, A Harvard Medical School Teaching Hospital, 2022 (n = 38)

Question	Agree,a no. (%)		Point change, %	P valueb
	Pre-survey	Post-survey
Knowledge of climate change and health/health equity
I have a good understanding of the pathways by which climate change can harm human health.	36 (94.7)	38 (100)	5.3	.16
I have a good understanding of the pathways by which climate change can cause racial/ethnic inequities in human health.	36 (94.7)	38 (100)	5.3	.16
I have a good understanding of the pathways by which climate change can cause socioeconomic inequities in human health.	35 (92.1)	38 (100)	7.9	.08
I have a good understanding of the historical context of health inequities related to climate change.	26 (68.4)	37 (97.4)	29.0	.0023c
I have a good understanding of the structural and systemic factors that impact health inequities related to climate change.	30 (78.9)	37 (97.4)	18.5	.0082c
Knowledge of community organizing skills
I have a good understanding of the principles of community organizing.	14 (36.8)	38 (100)	63.2	.00c
I have a good understanding of how to put principles of community organizing into practice.	12 (31.6)	36 (94.7)	63.1	.00c
I believe that community organizing is an effective approach to combating climate change.	33 (86.8)	37 (97.4)	10.6	.0455c
Sense of community, purpose, self-efficacy, and burnout in climate work
I feel isolated from my colleagues in my work to combat climate change.	22 (57.9)	17 (44.7)	−13.2	.20
I feel overwhelmed thinking about my ability to combat climate change.	28 (73.7)	22 (57.9)	−15.8	.13
I feel a sense of meaning and purpose in my climate change work.	36 (94.7)	38 (100)	5.3	.16
I believe I can make a difference in addressing climate change.	32 (84.2)	38 (100)	15.8	.01c
I have a good sense of how I can best contribute to addressing climate change.	24 (63.2)	37 (97.4)	34.2	.003c
I feel a sense of community among my colleagues in addressing climate change.	26 (68.4)	34 (89.5)	21.1	.02c
I am able to develop effective strategies to reduce adverse effects of climate change on people’s health.	19 (50.0)	37 (97.4)	47.4	.001c
I am able to develop effective strategies to combat climate change at my home organization.	18 (47.4)	37 (97.4)	50.0	.00c
I am able to develop effective strategies in my local community to combat climate change.	14 (36.8)	35 (92.1)	55.3	.00c

^a“Somewhat agree,” “agree,” or “strongly agree.”

^bP value calculated using McNemar’s test for paired nominal data comparing “somewhat agree,” “agree” and “strongly agree” responses to all other responses combined.

^cP < .05, statistically significant.

Post-survey participant assessments of the value and impact of the fellowship

Supplemental Digital Appendix 4, reports fellows’ perceptions of the value and effect of the fellowship. A large majority of respondents agreed that the fellowship was valuable (37/38, 97.4%) and well run (37/38, 97.4%). Most also believed that the fellowship increased their knowledge of the connections between climate change and health equity (32/38, 84.2%), enabled them to effectively participate in a community organizing campaign (37/38, 97.4%), and helped them find their role in combating climate change (34/38, 89.5%). In addition, most participants agreed (34/38, 89.5%) that taking this fellowship would increase the capacity and impact of their home climate organization.

Projects

All 12 teams developed climate health community organizing projects (Supplemental Digital Appendix 1) by the end of the fellowship. At our closing event, they invited members of their community to hear a presentation about the launch of their project.

Lessons learned

Our preliminary findings suggested we were largely successful in achieving the goals of the fellowship. Post-fellowship survey responses showed vast majorities of fellows found the program valuable and improved in domains associated with the goals of the fellowship. Pre- to post-fellowship improvements were noted in all domains, with 11/17 items analyzed showing statistically significant improvement. For some of items, high pre-fellowship levels of agreement may have limited the magnitude of post-fellowship improvements that were possible.

Our initial experience and findings highlight that teaching community organizing principles may offer valuable tools for health professionals to address large structural issues such as climate change. Initial findings suggest our pedagogical approaches helped some fellows increase a sense of community, purpose, and self-efficacy, and decrease burnout. Previous studies have suggested these domains are important in activating health professionals to become more engaged in climate action.⁶ An emphasis on personalized coaching may have been effective in helping fellows learn about community organizing and develop their projects. More studies are needed to further analyze these educational approaches. Our findings may be generalizable to other similar training initiatives. To our knowledge, no prior educational initiatives similar to this fellowship have been reported.

Next Steps

We have planned longitudinal, qualitative evaluations of fellowship alumni to assess the durability of the fellowship’s effects on the learner and progress on their projects. This separate assessment will address limitations to this evaluation, which include a small sample size and a lack of long-term analysis of the fellowship’s impact.

We plan to offer the fellowship yearly and expect to lengthen it to allow for greater discussion and community building exercises. Fellows informally told us during fellowship that they desired more time to debrief learning with the rest of the fellowship cohort. We plan to offer long-term programming for alumni of the fellowship 3–4 times a year to provide skill refresher workshops and sustain the community.