Institute on Healthcare Systems

Assessing Proven Relational Approaches to Social Transformation

We began this Relational Society Project by interviewing subject matter experts and studying the scholarship of early influencers identified through a snowball sampling methodology. See Appendix A for a list of those individuals. In these interviews and in our readings, we sought to identify models of social change that appeared to be based on relational society concepts. We carried out these interviews using the script shown in Appendix B.

Models were then chosen for further consideration based on three criteria. First, multiple components of the model were consistent with the relational society idea. Second, the model had strong theoretical and research underpinnings. Third, the model was affiliated with people with strong credentials in their area of practice. The selected models are summarized below in Table 1.  

The message that echoed throughout our interviews and subsequent research was consistent with observations shared with us by our first interviewee, Dr. Jack Shonkoff (Shonkoff, 2019). Dr. Shonkoff, a former dean of the Brandeis Heller School and an academic pediatrician, is currently the Director of the Harvard Center on the Developing Child. The Center focuses on using the cutting edge of research in neuroscience to innovate in the early childhood field and fundamentally change the lives of children facing adversity from intergenerational trauma and toxic stress in their parents’ lives. After listening to our initial vision and rationale, he observed that the Relational Society Framework has the potential to be a “very powerful” conceptual framework and that it “totally resonates.”  

“The challenge is that very committed people have been doing this... There is rhetoric that we have evidence.  However, it has been modest, not replicable, not scalable... The amount of progress has been very small... Disparities persist.”

In short, he argued, while it is true that committed researchers and practitioners have been working on a range of issues similar to ones proposed under the relational society project, no single initiative in the United States currently spans working on a range of issues similar to ones proposed under the relational society project, and no single initiative in the United States currently spans the wider conceptual arc of the Relational Society Framework. For example, the cutting edge innovations being developed by the Harvard Center on the Developing Child and their partner sites in the United States (The Washington Innovation Cluster) and abroad (The Alberta Family Wellness Initiative in Canada, and more recent clusters in Brazil and Mexico) are limiting their focus on the impact of psychological trauma on children’s brain development and brain-deficit related behavior. While these experiments do study the psychosocial factors associated with long-term personality and behavioral traits, they do not comprise the wider social environment as it pertains to early childhood developments and its causal pathways downstream in an individual child’s later years. Another missing element in these experiments is the multi-level, multi-dimensional relationality that is integral to our proposed study design.

In our subsequent interviews and readings, we have observed much of what Dr. Shonkoff described above.  In particular, we observe a similar absence of relationality in otherwise highly admirable work. Professor Mariana Chilton (2019), who is currently writing a book “close to [our relational society project] ideas,” said she “loves the framework and ideas” and thought it to be a “fantastic” project. Professor Chilton’s exemplary research focuses on poverty and child hunger especially among populations marginalized due to race, gender, Native American ethnicity, trauma, and exploitation of our natural resources in America. Relationality is not mentioned or developed. In the context of Relational Society, Chilton introduced us to scholarly work on indigenous philosophy on human coexistence with each other and with nature by Professor Robin Wall Kimmerer (2013). This work by Kimmerer includes relationality but a model of social change is not developed. We therefore do not include her work as one of the models in our table yet wanted to note its theoretical relevance for the Relational Society Framework, particularly its emphasis on the relationship between humans and the earth.

Another example of the absence of multi-level, multi-dimensional relationality is a pioneering model of assessing non-medical needs, or lived social realities, of patients in outpatient settings by Rebecca Onie, the founder of Health Leads. As an undergraduate student volunteer at the Boston Medical Center, Onie began with the idea of a “food prescription” after an otherwise healthy young patient presented with unexplained weight loss who happened to have gone hungry for lack of food, hunger was identified as the root cause of his weight loss as an incidental finding when someone in the practice thought of asking him whether he was hungry. This incident, described by Onie in her Ted Talk (2012), led to her building a low-cost, replicable model that melds the aspirations of college students and the unmet needs of health care institutions to address the link between poverty and poor health, and eventually the establishment of Health Leads. While the Health Leads model addresses social needs in a healthcare setting, it does not seek to build relationships or community by intention or design.

ReThink Health, a Rippel Foundation Initiative, is driven by the maxim that the dominant paradigm incorrectly assumes that health is produced when we pay for health care. The organization has designed a Local Health System Dynamics Model, a computer-based simulation that anticipates how a health system in a specified geographic area might respond to changes in its “Well-being Strategy Portfolio.” With technical assistance and other support from ReThink Health, local health system stewards, people or institutions, can use the simulation model to drive transformational change in the health and well-being of individuals or communities served by them.

While we recognize its design sophistication as well as its broader emphasis on social determinants of health, this model has at least two limitations in our assessment. First, the assumptions about the behavior of certain population-level variables may not be valid a priori or generalizable. Secondly, as is applicable to many similar simulation models, it may not be resilient or adaptable enough to capture real-life individual decisions made in real time in dissonance with decision-making patterns built into the simulation. Finally, we wonder about the effectiveness of the model in building robust, enduring person-to-person human relationships within a community.

Among the models we analyzed, the one that comes closest to our vision of a Relational Society is Hilary Cottam’s trailblazing work on unleashing the power of people’s untapped capabilities in high-risk vulnerable communities through the hard work of relationship-building one-one-one, often one community at a time, enabling agency and self-actualization for individuals living in despair on the margins of the society with support from England’s public welfare systems designed for restoration in the aftermath of World War II. Cottam’s community-based model of social transformation is grounded in empathetic listening for health and social care needs through the eyes of the care recipients, by one-on-one relational engagement with their lived realities in their own dwellings, and helping them realize their own capabilities in the context of these lived realities. Relationality is thus central to her model.  

At the same time, Cottam’s model argues that no matter how strong the will for change, or the power of the rhetoric behind a transformative approach, it will ultimately fail unless the technologies and programs through which participants are engaged are aligned with the 21st century era and its realities. Thus, the argument is that relationality can thrive in our current technologically intensive environment, if one-on-one human connections are intentionally kept at the center of everyday living, with technology used not to replace but rather to facilitate relationships. Outcome metrics must be changed as well.  Even when the need to grow and develop people’s capabilities is understood, if the success of a service remains determined by system-focused outcomes, rather than by capabilities grown; or when metrics emphasize costs saved rather than resources unlocked, then that service will be forced to continue to deliver in dehumanizing and disempowering ways and deep meaningful change will not be realized.

Cottam’s Participle Initiative, established over ten years ago, was at the forefront internationally of measuring capability growth at a personal level as well as understanding the wider systemic measures of success that are needed to fully embed a capability approach across public services. In sum, people in despair should be helped to build their own capabilities through an empathetic relational approach, thus enabling them to spread this approach through their own community connections. Organizations and their service delivery models must be designed to support this fundamentally relational approach. Cottam’s Participle model is thus a multi-level, multi-dimensional model of change, much more so than the other models we explored.

There is no better way to reflect on the powerful essence of the relational social transformation unleashed by Cottam’s vision and hard work than the words of Tara herself, a mother with troubled school-age children living in public housing in London’s Swindon locality and Cottam’s first community partner over ten years ago: 

“Whoever reads this, tell them not to feel sorry for me - that’s not what it’s about. I have to start changing things for the better and for the kids, too. Things are looking good already. Things need to change so that it doesn’t all happen to other people, too.” (Cottam, 2018).   

In conclusion, it is worth noting that the Relational Welfare model from Denmark has been seeking to solve many of the same issues that inspired Cottam’s early work, focused in Denmark on the municipalities through which social welfare is delivered. The Relational Welfare model has been heavily influenced by Cottam, and vice versa.

Table 1: Major Models of Relational Health and Social Transformation

Frontiers of Innovation - Harvard Center on the Developing Child - Boston, MA, USA: Jack Shonkoff 

Washington State Innovation Cluster - USA

Alberta Family Wellness Initiative - Canada

Participle - United Kingdom: Hilary Cottam 

Center for Hunger-free Communities - Philadelphia, PA, USA: Mariana Chilton

ReThink Health - Cambridge, MA, USA; Foresight - New Jersey, USA: The Rippel Foundation Health Initiatives

Health Leads - Boston, MA, USA: Rebecca Onie

Children’s Neighbourhoods - Scotland, U.K.: Claire Bynner

Relational Welfare - Joint Action Analytics, Denmark: Jacob Storch

Appendix A: Representative List of Subject Matter Experts and Influencers 

Dr. Jack Shonkoff, Director of the Harvard Center on the Developing Child; Former Dean of Brandeis Heller School (August 14)**

Dr. Charles Homer, Chief of Improvement Evaluation, EMPath Boston; DAS, Children’s Health Policy US-HHS under the Obama administration; Founding President and CEO of National Initiative for Children’s Healthcare Quality (August 15)**

Dr. Mariana Chilton, Professor Drexel Dornsife School of Public Health and Director of the Center for Hunger-Free Communities; Co-PI for the multi-site national Children’s HealthWatch research network (August 16)**

Dr. Marshall Ganz, Senior Lecturer in Leadership, Organizing, and Civil Society, Harvard Kennedy School of Government** 

Dr. Michael Rustin, Dean of Social Sciences, University of East London, UK*

Hilary Cottam, Innovator and Social Entrepreneur, UK; Author of Radical Help: How We can Remake the Relationships Between Us and Revolutionize the Welfare State (2018)*

Dr. Dolores Acevedo-Garcia, Professor of Human Development and Social Policy, Brandeis Heller School*

Dusan Stojicic, Brandeis Heller School; Leadership Development Coach, WeOwnIt**

Laurie Burnett, Education Consultant, Assabet Valley Collaborative **

Dr. Pedja Stojicic, Project Director, Rethink Health and the Rippel Foundation**

Bryan Stevenson JD, Founder and Executive Director, Equal Justice Initiative; Author of Just Mercy (2014)*

Dr. Virginia Eubanks, Professor SUNY Albany; Author of Automating Inequality (2018); Co-founder of Our Power, Our Knowledge 

Dr. Claire Bynner, Research Team Lead, Children’s Neighbourhood Network, University of Glasgow UK*

Sir Harry Burns, Professor Global Public Health, University of Strathclyde, Scotland UK

Dr. Robert Putnam, Professor of Public Policy/Harvard; Author of Bowling Alone (2000), Our Kids (2015)

Dr. Vivek Murthy, Former Surgeon-General, US 

Dr. David Weil, Dean, Brandeis Heller School

Thomas Piketty, Capital in the Twenty-First Century (2013)

Elinor Ostrom (deceased, 2012), Governing the Commons (1990), Nobel Laureate 2009  

Prof. John Rawls (deceased, 2002)

Prof. Michael Sandel

*One-on-one outreach in August/September 2019
**One-on-one meetings in August/September 2019

Appendix B: Script for Interviewing Subject Matter Experts 

Dear Colleague,

Many thanks for making the time for our upcoming meeting. I am sharing these few documents with you for background (please see attached; cited below in blue italics). 

The first is the small grant proposal I wrote to a private family foundation this past May and was funded for the Relational Society project

As I had mentioned in my introductory email, I am collaborating as co-PI with Jody Hoffer Gittell on this study. I have been following Jody’s scholarship on Relational Coordination for many years with absolute delight. Attached is her book chapter New Directions for Relational Coordination Theory published in the Oxford Handbook of Positive Organizational Scholarship.  

The 2013 essay, A Relational Society by Michael Rustin (UK), inspired me to think about the delivery of health and social care services from a new paradigm. It was hard for me to miss the potential synergy between the two constructs – Rustin’s Relational Society, and Jody’s Relational Coordination theory. The other article, The Economy We Need by Joseph Stiglitz, gave me further grounding to think it through.  

Given this backdrop, here is a snapshot of my thought process, for steering our conversation:

  • We human beings, while autonomous, are social beings and, therefore, individual freedom and choice cannot be sustained outside of the wider social context 

  • We are a product of our opportunities and consequently our global environment

  • Our health and well-being are highly interdependent and, therefore, we need strong social foundations and frameworks that are both equitable and balanced, as well as resilient

  • Given the many dire challenges we face as a society, the status quo is untenable 

  • In the absence of political will and corporate apathy, and despite the enormity of challenges, a relational society approach is our immediate and most viable hope

  • So, where can we start, and how do we operationalize the relational society construct into practice? 

    • Where? – Specific high-needs population/s, such as children and families with poor health status and chronic special needs due to “toxic stress” from insecure income, housing, food and nutrition, parenting, domestic life, neighborhoods, schooling, perinatal or intergenerational trauma, and/or access to primary and specialty care      

    • How?

      • Design a robust model of relational action from the population’s perspective, the population’s perspective being NOT perceived needs but their “lived reality,” 

      • That upends the emphasis on managing scarcity to building capacity through human connections and value-based problem-solving,

      • The values being empathy as in John Rawls’ Original Position (Attached – Page 212, A Theory of Justice), passionate humility, mutual trust and respect, clear shared goals, shared knowledge, multi-dimensionality, and distributed leadership, with various stakeholders coming together in this social coproduction process as parts of the whole.    

    Appendix C: Selected Resources for Health-Related Social, Emotional, and Structural Needs Assessment

    Micro:  Comprehensive Needs Assessment

    • Health Leads Living Conditions/Social Needs Assessment Tool  
    • The CDC-Kaiser Adverse Childhood Experiences Survey  
    • CMS Accountable Health Communities Health-Related Social Needs (AHC-HRSN) Screening Tool (10-item Core questionnaire; with eight supplemental domains)   
    • Core Questionnaire (10 items)
         Housing Stability
         Food Insecurity
         Transportation Needs
         Utility Support Needs
         Interpersonal Safety
    • Supplemental Domains (26 items, ranging 1-3 questions per domain)
         Family and community support
         Physical activity
         Substance use
         Mental health
    • Assessment of Self-Determination (Williams GC et al, 2011) 
         Autonomous Self-regulation
         Perceived Competence
         Perceived Need Support from Health Care Practitioners
         Perceived Need Support from Important Others 

    Meso: Relational Coordination

    • Relational Coordination Survey Tool (7 Dimensions)
         Frequent communication
         Timely communication
         Accurate communication
         Problem solving communication
         Shared goals
         Shared knowledge
         Mutual respect

    Macro: Social Policy Design, Stakeholder Alignment, and Public Policy Framework   

    • Healthier and More Equitable Communities (36 Measures of Health, Factors That Shape Health, and Drivers of Health Equity for Local Solutions: City Health Dashboard, 2018)a
    • Public Health (10 measures)
    • Social and Economic Factors (10 measures)
    • Health Behaviors (5 measures)

    • Physical Environment (6 measures)

    • Clinical Care (5 measures) Stakeholder Alignment Assessment (Cutcher-Gershenfeld, J et al, 2012)

    • Comparative Evidence-Base on Societal Impact of Public Policies (Kawachi I & Kennedy BP, 2006; Newman KS, et al 2011)
         Health and Social Policy
         Firearms and Public Safety
         Law and Criminal Justice

“The challenge is that very committed people have been doing this... There is rhetoric that we have evidence.  However, it has been modest, not replicable, not scalable... The amount of progress has been very small... Disparities persist.”