The Health Tree Metaphor and the Importance of Shared Language

Introduction

Dismantling structural and systemic racism is an essential part of promoting health equity and improving health outcomes. Yet the meaning of these nuanced concepts can differ depending on a person’s identities and lived experiences. We must develop a mutual understanding to operationalize these concepts so that they can inform both the day-to-day work and support the long-term vision. Doing so creates a shared language that can foster trust and build strong relationships among partners working to advance health equity.

In this piece, we share an example of how the work of creating shared language and understanding has been approached through one of our projects—the Massachusetts Community Health and Healthy Aging Funds (The Funds). In addition, we share a tool and guidance developed by the project team to help facilitate these conversations in a way that also promotes shared ownership of the work among partners.

The Massachusetts Community Health and Healthy Aging Funds

The Funds is a collaboration between the Massachusetts Department of Public Health (DPH) and Health Resources in Action (HRiA). This program is explicitly designed to disrupt and remove barriers to health, including structural and institutional racism, poverty, and deep power imbalances in the Commonwealth of Massachusetts. As the Funds’ fiscal agent, HRiA is responsible for managing the planning and implementation of the program including developing requests for proposals, providing technical assistance to grantees, measuring success of the program, and more. DPH oversees and makes final decisions regarding the Funds with support from the Executive Office of Elder Affairs (EOEA), which provides guidance and expertise and makes decisions regarding the Healthy Aging Fund. We also engage a statewide advisory committee to provide recommendations for the operations of the Funds. Led by Managing Director Alberte Altiné-Gibson, HRiA provides resources to groups throughout the Commonwealth that improve health outcomes through community-centered policy, systems, and environmental change approaches.

“Coming onto the team, I was immediately struck by how engaged and passionate the HRiA team, awardees, DPH, and EOEA were in doing this work.  Being intentional in how we do the work, how we talk about the work, and respecting and working closely to understand the experiences and perspectives of those doing the work at every stage of this intricate project demonstrates the core values of all involved in advancing healthy equity at its core.”  -Alberte Altiné-Gibson, Funds Director

HRiA’s Role

As stewards of these resources, we have a responsibility to tackle the root causes of health inequities., “The intentional allocation of investments to tackle systemic racism – which is entrenched in white supremacy culture,” explained Nineequa Blanding, former Vice President of Grantmaking at Health Resources in Action, in this 2020 blog post, “is a way to drive progress in creating conditions in which everyone, across all forms of identity, can thrive. This is the path toward health and racial equity.”

Disrupting structural and institutional racism throughout Massachusetts cannot be accomplished without strong collaboration. It requires a connected statewide movement of partners working toward a shared goal. This work requires these partners to develop a shared language and mutual understanding to ground and guide the work. One way the Funds team does this is by using the Health Tree. This visual metaphor is used by Human Impact Partners and other public health and social justice organizations to demonstrate the connection between health outcomes and their root causes.

The Evolution of the Health Tree

The health tree metaphor was a helpful tool to ground the development of our funding strategy in 2020, which focuses on funding efforts to disrupt and remove barriers to health including structural and systemic racism through transforming policies, systems, and environments. However, our team recognized a need and opportunity to update its graphic and written elements to better elicit the connection between health outcomes, social determinants of health, root causes, and white dominant culture.  We worked on a revision that made these connections explicit, better reflecting our shared values and unique contributions. Shared language must be established collaboratively, so our team sought wide ranging feedback and used a decision-making approach called the gradient of agreement to determine the final product. The approach employs wider range of responses than ‘yes’ or ‘no,’ helping team members and other stakeholders offer honest feedback and collectively reach a decision. The resulting version of this visual is called the Health EquiTREE.

The Health EquiTREE illustrates the relationship between health outcomes and the root causes of health inequities. It helps us envision how systems impact outcomes of individuals and groups. The framework below provides context to improve understanding of the tree metaphor.

The Health EquiTREE, an illustration of a tree, including leaves, branches, roots, and soil, each labeled to visualize the connection between the soil and the leaves

Understanding the Health EquiTREE

Below are descriptions of each part of the tree and how they map onto our understanding of the relationships among health outcomes and systems. The elements of the tree that are above ground (leaves, branches, and trunk) represent the components of health that are visible.

  • LEAVES – The leaves of the tree represent health outcomes. These include the physical and mental health of individuals and populations.
  • BRANCHES Health behaviors such as diet and exercise influence an individual’s risk of poor health outcomes. While individuals can make lifestyle changes to improve their health, it’s important to consider the factors that influence their ability to engage in healthy behaviors.
  • TRUNK – Certain conditions influence people’s ability to engage in healthy behaviors. Social determinants of health (SDOH) such as education, employment, and housing are the environmental conditions in which people live, learn, work, play, worship, and age. These conditions affect a wide range of health, functioning, and quality-of-life outcomes and risks.

As noted in the illustration, the tree does not just exist above ground. There are critical components that exist underground (roots and soil) and cannot be easily seen.

  • ROOTS – When we think about making lasting changes in the social determinants of health, we need to think about what created these conditions in the first place. How do policies and systems impact these conditions? The tree graphic highlights some of these root causes of health, including racism, poverty, ageism, and other structural and institutional barriers.
  • SOIL – The underlying systems of dominant culture and narratives are represented by the soil in which the tree stands. Dominant culture is “the culture that has been able, through economic, social, or political power, to impose its values, language, and ways of behaving on other cultures” (Integrative Inquiry). Like the soil surrounding the root system, dominant culture and narratives can often be nearly invisible given its position as “normal.” Through this work, we acknowledge and aim to dismantle white supremacy culture and narratives, which have tainted the soil, and restore it to a healthy, diverse, sustainable state of being. In this metaphor, healthy soil leads to healthy roots, trunk, branches, and leaves. (This conceptualization of the soil dovetails with another metaphor described in the Groundwater Approach by the Racial Equity Institute.)

The tree metaphor is designed to visualize how underlying systems, root causes, social determinants, and health outcomes are integral parts of a health ecosystem. Inequities in health outcomes and social determinants are a direct result of deeply rooted systems of oppression—policies, systems, and environments—and the culture and narratives in which they are steeped. The overlapping network of tree roots is an intentional design element illustrating the complexity of these influences that we must grapple with and embrace through our work to transform our communities.

Using the Health EquiTREE

Our Health EquiTREE is just one tree in a forest of interpretations. To support our partners in facilitating their own conversations, we created a blank version of the tree and some accompanying guidance on how to use it to evaluate the root causes of specific health outcomes. This exercise can help:

  • Build understanding of embedded concepts,
  • Brainstorm upstream approaches to address certain health outcomes, or
  • Identify the niche where the work would have the greatest impact.

As another example of its use in the field, HRiA’s Research & Evaluation team has used it to facilitate discussions with communities as a part of a Community Health Needs Assessment. This process helps a group identify key health needs and issues in a community. Our colleagues report that the Health EquiTREE has been useful in guiding discussions, informing analysis and interpretation of findings, and drawing attention to less visible causes of inequities.

Building on the context above, we offer this guidance on how to use the tree in your own discussions.

  • Begin with the leaves. When using the tree to discuss the overarching idea of health outcomes being a product of social determinants of health and root causes OR when using the tree to explore a specific health outcome affecting a community and potential solutions, work backwards, starting with the leaves and moving down the tree to the roots.
  • Be open-minded. A key element of effective brainstorming is saying yes. When exploring the many different factors that contribute to health outcomes, be willing to consider the range of potential factors related to the problem you are discussing. Then, narrow down as needed to achieve the goal of your exercise, whether it be finding your niche to create a solution, identifying an area to advocate for policy change, etc.
  • Imagine. Visualize what a healthy tree might look like for your particular situation. Put them side by side if it’s helpful for your group.
  • Revisit. Return to the tree as needed to monitor progress on a particular issue, reconsider or build your understanding of a particular issue, or to contemplate alternative approaches.

Conclusion

The Health EquiTREE is a powerful visual and exercise to help build shared understanding and shared language around foundational health equity concepts. Yet this exercise is only the beginning of a continuous process of learning and evolving together. The collective work that facilitates its development also serves as a pathway for deeper understanding and stronger connections. The way in which we communicate and the language we use as we learn with and from each other is key to effectively advancing our collective work. We have a responsibility to continue conversations that build trust and increase our understanding of one another and our varied experiences of health inequities.

If you would like to learn more about the Massachusetts Community Health & Healthy Aging Funds, please visit our website at mahealthfunds.org.

To download completed and blank versions of the Health EquiTREE, navigate to mahealthfunds.org/resources.  If you use the tree, please share your experience by contacting MACHHAFunds@hria.org. Please use the following attribution as appropriate:

The Health EquiTREE (2022), illustration by Health Resources in Action for the Massachusetts Community Health and Healthy Aging Funds. https://mahealthfunds.org/resources/

Acknowledgements

Many thanks to The Funds team—past and present—involved in updating and refining the tree illustration – Abby Atkins, Hannah Carliner, Jamiah Tappin, Jennifer Lee, Kevin Myers, Mayowa Sanusi, Nineequa Blanding, Pri Rana. Thank you to our colleagues at HRiA including Mo Barbosa and Brittany Chen, and our collaborators at DPH for their input. And to talented illustrator Chris Ariñez for patiently working with us to design the tree.

We thank the many organizations and people who have pushed these conversations forward: Integrative Inquiry, Human Impact Partners, Racial Equity Institute, including authors of the Groundwater Approach (Bayard Love and Deena Hayes-Greene) – and Dr. Camara Phyllis Jones’s whose insights inspired the Groundwater Approach and who inspires us.