The Journal of Extension -

June 2018 // Volume 56 // Number 3 // Ideas at Work // v56-3iw1

Bringing Family Voice to Determinants of Health

The Family Leadership Training Institute (FLTI) is a program that can respond to data documenting the health of the nation. Participants engage in individual civic projects that align with social determinants of health and seek to ameliorate health inequities. They also discover and/or increase their civic engagement skills to more effectively take part in policy and implementation discussions and decisions. With roots in Colorado, FLTI continues to expand into rural and urban communities throughout the state. The curriculum has been translated into Spanish, and a two-generation pilot implementation has indicated promise for including youths in a parallel program. Documentation regarding program effectiveness suggests that others in Extension may benefit interested communities by assisting them in replicating FLTI.

Jan B. Carroll
Director, Civic and Federal Engagement
Colorado State University Extension
Fort Collins, Colorado

Kyle Christensen
Program Coordinator
Colorado State University Extension
Fort Collins, Colorado

David MacPhee
Professor Emeritus, Human Development and Family Studies
Colorado State University
Fort Collins, Colorado

Patti Schmitt
Assistant Program Coordinator
Colorado State University Extension
Fort Collins, Colorado

Health Statistics

Seeing the annual report on the health of the nation (Centers for Disease Control and Prevention, 2017) can cause one to consider how trends emerging in cigarette smoking, prescription drug use, expenditures for hospitals and home health care, and other areas relate to health in one's family, community, and state and the nation as a whole. In addition, Extension professionals in particular may consider how can these data help drive decisions on program selection and implementation in communities. Andress and Fitch (2016) discussed ways that communities might integrate nutrition, health, environment, agriculture systems, and health policy issues to help individuals increase their health literacy, chronic disease prevention and management, health insurance literacy, and positive youth development efforts. The program we describe in this article is just such an endeavor.

Family Leadership Training Institute

In conjunction with families and other civic leaders in the state, we adapted the Parent Leadership Training Institute (National Parent Leadership Institute, 2016) to create the Family Leadership Training Institute (FLTI) of Colorado. FLTI is a learning experience that equips families with knowledge and skills to support their engagement with systems at the individual, community, and policy level. Grounded in the core values of partnership, dignity, and cultural respect, FLTI supports family and community leaders in understanding and using the tools of democracy so that they can contribute to policies and program changes for the health and well-being of children, families, and communities. The implementation of FLTI successfully brings family voice into community decision making. Urban and rural communities are replicating the model, and since 2009, more than 1,000 participants have graduated from the program in Colorado.

FLTI trainings bring together family leaders from diverse backgrounds and with diverse life experiences so that they may gain insights about the civic process and enhance their leadership competencies. Although many if not most issues explored in FLTI involve health and wellness, there is no singular special-interest policy agenda underlying FLTI. The goal is to dignify the role of grassroots leaders in communities and government by developing their leadership capacity. Participants acquire the civic tools necessary to address social determinants of health and health inequities of concern. The focus is on positive and transformational leadership and cocreation of solutions to a community's most difficult challenges.

Target Audience

FLTI participants attend at no cost, so there are no financial barriers to participation. FLTI's leaders also actively recruit participants from Colorado's vulnerable and marginalized populations, and each training cohort truly reflects the diversity of Colorado's population spectrum. Participants include youths, cohabitating parents, single parents, grandparents, aunts, uncles, stepparents, foster and adoptive families, community leaders, and others wanting to improve outcomes for children and families. They are racially and ethnically diverse (Figure 1) and have varying educational backgrounds (Figure 2), employment situations, and incomes.

Figure 1.
Races and Ethnicities of Family Leadership Training Institute Participants

Figure 2.
Highest Levels of Education Completed by Family Leadership Training Institute Participants

Program Delivery Methods

Once accepted into the program, emerging family and community leaders participate in a 20-week curriculum that integrates personal and child development, leadership training, civic literacy, and participation skills. The curriculum has these components:

  • community-building retreat;
  • two 10–week sessions focused on change processes, leadership skill building, and civic engagement tools; and
  • personally inspired civic projects.

Social Determinants of Health and Health Equity

What are the factors influencing people's health? The World Health Organization (WHO) (n.d.-b) has indicated that "the social determinants of health are the conditions in which people are born, grow, live, work and age" and that "these circumstances are shaped by the distribution of money, power and resources at global, national and local levels" ("About Social Determinants of Health"). Furthermore, the WHO (n.d.-b) states that "the social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries" ("About Social Determinants of Health"). Findings from an evaluation of FLTI demonstrate that the program is a viable approach to enhancing community well-being and moving the needle on social determinants of health (MacPhee, Forlenza, Christensen, & Prendergast, 2017).

Social determinants of health frequently are linked to indicators of health equity or health inequities. The WHO (n.d.-a) describes this linkage as follows:

A characteristic common to groups that experience health inequities—such as poor or marginalized persons, racial and ethnic minorities, and women—is lack of political, social or economic power. Thus, to be effective and sustainable, interventions that aim to redress inequities must typically go beyond remedying a particular health inequality and help empower the group in question through systemic changes, such as law reform or changes in economic or social relationships. ("Equity," para. 3)

FLTI Civic Projects and Skills

FLTI is an empowerment program focused on systems change (MacPhee et al., 2017) and so should redress health inequities. Content analysis of FLTI participants' civic projects documents their alignment with social determinants of health (Table 1). Nearly 80% of graduates' civic projects were organized around endeavors that align with social determinants of health, including awareness of health equity issues.

Table 1.
Health Foci of Family Leadership Training Institute Graduates' Civic Projects

Project topic %
Preventive health 43
Child development 37
Healthful living 21
Health care 14
Prosocial development 12
Health coverage 3
Focus on at least one of the above topics 76

Also, pretest and posttest data have demonstrated that participants gain the key civic engagement skills that are fundamental to being agents of change for improving communities' health and well-being statuses (Table 2).

Table 2.
Improvements in Family Leadership Training Institute Graduates' Civic Engagement Skills

Civic engagement skill %
Able to be a change agent for their families 82
Understand role in changing communities 81
Know what to do about community problems 70
Able to work with community professionals 70
Able to get information about community issues 69


For more than 25 years, organizers of the National Parent Leadership Institute and others have implemented programming to increase opportunities to include the family voice in discussions of health and health disparities. In Colorado, administration of an associated initiative relocated from the Colorado Department of Public Health and Environment to Colorado State University Extension in 2016. FLTI has consistently experienced expansion. Through 2017, FLTI had occurred in 11 Colorado communities and provided training to 13 cohorts. We project that by the end of 2018 FLTI will be in 14 communities and will have facilitated as many as 22 cohorts. At two sites, a two-generation training that includes youths is being pilot tested, and at some sites, the FLTI training is delivered in monolingual Spanish. Colorado State University Extension provides interested communities with community readiness and implementation guidance and technical assistance resources ( Others working in Extension can assist interested communities in successfully replicating FLTI and support the creation of a pipeline that brings the family voice to the forefront of discussions about health determinants and health equity for individuals, families, and communities.


This material is based on work that is supported in part by the National Institute of Food and Agriculture, U.S. Department of Agriculture, under award number 2013-41520-21275. FLTI is adapted with permission from the National Parent Leadership Institute ( Historical foundation in Colorado is due to work at the Colorado Department of Public Health and Environment. Funding from The Colorado Health Foundation supports statewide technical assistance and training, and some local sites.


Andress, L., & Fitch, C. (2016). Rural health inequities and the role of Cooperative Extension. Journal of Extension, 54(3), Article 3FEA4. Available at:

Centers for Disease Control and Prevention. (2017). Health, United States, 2016. Retrieved from

MacPhee, D., Forlenza, E., Christensen, K., & Prendergast, S. (2017). Promotion of civic engagement with the Family Leadership Training Institute. American Journal of Community Psychology, 60, 568–583. doi:10.1002/ajcp.12205

National Parent Leadership Institute. (2016). The PLTI curriculum. Retrieved from

World Health Organization. (n.d.-a). Health systems. Retrieved from

World Health Organization. (n.d.-b). Social determinants of health. Retrieved from