Section 1. Designing Community Interventions

Learn how to develop a program or a policy change that focuses on people's behaviors and how changes in the environment can support those behaviors.

 

Adapted from "Conducting intervention research: The design and development process" by Stephen B. Fawcett et al.

You've put together a group of motivated, savvy people, who really want to make a difference in the community. Maybe you want to increase adults' physical activity and reduce risks for heart attacks; perhaps you want kids to read more and do better in school. Whatever you want to do, the end is clear enough, but the means--ah, the means are giving you nightmares. How do you reach that goal your group has set for itself? What are the best things to do to achieve it?

Generally speaking, what you're thinking about is intervening in people's environments, making it easier and more rewarding for people to change their behaviors. In the case of encouraging people's physical activity, you might provide information about opportunities, increase access to opportunities, and enhance peer support. Different ways to do this are called, sensibly enough, interventions. Comprehensive interventions combine the various components needed to make a difference.

What is an intervention?

But what exactly is an intervention? Well, what it is can vary. It might be a program, a change in policy, or a certain practice that becomes popular. What is particularly important about interventions, however is what they do. Interventions focus on people's behaviors, and how changes in the environment can support those behaviors. For example, a group might have the goal of trying to stop men from raping women.

However, it's clearly not enough to broadcast messages saying, "You shouldn't commit a rape." And so, interventions that are more successful attempt to improve the conditions that allow and encourage those behaviors to occur. So interventions that might be used to stop rape include:

• Improving street lighting to make it easier to avoid potential attackers
• A "safe ride" program giving free rides so people don't need to walk alone after dark
• Skills training on date rape and how to avoid it, so that women will practice more careful decision making on dates with men they don't know well, especially in regard to using alcohol and drugs
• Policy changes such as stronger penalties on people who commit rapes, or that simplify the process a rape victim must go through to bring the perpetrator to justice

Why should you develop interventions?

There are many strong advantages to using interventions as a means to achieve your goals. Some are very apparent; some possibly less so. Some of the more important of these advantages are:

• By designing and implementing interventions in a clear, systematic manner, you can improve the health and well-being of your community and its residents.
• Interventions promote understanding of the condition you are working on and its causes and solutions. Simply put, when you do something well, people notice, and the word slowly spreads. In fact, such an intervention can produce a domino effect, sparking others to understand the issue you are working on and to work on it themselves.

For example, a grade school principal in the Midwest was struck by the amount of unsupervised free time students had between three and six o'clock, when their parents got home from work. From visiting her own mother in a nursing home, she knew, too, of the loneliness felt by many residents of such homes. So she decided to try to lessen both problems by starting a "Caring Hearts" program. Students went to nursing homes to see elders after school once or twice a week to visit, play games, and exchange stories.

Well, a reporter heard about the program, and did a feature article on it on the cover of the "Community Life" section of the local newspaper. The response was tremendous. Parents from all across town wanted their children involved, and similar programs were developed in several schools throughout the town.

• To do what you are already doing better. Finally, learning to design an intervention properly is important because you are probably doing it already. Most of us working to improve the health and well-being of members of our community design (or at least run) programs, or try to change policies such as local laws or school board regulations, or try to change the things some people regularly practice. By better understanding the theories behind choosing, designing, and developing an intervention, you will improve on the work you are currently doing.

When should you develop an intervention?

It makes sense to develop or redesign an intervention when:

• There is a community issue or problem that local people and organizations perceive as an unfilled need
• Your organization has the resources, ability, and desire to fill that need, and
• You have decided that your group is the appropriate one to accomplish it

The last of these three points deserves some explanation. There will always be things that your organization could do, that quite probably should be left to other organizations or individuals. For example, a volunteer crisis counseling center might find they have the ability to serve as a shelter for people needing a place to stay for a few nights. However, doing so would strain their resources and take staff and volunteers away from the primary mission of the agency.

In cases like this, where could does not equal should, your organization might want to think twice about developing a new intervention that will take away from the mission.

How do you develop an intervention?

So, people are mobilized, the coffee's hot, and you're ready to roll. Your group is ready to take on the issue--you want to design an intervention that will really improve conditions in the area. How do you start?

Decide what needs to happen

This could be a problem that needs to be solved, such as, "too many students are dropping out of school." However, it might be also a good thing, and you want to find a way to make more of it happen. For example, you might want to find a way to convince more adults to volunteer with school-aged children. At this point, you will probably want to define the problem broadly, as you will be learning more about it in the next few steps. Keep in mind these questions as you think about this:

• What behavior needs to change?
• Whose behavior needs to change?
• If people are going to change their behavior, what changes in the environment need to occur to make it happen? For example, if you want people to recycle, you'll have much better results if there is easy access to recycling bins.
• What specific changes should happen as a result of the intervention?

You don't need to have answers to all of these questions at this point. In fact, it's probably better to keep an open mind until you gather more information, including by talking with people who are affected (we'll get to that in the next few steps ). But thinking about these questions will help orient you and get you geared in the right direction.

Use a measurement system to gather information about the level of the problem

You will need to gather information about the level of the problem before you do anything to see if it is as serious as it seems, and to establish a standard for later improvement (or worsening).

Measurement instruments include:

• Direct observations of behavior. For example, you can watch whether merchants sell alcohol to people under the age of 21.
• Behavioral surveys. For example, the Youth Risk Behavior Survey of the U.S. Centers for Disease Control and Prevention asks questions about drug use, unprotected sexual activity, and violence.
• Interviews with key people. For example, you might ask about changes in programs, policies, and practices that the group helped bring about.
• Review of archival or existing records. For example, we might look at records of the rate of adolescent pregnancy, unemployment, or children living in poverty.

The group might review the level of the problem over time to detect trends--is the problem getting better or worse? It also might gather comparison information-- how are we doing compared to other, similar communities?

Decide who the intervention should help

In a childhood immunization program, your interventions would be aimed at helping children. Likewise, in a program helping people to live independently, the intervention would try to help older adults or people with disabilities. Your intervention might not be targeted at all, but be for the entire community. For example, perhaps you are trying to increase the amount of policing to make local parks safer. This change of law enforcement policy would affect people throughout the community.

Usually, interventions will target the people who will directly benefit from the intervention, but this isn't always the case. For example, a program to try to increase the number of parents and guardians who bring in their children for immunizations on time would benefit the children most directly. However, interventions wouldn't target them, since children aren't the ones making the decision. Instead, the primary "targets of change" for your interventions might be parents and health care professionals.

Before we go on, some brief definitions may be helpful. Targets of change are those people whose behavior you are trying to change. As we saw above, these people may be--but are not always--the same people who will benefit directly from the intervention. They often include others, such as public officials, who have the power to make needed changes in the environment. Agents of change are those people who can help make change occur. Examples might be local residents, community leaders, and policy makers. The "movers and the shakers," they are the ones who can make things happen--and who you definitely want to contribute to the solution.

Involve potential clients or end users of the intervention

Once you have decided broadly what should happen and who it should happen with, you need to make sure you have involved the people affected. Even if you think you know what they want--ask anyway. For your intervention to be successful, you can't have too much feedback. Some of these folks will likely have a perspective on the issue you hadn't even thought of.

Also, by asking for their help, the program becomes theirs. For example, by giving teachers and parents input in designing a "school success" intervention, they take "ownership" for the program. They become proud of it--which means they won't only use it, they?ll also support it and tell their friends, and word will spread.

Again, for ideas on how to find and choose these people, the section mentioned above on targets and agents of change may be helpful.

Identify the issues or problems you will attempt to solve together

There are a lot of ways in which you can talk with people affected about the information that interests you. Some of the more common methods include:

• Informal personal contact - just talking with people, and seeing what they have to say
• Interviews
• Focus groups
• Community forums
• Concerns surveys

When you are talking to people, try and get at the real issue--the one that is the underlying reason for what's going on. It's often necessary to focus not on the problem itself, but on affecting the cause of the problem.

For example, if you want to reduce the number of people in your town who are homeless, you need to find out why so many people in your town lack decent shelter: Do they lack the proper skills to get jobs? Is there a large mentally ill population that isn't receiving the help it should? Your eventual intervention may address deeper causes, seeming to have little to do with reducing homelessness directly, although that remains the goal.

Analyze these problems or the issue to be addressed in the intervention

Using the information you gathered in step five, you need to decide on answers to some important questions. These will depend on your situation, but many of the following questions might be appropriate for your purpose:

• What factors put people at risk for (or protect them against) the problem or concern?
• Whose behavior (or lack of behavior) caused the problem?
• Whose behavior (or lack of behavior) maintains the problem?
• For whom is the situation a problem?
• What are the negative consequences for those directly affected?
• What are the negative consequences for the community?
• Who, if anyone, benefits from things being the way they are now?
• How do they benefit?
• Who should share the responsibility for solving the problem?
• What behaviors need to change to consider the problem "solved"?
• What conditions need to change to address the issue or problem?
• How much change is necessary?
• At what level(s) should the problem be addressed? Is it something that should be addressed by individuals; by families working together; by local organizations or neighborhoods; or at the level of the city, town, or broader environment?
• Will you be able to make changes at the level(s) identified? This question includes technical capability, ensuring you have enough money to do it, and that it is going to be politically possible.

Set goals and objectives

When you have gotten this far, you are ready to set the broad goals and objectives of what the intervention will do. Remember, at this point you still have NOT decided what that intervention will be. This may seem a little backwards to your normal thinking--but we're starting from the finish line, and asking you to move backwards. Give it a try--we think it will work for you.

Specifically, you will want to answer the following questions as concretely as you can:

• What should the intervention accomplish? For example, your goal might be for most of the homeless people who are able to hold jobs do so by the end of the intervention.
• What will success look like? If your intervention is successful, how will you know it? How will you explain to other people that the intervention has worked? What are the "benchmarks" or indicators that show you are moving in the right direction?
• Finally, what are the specific objectives you want to achieve? When you are writing down your objectives, be as specific as possible. State how much change you want to see happen in what behaviors and activities. By whom? By when?
  • For example, you might say, "By 2010 (when), 80% of those now homeless (who) will be successfully employed at least part time (change sought)."

Learn what others have done

Now, armed with all of the information you have found so far, you are ready to start concentrating on the specific intervention itself. The easiest way to start this is by finding out what other people in your situation have done. Don't reinvent the wheel! There might be some "best practices"-- exceptional programs or policies--out there that are close to what you want to do. It's worth taking the time to try to find them.

Where do you look for promising approaches? There are a lot of possibilities, and how exhaustive your search will be will depend on the time and resources you have (not to mention how long it takes you to find something you like!) But some of the more common resources you might start with include:

• See what local examples are available. What has worked in your community? How about in nearby places? Can you figure out why it worked? If possible, talk to the people responsible for those approaches, and try to understand why and how they did what they did.
• Look for examples of what has been done in articles and studies in related fields. Sources might be professional journals, such as the American Journal of Public Health, or even occasionally, general news magazines. Also, look at interventions that have been done for related problems--perhaps they can be adapted for use by your group. Information and awareness events, for example, tend to be general in nature--you can do a similar event and change what it's for. A 5-K race might be planned, for example, to raise awareness of and money for breast cancer, to protest environmental destruction, and so on.
• National conferences. If you can, attending national meetings or conferences on the problem or issue you are trying to solve can give you excellent insight on some of the "best practices" that are out there.

Brainstorm ideas of your own

Take a sheet of paper and write down all of the possibilities you can think of. If you are deciding as a group, this could be done on poster paper attached to a wall, so everyone can see the possibilities-- this often works to help people come up with other ideas. Be creative!

Try to decide what interventions or parts of interventions have worked, and what might be applicable to your situation

What can your organization afford to do? And by afford, we mean financially, politically, time, and resource wise. For example, how much time can you put into this? Will the group lose stature in the community, or support from certain people, by doing a particular intervention?

When you are considering interventions done by others, look specifically for ones that are:

• Appropriate - Do they fit the group's purpose?
• Effective - Did they make a difference on behavior and outcome?
• Replicable - Are the details and results of what happened in the original intervention explained well enough to repeat what was done? Unfortunately, this isn't always the case--many people, when you talk to them, will say, "Oh! We just did it! "
• Simple - Is it clear enough for people in your group to do?
• Practical - Do we have the time and money to do this?
• Compatible with your situation - Does it fit local needs, resources, and values

Identify barriers and resistance you might come up against

What barriers and resistance might we face? How can they be overcome? Be prepared for whatever may come your way.

For example, a youth group to prevent substance use wanted to outlaw smoking on the high school campus by everyone, including the teachers and other staff members. However, they knew they would come up against resistance among teachers and staff members who smoked. How might they overcome that opposition?

Identify core components and elements of the intervention

Here is where we get to the nuts and bolts of designing an intervention.

First, decide the core components that will be used in the intervention. Much like broad strategies, these are the general things you will do as part of the intervention. They are the "big ideas" that can then be further broken down.

There are four classes of components to consider when designing your intervention:

1. Providing information and skills training
2. Enhancing support and resources
3. Modifying access and barriers
4. Monitoring and giving feedback

A comprehensive intervention will choose components for each of these four categories. For example, a youth mentoring program might choose the following components:

• For providing information and skills training, a component might be recruitment of youth and mentors
• For enhancing support and reinforcement, a component might be arranging celebrations among program participants
• For modifying access and barriers, a component might be making it easier to volunteer
• For monitoring and giving feedback, a component might be tracking the number of young people and volunteers involved

Next, decide the specific elements that compose each of the components. These elements are the distinct activities that will be done to implement the components.

For example, a comprehensive effort to prevent youth smoking might include public awareness and skills training, restricting tobacco advertising, and modifying access to tobacco products. For the component of trying to modify access, an element of this strategy might be to do 'stings' at convenience stores to see which merchants are selling tobacco illegally to teens. Another element might be to give stiffer penalties to teens who try to buy cigarettes, and to those merchants who sell.

Develop an action plan to carry out the intervention

When you are developing your action plan, you will want it to answer the following questions:

• What components and elements will be implemented?
• Who should implement what by when?
• What resources and support are needed? What are available?
• What potential barriers or resistance are expected? How will they be minimized?
• What individuals or organizations need to be informed? What do you need to tell them?

Pilot-test your intervention

None of us likes to fall flat on our face, but frankly, it's a lot easier when there aren't very many people there to watch us, and when there isn't a lot on the line. By testing your intervention on a small scale, you have the chance to work out the bugs and get back on your feet before the crowd comes in. When doing your pilot test, you need to do the following things:

• Decide how the intervention will be tested on a small scale
• Evaluate your results
• Pay particular attention to unintended consequences or side effects that you find when you evaluate your work
• Use feedback from those who tried the intervention to simplify and refine your plan

Implement your intervention

If you have followed all of the steps above, implementing your action plan will be easier. Go to it!

Constantly monitor and evaluate your work

When the wheels are turning and things seem to be under control, congratulations! You have successfully implemented your intervention! But of course, the work never ends. It's important to see if the intervention is working, and to "tweak" it and make changes as necessary.

In Summary

Designing an intervention, and doing it well, isn't necessarily an easy task. There are a lot of steps involved, and a lot of work to be done, if you are going to do it well. But by systematically going through the process, you are able to catch mistakes before they happen; you can stand on the shoulders of those who have done this work before you and learn from their successes and failures.