OVERVIEW AND EVIDENCE BASE
What do we mean by this process?
Sustaining the Work is a process of developing financial, community, and organizational supports for interventions to remain viable in the long-term. The changes that communities seek often require more time than typically funded by an external agent. In addition, although not all efforts merit continuation, problems may return when the interventions - and even the collaborative processes that support them - are no longer in place. Many foundations and other external funding agencies expect efforts to leave something behind to continue successful change interventions and improvements. Yet when funding and support end, it is up to the community to find ways to maintain successful programs and effects. The process of Sustaining the Work can help community initiatives plan and implement efforts for the long haul. When groups engage in the process of Sustaining the Work, they can develop the necessary commitment, capacity, and resources (e.g., funds, community leaders, and organizations) to ensure (a) that the values, ideas, and processes of the effort are widely shared and deeply felt, (b) that important relationships are nurtured and remain strong, (c) that policy and practice innovations are institutionalized and become the norm, and (d) that needed financial and human resources are secured for the long term (Cornerstone Consulting Group, 2002).
Sustaining the Work is a key process to help groups advance toward the behavioral changes and population-level improvements they seek.
How it works
Population-level change often requires more time than is funded by external funding agents, so enabling communities to maintain interventions and their effects is a priority (Thompson, Lichtenstein, Corbett, Nettekoven, & Feng, 2000). Yet promising, early results do not naturally lead to a desire or the capacity to continue intervention activities. Maintenance of community participation, project activities, and effects are difficult to attain in the absence of sufficient time, funding, community support, and other resources (Merzel & D'Affliti, 2003). The process of Sustaining the Work can help communities "institutionalize" the effort - that is, continue the process of building capacities to maintain processes, programs, and their effects (Sorensen, Emmons, Hunt, & Johnston, 1998).
Although the exact mechanisms are unclear for how Sustaining the Work contributes to change and improvement, participation in this process can help groups to:
- Extend prevention activities beyond the limited timeframe of most studies that is often insufficient for changing and maintaining complex behaviors (Sorensen, Emmons, Hunt, & Johnston, 1998). Many community studies are less than the 5-year timeframe often recommended as the duration necessary for community mobilization, action, and change (Mittlemark, Hunt, Heath, & Schmid, 1993).
- Draw on existing resources and generate others to bring about durable changes in the environment (Lewis et al., 1996; Paine-Andrews, Fisher, Campuzano, Fawcett, & Berkley-Patton, 2000).
- Plan for continued implementation through times of change. Many groups note that the struggle to find new resources and uncertainty about continuation can limit implementation during the last two years of initiatives; loss of momentum and departure of key staff are often noted (Cornerstone Consulting Group, 2002).
- Refine and institutionalize interventions with other resources and community partners to help ensure that a community continues to address particular issues (Merzel & D'Affliti, 2003).
- Leave behind an organization capable of carrying on the work (Cornerstone Consulting Group, 2002).
In addition, it is unrealistic to assume that community members are willing and/or able to sustain a community intervention long-term. Community change and improvement efforts require passion for the issues, expertise in planning and program development, and appreciation for existing community networks, leadership skills, and time (Goodman, Steckler, Hoover, & Schwartz, 1993). Likewise, funders are not necessarily willing to finance, on a continual basis, the very things needed for a strong community effort - competencies and processes such as strategic planning, capacity building, data and feedback (Cornerstone Consulting Group, 2002). The process of Sustaining the Work may also require attention to Assuring Technical Assistance.
Empirical and Experiential Evidence
Attention to the issue of sustaining community initiatives and interventions is increasing, but little consensus exists about what to sustain and its contributions to effectiveness. Among the few published data-based studies on maintenance (also known as durability, institutionalization, or sustainability), the COMMIT study examined tobacco control activities two years after the end of the intervention phase. Previously, all 11 intervention communities wrote a plan for continuation of project activities at the beginning of the final project year. Overall, intervention and comparison communities both reported similar amounts of prevention activities; intervention communities showed slight gains in availability of smoking cessation events and enforcement of prohibitions against youth smoking. Investigators suggested that COMMIT did not spend enough time planning for sustainability Communities received little or not training or technical assistance to assure continuation of activities. In addition, efforts to institutionalize programs competed with the time-consuming task of fund-raising, which may have reduced energy to create conditions for ongoing activities (Thompson, Lichtenstein, Corbett, Nettekoven, & Feng, 2000).
By contrast, empirical analysis of community initiatives funded by the Kansas Health Foundation suggested that early and ongoing support for sustainability resulted in institutionalization of programs, policies, and practices (community change). During four-year teen pregnancy and substance use prevention interventions in six Kansas communities, members participated in technical assistance and support activities (e.g., sustainability workshops, site visits, development of a financial sustainability plan) to facilitate concrete steps toward sustainability after grant termination. One year after funding, survey and interview data indicated that communities had relied on 7 out of 13 suggested strategies for sustainability (e.g., leveraging shared positions, grant writing, incorporating activities into organizations with similar missions) (Paine-Andrews, Fisher, Campuzano, Fawcett, & Berkley-Patton, 2000). Accordingly, at one-year post intervention, many different efforts, such as mentoring programs and health department policies, were institutionalized with different organizations throughout the communities. Lead agency support and community leadership were factors often associated with sustainability. Five years after intervention funding concluded, subsequent interview data indicated that certain components (e.g., certain programs and community leaders) continued to address teen pregnancy prevention priorities, and that trends in estimated pregnancy rates continued to decrease beyond state and county comparisons (Boothroyd, Paine-Andrews, Fisher, & Ransom, 2003).
More often, sustainability is a latent concern. Despite ideas of expansion, commitment by some community organizations, and other best intentions, resources are too few and planning too late to successfully transition a group's efforts (Shediac-Rizkallah & Bone, 1998). As such, the potential impact of this process on effectiveness remains unclear.
Implications for Research and Practices
At present, much of the information available on Sustaining the Work does not explicitly manipulate or test this process and its effects on community change and improvement. Although this process has been identified in empirical and experiential reviews as a key ingredient for advancing change, there is a need for more systematic evaluations of its effects. Such research would provide a better understanding of the factors that enable communities to come together and address shared problems and goals.
Some key research questions include: (a) How does the structure of initiative funding - required community matches, grant size, reductions in annual awards - influence community ownership and planning for sustainability? (b) What characteristics of lead agency or sponsoring organizations - size, structure, relationship in the community - influence an initiative's continuation opportunities? (c) How do community characteristics - rural/urban, income, available resources - influence program institutionalization and financial sustainability efforts? And (d) What capacity building areas are needed to make an initiative sustainable?
Overall Recommendation for Practice
Based on research and experience, we recommend (with qualifications) Sustaining the Work as a key process to advance community change and improvement. The process is suggested by researchers and practitioners as an important tool for extending the impact of community change and improvement interventions. Yet, the prevalence of empirical and experiential evidence regarding its effectiveness is at an early stage compared to what is known about other Best Processes.