Chapter 17. Analyzing Community Problems and Solutions | Community Tool Box

• What is a problem?

• Why can a collaborative process be important?

• What is the problem-solving process?

Imagine that a community coalition has formed to support economic development in a neighborhood that has experienced long-term disinvestment.

After months of outreach, the coalition has brought together residents, local businesses, community organizations, public agencies, young people, and other partners.

At its first major planning session, however, participants discover that they do not agree about the problem.

Some believe affordable commercial space is the highest priority. Others are concerned about housing costs and displacement. Some want immediate investment in public safety and infrastructure. Others argue that residents should have more authority over how development funding is used.

The coalition also has limited money, different organizations have different decision-making authority, and several participants are uncertain whether their input will actually affect the final decisions.

What should the coalition do next?

Community problems are often more complicated than they first appear.

What looks like one problem may involve several interconnected conditions, institutions, policies, incentives, resources, behaviors, and histories.

Changing one part of the system may affect another, sometimes in ways that were not anticipated.

Effective problem solving therefore requires more than identifying a problem and selecting a solution. It requires understanding the situation, deciding who needs to be involved, examining evidence and uncertainty, considering alternatives, selecting an appropriate response, implementing it, monitoring what happens, and adapting when necessary.

What is a problem?

A problem is an observed condition, gap, risk, unmet need, or unwanted outcome that people or organizations believe requires attention.

A useful problem statement describes:

• What is happening
• Who or what is affected
• Where it is occurring
• How large or serious it is
• How it has changed over time
• Why it matters

The standard used to define a problem should also be clear.

For example, a difference between current conditions and a desired condition may be identified through:

• Community priorities
• Program goals
• Health or safety standards
• Law or policy
• Evidence of avoidable harm
• Comparison with an appropriate benchmark

Problems vary in complexity

Some problems are relatively straightforward.

If a required supply is repeatedly unavailable because no one has responsibility for ordering it, the organization may be able to solve the problem by assigning ownership and establishing a reorder process.

Other problems are systems problems.

They may:

• Change over time
• Have several interacting causes
• Involve multiple organizations or sectors
• Affect different groups differently
• Be influenced by policy, infrastructure, economics, history, or institutional practices
• Produce feedback effects
• Respond unpredictably to an intervention

Complex problems may not have one root cause or one permanent solution.

The goal may instead be to reduce harm, improve conditions, manage risk, strengthen protective factors, or change part of the system over time.

Problems are not automatically opportunities

A problem may lead an organization or community to identify an opportunity for improvement.

But problems may also involve real loss, inequity, danger, or hardship.

Avoid treating the existence of a serious problem as inherently positive or character-building.

The useful question is:

What can we understand, improve, prevent, reduce, or change?

Avoid embedding the solution in the problem statement

A problem statement should describe the condition before assuming how it must be solved.

For example:

Less useful: We need to hire more outreach workers.

More useful: Participation in the program has declined by 30% over the past year, with the largest decrease among residents in three neighborhoods.

The second statement leaves room to determine whether staffing, program design, transportation, scheduling, trust, communication, eligibility rules, competing services, or another condition is contributing to the decline.

Why can a collaborative process be important?

Many organizational and community problems involve knowledge that is distributed among different people.

Staff may understand operational barriers. Community members may understand how a policy is experienced in practice. Technical specialists may understand evidence or infrastructure. Leaders may understand funding, legal, or governance constraints. Partners may understand other parts of the system.

Bringing these forms of knowledge together can improve problem definition and reveal options that one person might miss.

Collaboration, however, does not mean that every person needs to participate in every step or that everyone has the same decision authority.

Decide who needs to be involved

Consider who:

• Experiences the problem or its consequences
• Has relevant community or lived knowledge
• Has technical or professional expertise
• Controls resources or authority needed for action
• Will implement the response
• May experience unintended consequences
• Is legally or organizationally responsible for the final decision

Clarify roles in the process

Before beginning, identify:

• Who provides information
• Who is consulted
• Who helps develop options
• Who recommends an approach
• Who decides
• Who implements
• Who remains accountable

These roles may belong to different people.

Be clear when a process is consultative rather than giving participants the impression that they hold decision authority they do not actually have.

Pay attention to power

People do not enter collaborative processes with equal authority or freedom to speak.

Consider differences involving:

• Employment authority
• Funding
• Professional status
• Government authority
• Community influence
• Access to information

When public disagreement may be risky, consider written, anonymous, confidential, small-group, or separate input methods.

Make participation accessible

Depending on the participants, meaningful involvement may require:

• Language access
• Accessible electronic materials
• Captioning
• Interpretation
• Accessible meeting spaces
• Remote participation
• Flexible ways to contribute

Create psychological safety

People need to be able to:

• Ask questions
• Identify uncertainty
• Admit mistakes
• Challenge assumptions
• Raise risks
• Disagree respectfully

Psychological safety does not mean that everyone agrees, that every idea is accepted, or that accountability disappears.

Use group processes where they add value

Not every part of problem solving requires a meeting.

Useful methods may include:

• Data analysis
• Individual interviews
• Community listening sessions
• Surveys
• Observation
• Document review
• Technical analysis
• Workshops
• Facilitated discussions
• Shared digital work

Choose the method according to the question rather than assuming that putting everyone into a meeting will produce a better answer.

What is the problem-solving process?

Problem solving can be organized into a series of related steps.

The steps are useful, but the process is not always linear.

New evidence may require returning to the problem definition. Implementation may reveal a condition that was not visible during planning. Evaluation may show that the selected strategy needs to be changed or stopped.

1. Clarify the problem and the purpose of the process

Ask:

• What condition are we trying to understand or change?
• Why does it matter?
• Who is affected?
• What decision or action may result from this process?
• What is outside the scope?

Write a preliminary problem statement.

Treat it as a starting point that may change as evidence is gathered.

2. Determine who needs to be involved and who decides

Identify relevant participants, affected communities, experts, implementers, partners, and decision-makers.

Clarify decision rights before asking people to invest substantial time in the process.

3. Gather credible information

Depending on the problem, information may include:

• Quantitative data
• Qualitative information
• Research
• Program records
• Community and lived experience
• Professional expertise
• Financial information
• Policy or legal requirements
• Information from comparable communities or organizations

Consider the quality and limitations of the information.

Distinguish:

• What is known
• What is estimated
• What is assumed
• What remains unknown

4. Examine context, causes, and system relationships

Ask what produces or maintains the condition.

Consider:

• Policies and rules
• Resources
• Incentives
• Infrastructure
• Organizational practices
• Access barriers
• Social and economic conditions
• Historical conditions
• Relationships among organizations
• Community assets and protective factors

A complex problem may have several interacting causes rather than one root cause.

Systems maps, causal diagrams, process maps, timelines, or other tools may help when relationships are difficult to see.

5. Refine the problem statement

After analysis, ask whether the original problem was defined correctly.

A useful problem statement should be specific enough to guide action without prematurely prescribing the solution.

6. Generate a range of options

Consider more than the first idea that appears workable.

Options may include:

• Improving an existing approach
• Changing a policy or process
• Creating a new intervention
• Partnering with another organization
• Removing an unnecessary barrier
• Testing a pilot
• Implementing in stages
• Stopping an ineffective activity
• Maintaining the current approach while gathering more information
• Referring the issue to another authority

7. Establish criteria for comparing options

Possible criteria include:

• Expected effectiveness
• Strength of evidence
• Equity
• Safety
• Accessibility
• Legal and ethical requirements
• Community impact
• Cost
• Staff and organizational capacity
• Feasibility
• Sustainability
• Time
• Reversibility
• Potential unintended consequences

Also ask:

• Who is likely to benefit?
• Who may bear costs, burdens, or risks?
• What other work will not be possible if resources are committed here?

8. Compare options and choose an approach

Use the agreed decision process.

There may not be one objectively best solution.

Several options may be reasonable, each with different tradeoffs.

Document:

• What was selected
• Who decided
• What criteria were used
• Important assumptions
• Major risks and tradeoffs

9. Test when appropriate

When uncertainty is substantial and a smaller-scale test is practical, consider a pilot.

Define:

• What the pilot is testing
• Who will participate
• What outcomes will be monitored
• How long the pilot will run
• What would lead to expansion, revision, or stopping

10. Plan implementation

Implementation deserves as much attention as selecting the approach.

Clarify:

• Who is responsible
• What authority they have
• What staffing and resources are needed
• What training is required
• What partners or vendors are involved
• What milestones and deadlines apply
• How progress will be communicated
• What risks require escalation

Do not assume that a well-designed solution will automatically be easy to implement.

11. Monitor implementation

While the approach is being carried out, ask:

• Is implementation occurring as intended?
• Are intended participants being reached?
• Are resources sufficient?
• Are unexpected barriers appearing?
• Are unintended consequences occurring?
• Are some groups experiencing different effects than others?

Monitoring allows the organization to identify problems before waiting for a final evaluation.

12. Evaluate results

Determine whether the approach produced the intended results.

Evaluation questions may include:

• What changed?
• For whom?
• Under what conditions?
• At what cost?
• What unintended effects occurred?
• What evidence supports the conclusion?
• What limitations remain?

Choose evaluation methods appropriate to the question, scale, resources, and maturity of the intervention.

13. Adapt, continue, expand, or stop

Use monitoring and evaluation findings to decide what happens next.

The organization may:

• Continue the approach
• Modify it
• Expand it
• Reduce its scope
• Test another strategy
• Stop it
• Revisit the original problem definition

Changing course when evidence changes is not necessarily failure. It can be part of responsible problem solving.

14. Communicate what was learned

Share appropriate findings with the people who participated in or were affected by the process.

Explain:

• What was decided
• What was implemented
• What happened
• What was learned
• What will happen next

If community members or other participants provided input but did not make the final decision, explain how their input influenced the result.

Related group-process skills

Several skills discussed elsewhere in the Community Tool Box can support problem solving.

• Running effective meetings can help when real-time discussion, coordination, or decision-making is needed. Not every step of problem solving requires a meeting.
• Developing facilitation skills can support fair participation, clarify disagreement, manage time and process, and help participants understand how decisions will be made.
• Developing recorder skills can help preserve decisions, significant findings, action items, and unresolved questions when documentation is useful.
• Defining and analyzing the problem helps distinguish symptoms from underlying conditions and identify the scope and context of the issue.
• Generating and choosing solutions can help groups identify and compare different possible responses.
• Putting your solution into practice addresses the implementation work that begins after an approach has been selected.

In Summary

Community and organizational problems vary greatly in complexity.

Some have relatively direct solutions. Others involve interacting systems, several organizations, unequal power, changing conditions, uncertainty, and competing priorities.

A structured problem-solving process can help people understand these conditions without assuming that every problem has one root cause or one correct solution.

Begin by defining the problem carefully and determining who needs to be involved. Gather credible information, examine context and system relationships, and distinguish what is known from what remains uncertain.

Generate several possible responses and compare them using explicit criteria such as effectiveness, equity, safety, accessibility, evidence, feasibility, cost, sustainability, and unintended consequences.

Then plan implementation deliberately. Assign responsibility, provide necessary resources, monitor what happens, evaluate results, and be willing to modify or stop an approach when evidence shows that conditions or assumptions have changed.

Collaboration can improve problem solving when participants bring relevant knowledge and have meaningful opportunities to influence the process. It should not obscure decision authority or create the impression that everyone has equal power when they do not.

Effective problem solving is therefore not simply finding an answer. It is an ongoing cycle of understanding, deciding, acting, learning, and adapting.

About problems.

___Problems are usually seen as negative.

___Advantages problems may bring:

• Most problems are solvable (or partially solvable, or at least improvable).
• Problems are opportunities to make some good things happen and to create change.
• Problems call upon the best of our abilities, and ask us to go beyond what we thought we could do.

Why is a group problem-solving process important?

___Effective group processes enhance a group's ability to solve problems and make decisions. When working with more than just a couple of people, solving a problem with a set process becomes more manageable.

___It increases the group's efficiency and productivity.

___It increases the group's participation - more people tend to be involved, and, as a result,

___It increases group satisfaction. This means, among other things, that the group is more likely to want to take on other problems. And when they do so, they'll be better placed to solve them.

What is the problem-solving process?

___Run effective meetings.

___Develop facilitation skills.

___Develop recorder skills.

___Define and analyze the problem.

___Generate and choose solutions.

___Put your solution into practice.

Tool #1: Problem analysis sheet

The following page gives you room to analyze the problem or issue you want your group to address. This information can then be used when you go to step 7 in the "how-to's": Set goals and objectives.

Problem Analysis Sheet

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?
Will you be able to make changes at the level(s) identified?

Tool #2: Components and Elements Background Table

Use this table to look holistically at the intervention you will develop.

	Enhancing Support	Providing Information and Skills Training
Problem/ Issue to be Addressed
Risk/ Protective Factors
Targets of Change
Agents of Change
Components
Elements
Mode/ Context of Delivery

Tool # 3: Table of Components and Elements

You can fill in this table to look at all of the components and elements that will be done as a part of your intervention. By filling this out, you can see if there are any gaps in your plan that need to be filled in. (For example, if your plan doesn't have any elements related to providing information and skills training, that gap will be very apparent on this table.)

	Providing Information and Skills Training	Enhancing Support and Resources	Modifying Opportunities and Barriers	Monitoring and feedback
Components
Elements

Tool # 4: Determining if interventions done by others are appropriate for your purpose and situation

Use this table to help you determine if a particular intervention you know about is right for your purpose and situation.

What is the intervention?
Is it appropriate for our purpose?
Is it effective?
Is it replaceable?
Is it simple?
Is it practical?
Is it compatible to our situation?

Additional comments:

A PowerPoint presentation summarizing the major points in the section.

• What is critical thinking?

• Why is critical thinking important?

• Who can and should learn to think critically?

• How do you help people learn to think critically?

Suppose you see a widely shared online post claiming that a particular community program has dramatically reduced a serious local problem.

Before accepting or rejecting the claim, what would you want to know?

You might begin with the claim itself. What exactly is being said? Does "dramatically reduced" refer to a percentage, a number of people, or someone's impression? Over what period did the change occur? Compared with what?

Next, you might ask about the evidence. Where did the numbers come from? How were they measured? Is there information from before the program began? Are other explanations possible? Does the original report support the way the social-media post summarizes it?

You might also investigate the source. Who created the post? Who conducted the evaluation? Do they have relevant expertise? What interests or incentives might affect how the findings are presented? Can you find the original report or data? Do independent sources support the same conclusion?

Finally, you might consider context. Did anything else change in the community during the same period? Who benefited? Were some groups affected differently? What remains uncertain?

If you ask questions like these when you encounter information, consider a problem, make a decision, or evaluate your own conclusions, you are using critical thinking.

Critical thinking is especially important in health, human service, and community work because decisions can affect people's opportunities, resources, safety, health, rights, and everyday lives.

What is critical thinking?

There are many ways to describe critical thinking.

In this section, critical thinking means a disciplined process of examining information, claims, assumptions, evidence, reasoning, context, and alternatives before deciding what conclusion or action is justified.

Critical thinking includes questioning:

• Survey and evaluation results
• Research findings
• Theories
• Personal observations and anecdotes
• Media reports
• Social-media posts
• AI-generated information
• Data visualizations
• Historical accounts
• Political statements
• Professional recommendations
• Organizational traditions
• Conventional wisdom
• Statements from authority figures
• Our own assumptions and preferred explanations

Critical thinking does not mean automatically rejecting authority, conventional wisdom, or widely accepted knowledge.

It also does not mean treating every claim as equally uncertain.

Instead, it means asking what level of confidence is justified by the available evidence and being willing to change that confidence when better evidence becomes available.

Elements of critical thinking

Critical thinking is not always a rigid sequence, but several recurring activities are useful.

• Clarify the question or problem: What are we actually trying to understand, decide, or change?
• Examine what is known: What evidence and experience are available? How strong are they?
• Identify uncertainty: What do we not know? What are we estimating or assuming?
• Examine assumptions: What beliefs, values, definitions, or expectations are shaping the way the issue is framed?
• Consider context: What historical, social, economic, organizational, cultural, legal, or physical conditions matter?
• Consider alternatives: What other explanations, interpretations, options, or responses are plausible?
• Evaluate reasoning: Do the conclusions actually follow from the evidence?
• Make a judgment: What conclusion or action is best supported at this point, and with what degree of confidence?
• Act when appropriate: Carry out the decision proportionately to the evidence, stakes, and uncertainty.
• Reflect and revise: What happened? What did we learn? What evidence would cause us to change our conclusion or approach?

Critical thinking is therefore both analytical and reflective.

It includes examining the issue and examining your own reasoning about the issue.

Goals of critical thinking

Accuracy

Critical thinking helps distinguish well-supported claims from claims that are inaccurate, incomplete, exaggerated, misleading, or unsupported.

Not every question has a simple true-or-false answer.

Sometimes the most accurate conclusion is:

The available evidence suggests this is probably true, but important uncertainty remains.

Context

Information rarely exists in isolation.

Consider:

• When the information was produced
• Why it was produced
• What happened before it
• What conditions existed at the time
• Whether those conditions are still present

Assumptions

Critical thinking helps make assumptions visible.

Ask:

• What are we taking for granted?
• Why do we believe it?
• What evidence supports it?
• What would happen to our conclusion if it were wrong?

Alternatives

An early explanation or solution may feel obvious because it is the first one that came to mind.

Critical thinking asks what other explanations or approaches deserve consideration.

Calibration

Confidence should match the strength of the evidence.

Be cautious about being highly certain when:

• Data are limited
• Sources conflict
• Important information is missing
• The situation is changing rapidly
• Results depend heavily on assumptions

Intellectual humility

Critical thinking includes the ability to say:

I may be wrong.

That does not mean treating every conclusion as equally doubtful.

It means remaining willing to revise a conclusion when the evidence warrants it.

Critical thinking and action

In community work, critical thinking often informs action.

But action is not always the immediate result.

Critical analysis may show that the organization should:

• Act
• Test a smaller intervention first
• Gather additional evidence
• Consult people with relevant expertise or experience
• Change the problem definition
• Delay an irreversible decision
• Decide that no additional action is justified

Critical thinking should improve the quality of judgment, not create pressure to act before the evidence supports action.

Why is critical thinking important?

People encounter more information than they can examine in depth.

Some of that information is accurate and useful. Some is incomplete or outdated. Some is opinion presented as fact. Some is advertising, advocacy, entertainment, satire, or speculation. Some misinformation is shared unintentionally, while some misleading information is deliberately created or amplified.

Critical thinking helps people decide what deserves attention, what evidence deserves greater weight, and what conclusions are justified.

It helps examine assumptions

Every person approaches information with prior knowledge, values, expectations, experiences, and beliefs.

These can be useful.

They can also cause us to overlook evidence, interpret ambiguous information too quickly, or favor explanations that already fit what we believe.

Ask:

• What did I expect to find?
• Am I treating evidence differently because I like or dislike the conclusion?
• Would I accept the same evidence if it supported the opposite position?
• What evidence would change my mind?

It helps distinguish evidence from interpretation

Consider these two statements:

Program enrollment fell from 300 participants to 220 participants.

The community has lost interest in the program.

The first is a description of a measured change.

The second is an interpretation that may or may not explain the change.

Other explanations might include:

• Changes in eligibility
• Transportation barriers
• Reduced outreach
• Different program hours
• A competing service
• Problems with how enrollment was measured

Critical thinking helps prevent an interpretation from becoming a fact merely because it sounds plausible.

It helps evaluate evidence

Evidence varies in quality.

Ask:

• How was the information collected?
• How many people or cases were included?
• Who was included and excluded?
• What was measured?
• Were appropriate comparisons made?
• How much uncertainty is present?
• Do the conclusions go beyond what the data support?

It reduces overreliance on anecdotes

Individual experiences can provide important information and can identify questions that larger data sets miss.

But one person's experience does not automatically tell us how common something is.

For example:

One participant had a negative experience with the program, so the program does not work.

That experience should be taken seriously, but additional evidence is needed to determine whether it reflects a broader pattern.

It helps examine cause and effect

Two things occurring together does not necessarily mean one caused the other.

Ask:

• Did the proposed cause occur before the effect?
• Is there a plausible mechanism connecting them?
• Could another factor explain both?
• What happens in comparable situations?
• Is the evidence strong enough to support a causal conclusion?

It helps people work with numbers more carefully

Numbers can create an impression of certainty even when the interpretation is weak.

When evaluating statistics, ask:

• What is the denominator?
• Is the change an absolute number or a percentage?
• What is the baseline?
• What time period is being compared?
• Is an average hiding important differences?
• How uncertain is the estimate?

A claim that a risk "doubled," for example, means something very different if it increased from 1 in 1,000,000 to 2 in 1,000,000 than if it increased from 1 in 10 to 2 in 10.

It helps people evaluate digital information

Online information requires more than judging whether a page looks professional.

Useful questions include:

• Who is behind the information?
• What is the original source?
• Is the account or organization what it claims to be?
• What do reliable independent sources say?
• Is the image, video, quotation, or statistic being shown in its original context?
• Is the information current?

Sometimes the quickest way to evaluate a website, post, or video is to leave it temporarily and investigate the source elsewhere.

It helps people use AI-generated information responsibly

Generative AI can help summarize, brainstorm, translate, explain, or organize information.

Fluent output is not proof that the information is correct.

When important decisions depend on AI-generated information:

• Verify important factual claims
• Check cited sources
• Confirm that a source actually supports the claim attributed to it
• Look for missing context
• Avoid treating invented detail as evidence
• Use appropriate human expertise for high-stakes decisions

It helps people distinguish facts, opinions, values, and narratives

These categories can overlap, but they are not interchangeable.

A value judgment cannot always be settled simply by collecting more data.

For example, evidence may estimate how much a policy costs and who is affected. Evidence alone may not determine how a community should weigh cost, fairness, freedom, safety, or other competing values.

Critical thinking makes those differences visible instead of disguising a value disagreement as a factual one.

It helps people understand context

An approach that worked in one organization or community may not work the same way somewhere else.

Consider:

• Local resources
• Infrastructure
• Population characteristics relevant to the issue
• Institutions
• Policies
• History
• Trust
• Economic conditions
• Geography
• Existing programs and partnerships

It supports better decisions without promising certainty

Critical thinking cannot guarantee that a decision will succeed.

People may have incomplete information, conditions may change, or an intervention may create unexpected effects.

The goal is to make a decision that is better supported, clearer about its assumptions, and easier to revise when new evidence appears.

Who can and should learn to think critically?

Critical thinking is useful across ages, occupations, education levels, and communities.

Children can begin by asking simple questions about evidence, comparison, cause and effect, and how they know something.

More advanced learners can examine:

• Competing explanations
• Statistical evidence
• Research methods
• Complex systems
• Uncertainty
• Ethical tradeoffs

Adults continue to need critical-thinking skills as information environments, technology, professional knowledge, and community conditions change.

Critical thinking is not a trait that some groups possess and others lack

Avoid assuming that someone's education level, income, occupation, age, community, political beliefs, religion, or other background tells you whether they can think critically.

People may have deep expertise in one domain and limited knowledge in another.

Critical thinking is affected by both reasoning skills and subject knowledge.

Someone who knows how to ask good questions may still reach a poor conclusion if important factual knowledge is missing.

Likewise, a person with substantial factual knowledge may still reason poorly if they do not examine assumptions, uncertainty, or competing evidence.

Opportunities to develop critical thinking are not distributed equally

Some people have had more opportunities than others to practice:

• Asking questions
• Discussing evidence
• Challenging ideas safely
• Working with data
• Conducting research
• Reflecting on their own reasoning

The appropriate response is to provide opportunities, instruction, tools, and practice rather than viewing learners through a deficit lens.

Critical thinking can begin with concrete problems

People do not need to master abstract philosophy before they can practice critical thinking.

Concrete questions can provide a useful starting point:

Why did attendance decrease?

How do we know this outreach strategy is reaching the intended audience?

What evidence supports this claim?

What other explanation is possible?

More complex reasoning can be built progressively through modeling, practice, feedback, and reflection.

How do you help people learn to think critically?

Critical thinking develops through practice.

It is most useful when connected to real subject matter rather than taught only as an abstract set of thinking rules.

Learners need opportunities to apply critical thinking to questions that require knowledge, evidence, interpretation, judgment, and reflection.

Teaching critical thinking can be considered in three connected areas:

• Creating conditions that support questioning and revision
• Teaching metacognitive and information-evaluation strategies
• Applying those strategies to real problems and decisions

Create conditions that support critical thinking

People are less likely to question assumptions when doing so routinely leads to ridicule, retaliation, or dismissal.

Create an environment in which learners can:

• Ask for evidence
• Admit that they do not know
• Change their minds
• Challenge the facilitator respectfully
• Identify mistakes
• Raise alternative explanations

Critical thinking does not require treating every claim as equally credible.

Evidence and reasoning still matter.

Model the process

Make useful reasoning practices visible.

For example, a facilitator might say:

My first interpretation was that participation decreased because people lost interest. But I realized I was assuming we had maintained the same outreach and schedule. Before I accept that explanation, I want to check whether those conditions changed.

Modeling should focus on the reasoning strategy that learners can reuse:

• Identify the assumption
• Identify missing information
• Look for another explanation
• Check evidence
• Revise the conclusion if necessary

Teach metacognition

Metacognition means thinking about and monitoring your own thinking.

Encourage learners to plan, monitor, and evaluate their reasoning.

Before analyzing

Ask:

• What is the question?
• What do I already know?
• What might I be assuming?
• What information will I need?

During analysis

Ask:

• Am I answering the actual question?
• Am I relying too heavily on one source?
• Have I considered another explanation?
• Does the evidence support the strength of my conclusion?

Afterward

Ask:

• How confident am I?
• What evidence would change my mind?
• What did I find difficult?
• Which strategy helped?
• What should I do differently next time?

Help learners recognize assumptions

Assumptions are ideas or expectations we accept without examining them each time.

They can come from:

• Prior knowledge
• Personal experience
• Values
• Professional training
• Community and organizational history
• Social and cultural context
• Interests and incentives
• Repeated messages
• Institutions and authority
• The information environments we participate in

An assumption is not automatically wrong.

The question is whether an important conclusion depends on it and whether there is reason to test it.

Examine values and interests without pretending they can always be removed

Community decisions often involve both evidence and values.

Ask:

• What outcomes are we prioritizing?
• Who benefits?
• Who bears costs or risks?
• What rights or responsibilities are involved?
• Which tradeoffs are factual questions and which are value judgments?

Being explicit about values can improve reasoning more than pretending that values are absent.

Recognize the role of emotion

Emotions can affect attention, interpretation, and decision-making.

They are not automatically evidence that a factual conclusion is true or false.

They can, however, identify something worth examining.

For example, anger about a proposed policy may lead to questions about fairness, harm, or rights that deserve investigation.

The critical-thinking task is to examine both the reaction and the relevant evidence rather than simply suppressing the reaction.

Examine information systematically

Useful questions include:

What exactly is the claim?

State it precisely enough that evidence could support or challenge it.

What is the source?

Determine:

• Who produced the information
• Their relevant expertise
• Their purpose
• Their evidence
• Whether significant conflicts or incentives are present

Do not decide that information is true or false solely because you agree or disagree with the source's politics, institution, profession, or identity.

Can you trace the claim to original evidence?

A news story, social-media post, AI answer, or advocacy document may summarize another source.

When the issue is important, look for the underlying:

• Research study
• Dataset
• Government document
• Court decision
• Policy
• Speech or recording
• Evaluation report

What do independent sources say?

Corroboration is especially useful when:

• A claim is surprising
• The source has a strong stake in the outcome
• The information is spreading rapidly online
• The consequences of acting on it are significant

Is the information current and in context?

Accurate information can become misleading if:

• It is old
• A quotation is shortened in a way that changes its meaning
• An image comes from another event
• A statistic refers to a different population
• Conditions have changed since the evidence was collected

Is the information complete enough for the decision?

No source contains everything.

Ask whether important missing information could change the conclusion.

Is the reasoning sound?

Watch for problems such as:

• Generalizing from one or a few examples
• Treating correlation as causation
• Presenting only two choices when more exist
• Selecting only evidence that supports a preferred conclusion
• Ignoring relevant base rates or comparison groups
• Attacking a person instead of addressing the argument
• Changing the standard of evidence depending on who makes the claim

How strong is the evidence?

Avoid treating all evidence as equivalent.

A personal story, a carefully conducted study, an administrative dataset, professional judgment, and a community survey may each provide useful information, but they answer different questions and have different limitations.

Teach digital verification

Information online often needs to be checked beyond the page where it appears.

Learners can practice:

• Searching for the organization or author in independent sources
• Finding the original claim
• Checking whether a quotation is complete
• Checking publication and event dates
• Comparing several credible sources
• Verifying images or videos
• Looking for corrections or updated information

The visual appearance of a website or social-media account should not substitute for verification.

Teach people to work with AI-generated information critically

AI systems can produce useful explanations and summaries, but they can also produce incorrect details, unsupported claims, incomplete context, or nonexistent citations.

Practice asking:

• Which claims here need verification?
• What source would be authoritative for this question?
• Can I confirm the cited source exists?
• Does that source actually support the statement?
• What information might be missing?
• Is this a factual question, interpretation, prediction, or recommendation?

Consider context

When examining a community issue, relevant context may include:

• Community priorities
• Geography
• Infrastructure
• Economic conditions
• Policies and laws
• Institutions
• Existing programs and services
• Community assets
• Relationships among organizations
• Historical experience
• Trust
• Information access

History

Previous efforts can reveal both useful lessons and unresolved concerns.

Ask:

• Has this approach been tried before?
• What happened?
• Why?
• Have important conditions changed since then?
• Whose account of the history are we hearing?

Use more than one perspective when the history is contested or when earlier decisions affected groups differently.

Interests and power

Consider:

• Who has decision authority?
• Who controls resources?
• Who experiences the consequences?
• Who benefits from the current situation?
• Who might benefit or lose under different alternatives?

An interested party's evidence should not automatically be dismissed, but the interest should be considered when evaluating how claims are presented and what additional verification is needed.

Information environment

What people encounter is shaped partly by:

• Search and recommendation systems
• Social networks
• Repetition
• Influencers and content creators
• Platform incentives
• Advertising
• AI-generated and algorithmically selected content

Repeated exposure can make a claim feel familiar without making it more accurate.

Facilitating problem solving using critical thinking

Critical thinking can be applied directly to community and organizational problems.

Clarify the current situation

Ask:

• What is actually happening?
• How do we know?
• Who is affected?
• How large is the problem?
• Over what period?
• Compared with what?

Identify assumptions about the problem

Ask:

• What are we assuming causes the problem?
• What evidence supports that assumption?
• What other explanation might fit the evidence?
• Are we confusing a symptom with an underlying condition?

Test important assumptions

Not every assumption needs an exhaustive investigation.

Focus on assumptions that would materially affect the decision.

Ask:

If this assumption were wrong, would we choose a different strategy?

If the answer is yes, the assumption deserves closer examination.

Identify what evidence would change your mind

Before choosing a solution, ask participants:

What would we need to learn to conclude that our current explanation is wrong?

This can reduce the tendency to search only for evidence supporting the group's preferred view.

Generate alternative explanations

Before generating solutions, consider several plausible explanations for what is happening.

A program may have low participation because of:

• Limited awareness
• Eligibility requirements
• Schedule
• Transportation
• Accessibility
• Lack of trust
• Program design
• Competing services
• Measurement problems

Different explanations may imply different responses.

Generate alternatives

Once the problem is reasonably understood, generate more than one possible response.

Brainstorming can be useful, especially when participants temporarily separate idea generation from evaluation.

Broad idea generation does not require accepting proposals that are clearly outside legal, ethical, safety, or organizational boundaries.

Work backward from a desired outcome

Another useful approach is to define the condition you want to create and work backward.

For example, if the goal is reliable access to a community service, ask:

• What would reliable access look like?
• What conditions would have to exist?
• Which of those conditions are currently missing?
• Which conditions can the organization influence?

This approach can identify necessary steps, but it does not prove that a particular intervention will produce the desired outcome.

Compare alternatives using explicit criteria

Criteria may include:

• Evidence of effectiveness
• Expected benefits
• Costs
• Feasibility
• Equity
• Safety
• Accessibility
• Legal requirements
• Ethical considerations
• Community priorities
• Organizational capacity
• Sustainability
• Potential unintended consequences
• Reversibility

Some criteria may matter more than others.

Make those priorities explicit rather than allowing them to influence the decision invisibly.

Examine tradeoffs

Several alternatives may be defensible.

Ask:

• What do we gain with this option?
• What do we give up?
• Who experiences the benefits?
• Who bears the costs or risks?
• What opportunity are we giving up by using resources here?

Reframe the problem when necessary

Critical analysis may show that the original problem statement was incomplete or wrong.

Restate:

• The current situation
• The problem as it is now understood
• Important causes or contributing conditions
• What remains uncertain
• The outcomes the group hopes to achieve

Reframing is not a failure of the original process.

It is often evidence that the analysis has improved.

Make a proportionate decision

Decide using the strongest available evidence while acknowledging uncertainty.

When uncertainty is high and the decision is reversible, a pilot or limited test may be appropriate.

When a decision is difficult to reverse or could create significant harm, stronger evidence and review may be necessary.

Continue thinking critically during implementation

Critical thinking does not end when a solution is selected.

Monitor:

• Whether implementation is occurring as intended
• Whether the expected results are occurring
• Whether assumptions remain valid
• Whether unexpected effects are appearing
• Whether some groups are affected differently

Evaluate and revise

Ask:

• What happened?
• What evidence supports that conclusion?
• What did we misunderstand?
• What worked?
• What did not?
• What should continue?
• What should change?
• What have we learned that applies elsewhere?

A strong critical thinker is not someone who never reaches a wrong conclusion.

It is someone who can recognize when a conclusion is no longer supported and revise it.

In Summary

Critical thinking is a vital skill in health, human service, organizational, and community work.

It involves examining claims, evidence, assumptions, reasoning, context, alternatives, uncertainty, and one's own thinking before deciding what conclusion or action is justified.

Critical thinking does not require automatic skepticism toward authority, conventional wisdom, institutions, or unfamiliar ideas. Nor does it mean attempting to eliminate every value, emotion, or perspective from judgment.

Instead, it asks people to distinguish evidence from interpretation, make assumptions visible, seek appropriate context, compare competing explanations, evaluate the quality of information, and match confidence to the strength of the evidence.

These skills are especially important in a digital environment where people encounter social media, rapidly changing information, synthetic images and video, online influencers, algorithmically selected content, and generative AI alongside traditional research and news sources.

Critical thinking can be developed across ages and backgrounds. Teaching it works best when people practice the skills in meaningful subject matter and real situations, with explicit modeling, opportunities for reasoning and discussion, feedback, and metacognitive reflection.

Finally, critical thinking continues after a decision is made. People should monitor results, test assumptions against what actually happens, evaluate new evidence, and be prepared to revise conclusions and actions when the evidence changes.

What is critical thinking?

___You know that critical thinking is the process of examining, analyzing, questioning, and challenging situations, issues and information of all kinds.

___You know the elements of critical thinking:

• Problem/goal identification
• Diagnosis
• Exploration
• Action
• Reflection
• Repeat the process

___You know the goals of critical thinking:

• Finding the truth
• Considering the context
• Understanding assumptions
• Creating alternative approaches

Why is critical thinking important?

You understand that:

___It identifies bias

___It's oriented toward the problem, issue, or situation that you're addressing

___It brings in other necessary factors

___It considers both the simplicity and the complexity of its object

___It gives you the most nearly accurate view of reality

___It is most likely to get you the results you want

Who can (and should) learn to think critically?

___You know that most people can and should learn to think critically

___You know that the many adults who have the capacity for critical thinking, but who haven't been taught and lack the experiences to learn on their own are both most in need of, and most receptive to, learning critical thinking.

How to help others learn to think critically

___You know that learning critical thinking is an irreversible, often frightening process that requires support.

___You understand how to be a facilitator of critical thinking:

• Affirm learners' self-worth
• Listen attentively to learners
• Show your support for critical thinking efforts
• Reflect and mirror learners' ideas and actions
• Motivate people to think critically, but help them to understand when it's appropriate to voice critical ideas and when it's not.
• Regularly evaluate progress with learners
• Be a critical teacher
• Make people aware of how they learn critical thinking
• Model critical thinking

___You know how to encourage the critical stance (i.e. applying critical thinking to whatever you encounter):

• Help learners recognize and examine their own assumptions
• Examine information for accuracy, assumptions, biases, or specific interests
• Consider the context of what you're looking at

___You know how to facilitate problem solving using critical thinking

• Identify the assumptions behind the problem
• Challenge those assumptions
• Imagine alternatives to what you started with
• Critique those alternatives
• Reframe the problem and solution

Tool #1: Two Conceptions of Cognitive Development

There are a number of ways to look at cognitive development, i.e. the development of thinking. Perhaps the most familiar is the conception of Jean Piaget, a Swiss philosopher, who looked at the development of his own children to try to understand the development of the intellect in general. From his sample of three, he saw a pattern of development that had, in its simplest terms, three stages:

• Preoperational: Piaget used the word "operations" to refer to the logical structures of thinking. At the preoperational stage, logical structures really aren't much of a factor except in the most fundamental ways. The light comes on when you flip the switch simply because it does. There's very little, if any, understanding of cause and effect, or of the consequences of any but the simplest actions.

A defining moment in my own life came when I was three. I was coasting down an incline on my tricycle, and realized that I was about to hit some bushes. I turned right...down a flight of stairs I knew full well was there. It just hadn't occurred to me that my action would have a consequence in the future, even the future that was only two or three seconds ahead.

• Concrete operations: At this stage, people can understand what they can take in through the evidence of their senses (things that are "concrete" enough to touch or see). Thus, addition and subtraction are easy -- you can manipulate objects to see how they work -- but algebra, which involves "unknowns" is harder. You can't see the unknowns, so they're a great deal more difficult to understand.

A professor of cognitive psychology used to tell his classes this story: "When the channel changer knob fell off my TV set, the channel had to be changed with a pair of pliers. Without the numbers on the channel changer, I could never find the stations. One day when I was struggling with the thing, my eight-year-old daughter asked what was wrong. I said,'I can't find Channel Four.' My daughter went over and picked up the knob, pointed to the number, and said'There's Channel Four.' That's concrete operations."

• Formal operations: At this highest stage (which has a number of more narrowly defined substages within it), people are capable of abstract thought. This is often defined as the ability to think about thinking. It includes bringing ideas or events that aren't present or obvious to bear on a particular issue; being able to project consequences into the future; predicting what others might do, even if it's very different from what you might do; envisioning several possible outcomes from the same action; etc.

A couple of older-children examples of formal operations:

A sixth-grade class in the '50's was told that English newspapers were seldom longer than eight pages, and were printed on thin paper. The teacher asked why this was the case. Two of the children understood immediately that the answer had to do with a fact they had learned the week before: that England had cut down most of its forests. They realized that its relatively few trees were much too valuable to be used for making paper.

A nine-year-old was asked to explain why Earth was a sphere. After a few seconds of thought, he was able to explain that, since gravity pulls equally in all directions, the shape that would be formed by gravity pulling space debris and dust together from a central point would be a sphere. Every point on a ball, if it's perfectly spherical, is exactly the same distance from the center.

Since he observed, for many years, only his own children, Piaget assumed that their development was typical. He therefore assigned preoperational thinking to very early childhood; concrete operations to the elementary school years, about ages 6 to 11 or 12; and the start of formal operations to puberty or early adolescence.

As it happens, there are great variations in development, depending to a large extent upon an individual's experiences and stimulation, and probably upon brain development as well. A large number -- perhaps a majority -- of adults still function at concrete operations in at least some areas.

And that's another issue: even people who spend much of their cognitive lives at the highest levels of thought -- theoretical physicists, for instance -- probably don't use formal operations all the time. Certain issues, such as dealing with their parents, may present emotional barriers to thinking in critical or logical ways. In reality, few of us are able to turn the full force of our intellect on everything we encounter.

Piaget saw cognitive development as a process of increasing differentiation (understanding how things, people, events, ideas, etc. differ from one another) and increasing integration (understanding the connections among all those different things, people, etc.) The mechanism of that process is set off by a person coming into contact with something that doesn't match his view of reality.

Someone in this situation has two options: he can ignore the new phenomenon, and simply continue seeing the world as he always has; or he can try to make sense of the world in a different way in light of the new reality he has seen. It may take many encounters with reality to start a change in perception, especially if cognitive development means leaving behind some basic belief. Some people simply are unable ever to see anything that doesn't agree with their preconceptions.

Although textbooks tend to present this material as if changes happened abruptly, in fact change is going on all the time. People's thinking may get more sophisticated in some areas, but not others, which brings us to another theory of cognitive development.

Howard Gardner sees Piaget as looking at only one part of cognitive functioning. Gardner finds eight aspects of intelligence, rather than just one:

• Logical-mathematical (what he believes Piaget was examining)
• Verbal (speaking and writing ability, learning languages, etc.)
• Interpersonal (relations with others)
• Intrapersonal (understanding of self)
• Spatial (ability to see, understand, and use spatial relationships, including talent for painting and the other visual arts)
• Kinesthetic (physical and athletic ability)
• Music
• Environmental (Being able to recognize patterns in one's environment)

According to Gardner, each of these aspects is separate from the others. Different aspects develop at different rates in different people, so that some who are far advanced in, for instance, music at an early age, may still have very little interpersonal capacity. This is one way of explaining those theoretical physicists we mentioned earlier: some of their intelligence's are highly developed, while others are not.

For the most part, at least in the past century, schools and the society at large have valued the logical/mathematical and verbal abilities, while paying little attention to the others. If Gardner is right, his theory has major implications for education, as he himself has written. We should be stimulating children in all areas, so that they can become adults who are competent in every aspect of intelligence.

A PowerPoint presentation summarizing the major points in the section.

• The nature of problems

• Clarifying the problem

• Deciding whether and how to act

• Analyzing the problem

When people encounter a community or organizational problem, the first impulse is often to move quickly toward a solution.

But the way a problem is defined strongly influences which solutions appear reasonable.

If the problem is defined too broadly, the group may not know where to begin. If it is defined too narrowly, important contributing conditions may be ignored. If the definition already contains a preferred solution, other potentially more effective approaches may never be considered.

Defining and analyzing the problem therefore deserves deliberate attention.

This section focuses on four related tasks:

• Understanding the nature of the problem
• Clarifying what is known and what remains uncertain
• Deciding whether and how your organization should act
• Analyzing contributing conditions, context, assets, and system relationships

These tasks are related and often iterative. New information may cause you to revise a problem statement that originally seemed clear.

The nature of problems

A concern may first appear as a pattern, complaint, unexpected result, safety issue, gap in services, inequity, unmet goal, or observation that conditions are not working as intended.

Intuition or discomfort can be a useful signal that something deserves investigation.

It should not, however, be treated as proof of what the problem is or what causes it.

What is a problem?

A problem can be understood as an observed condition, gap, risk, unmet need, or unwanted outcome that warrants attention.

Often, the problem involves a difference between current conditions and a desired condition.

When using that definition, make the desired condition explicit.

Ask:

• What is happening now?
• What condition are we comparing it with?
• Where does that standard or goal come from?
• Is it based on community priorities, evidence, policy, law, safety standards, organizational goals, rights, or another benchmark?

For example:

Current condition: Fewer than half of eligible residents complete the program's enrollment process.

Desired condition: Eligible residents can complete enrollment without unnecessary procedural, communication, transportation, technology, or accessibility barriers.

This identifies a gap without assuming what intervention will close it.

Problems differ in complexity

Some problems are relatively straightforward.

For example, if required supplies are repeatedly unavailable because no one is responsible for reordering them, assigning ownership and establishing a reorder process may resolve the problem.

Other problems involve systems.

They may:

• Change over time
• Involve multiple organizations and groups
• Have several interacting causes
• Be affected by policy, funding, infrastructure, institutions, and behavior
• Affect different groups differently
• Produce feedback effects or unintended consequences

A complex problem may not have one root cause or a single permanent solution.

The goal may instead be to reduce harm, improve conditions, change a particular part of the system, strengthen protective factors, or manage risk over time.

Do not define people as the problem

Define problems in terms of conditions, outcomes, systems, policies, practices, barriers, or risks rather than labeling populations.

For example:

Less useful: Young people are the problem because they do not participate.

More useful: Participation among residents ages 16–24 has declined over the past two years, and the organization does not yet know which barriers are contributing to the decline.

This keeps the analysis focused on conditions that can be investigated.

Look for assets as well as problems

Communities and organizations usually have strengths, protective factors, existing relationships, successful practices, and other resources that can help address the problem.

Ask:

• Where is the problem less severe?
• What is working there?
• What strengths already exist?
• Which organizations, relationships, practices, or community assets could support improvement?

Clarifying the problem

Before finalizing a problem statement, clarify what is known, what is believed, and what still needs investigation.

Start with what is currently known

Gather existing information before deciding what additional information is necessary.

Sources might include:

• Program and administrative records
• Surveys
• Interviews
• Community listening sessions
• Observations
• Research studies
• Public datasets
• Policies and regulations
• Previous evaluations
• Geographic information
• Professional expertise
• Community and lived experience

Not every source answers the same kind of question.

A community member's experience may reveal a barrier that administrative data do not show. Administrative records may reveal the scale or frequency of a pattern that individual experiences cannot establish by themselves.

Distinguish different kinds of information

As information is gathered, distinguish among:

• Observed evidence: information directly documented through reliable data, records, observation, or other appropriate methods.
• Interpretation: an explanation of what the evidence may mean.
• Hypothesis: a possible explanation that can be examined further.
• Lived or community experience: information about how a condition is experienced by people affected by it.
• Value judgment: a conclusion about what is desirable, fair, acceptable, or important.
• Unsupported assertion: a claim for which adequate evidence has not yet been provided.

These forms of information can all influence problem analysis, but they should not be treated as interchangeable.

Identify what information is missing

Ask:

• What information would materially change how we understand the problem?
• What do we currently assume rather than know?
• Are important groups or perspectives missing?
• Do we know how conditions differ by location, time, or population?
• Do we have enough information to distinguish symptoms from contributing conditions?

Do not collect information simply because it might be interesting.

Focus on information that can improve understanding or decision-making.

Examine the quality and limitations of information

For important evidence, ask:

• Who produced it?
• How was it collected?
• Who or what was included?
• Who or what may have been left out?
• How current is it?
• What does it actually measure?
• What uncertainty or limitations are present?
• Does another credible source support the same conclusion?

Gather information ethically

When collecting information from people, consider:

• Privacy
• Confidentiality
• Informed participation where appropriate
• Accessibility
• Language access
• Burden on participants
• How information will be stored and used

Community engagement should be a two-way relationship rather than a process in which organizations simply extract information and disappear.

Define the problem without embedding the solution

A problem statement should describe the condition that needs attention.

For example:

Less useful: We need to create a mobile outreach team.

More useful: Residents in three neighborhoods use the service at substantially lower rates than eligible residents elsewhere, and transportation, scheduling, awareness, eligibility, accessibility, or trust may be contributing factors.

The second statement leaves room to investigate whether a mobile team, schedule change, transportation support, communication change, eligibility reform, partnership, or another approach would be most appropriate.

Do not manufacture agreement

People may understand or experience a problem differently.

The goal is not necessarily to write a statement that makes everyone equally satisfied.

Instead:

• Identify areas of agreement
• Document important differences
• Identify which claims are supported by evidence
• Identify what remains uncertain
• Clarify who has responsibility for deciding how the problem will ultimately be framed for organizational action

Define important terms

Words such as access, community, safety, participation, affordable, quality, success, and underserved can mean different things to different people.

Define important terms precisely enough that participants know what is being discussed and, where possible, how the condition will be measured.

Deciding whether and how to act

After clarifying the problem, determine what role your organization should play.

Not every important problem should be addressed by every organization.

Your organization may decide to:

• Lead the response
• Work in partnership
• Support another organization
• Refer the issue to an authority with greater expertise or responsibility
• Gather more information before acting
• Address only one part of a larger problem
• Maintain the current approach while monitoring conditions

Consider severity and urgency

Ask:

• How serious is the harm or risk?
• How many people are affected?
• How severely are they affected?
• Is the condition worsening?
• Are immediate protective actions required?

Some safety, legal, safeguarding, or public-health concerns may require action before a complete analysis can be finished.

Immediate action can occur while deeper analysis continues.

Consider equity

Overall averages can hide large differences.

Ask:

• Who experiences the greatest burden?
• Are barriers concentrated among particular groups or places?
• Who has historically had the least influence over decisions about the issue?
• Could a proposed response reduce one problem while increasing another inequity?

Consider organizational authority and fit

Ask:

• Does the issue fit the organization's mission and responsibilities?
• Does the organization have legal or professional authority to act?
• Does another organization already have primary responsibility?
• Would partnership be more effective than acting alone?

Consider feasibility and capacity

Consider:

• Staff and volunteer capacity
• Funding
• Expertise
• Technology
• Partnerships
• Time
• Political or organizational conditions

Feasibility should not be used to dismiss an important problem merely because it is difficult.

It may instead indicate that the organization needs partners, a smaller initial objective, or a longer-term strategy.

Consider consequences and tradeoffs

Ask:

• What benefits are expected?
• What harms or burdens could occur?
• Who receives the benefits?
• Who bears the costs or risks?
• What unintended effects are plausible?
• Can those effects be prevented or reduced?

Legal, ethical, safety, or rights-based obligations should not be treated merely as optional costs to be balanced away.

Consider opportunity cost

Resources used for one problem are not available for another.

Ask:

If we devote substantial staff time, funding, and leadership attention here, what other work will receive less attention?

Consider what happens if you do not act

Maintaining the current approach is itself a choice.

Compare the likely consequences of action with the likely consequences of no additional action.

Prioritize among several problems

When several problems compete for attention, establish criteria before choosing among them.

Criteria might include:

• Severity
• Urgency
• Number of people affected
• Equity
• Organizational responsibility
• Evidence that meaningful improvement is possible
• Available capacity
• Community priority
• Opportunity cost

A simple matrix can help participants compare problems consistently.

Numerical scores may be useful in some situations but should not create an illusion of precision where judgments remain uncertain.

Analyzing the problem

After developing a preliminary problem definition and deciding that the issue warrants attention, examine it in greater depth.

The purpose is not to force everyone toward one causal story.

It is to develop a sufficiently accurate understanding of the conditions that create, maintain, worsen, or reduce the problem.

Ask the basic descriptive questions

What is happening?

Describe the condition as specifically as possible.

Ask:

• What outcome or condition are we observing?
• How is it measured?
• What evidence supports the description?

Who is affected?

Ask:

• Who experiences the condition directly?
• Are effects different among groups?
• Who may experience indirect effects?

Avoid assuming that the people most affected are also the people responsible for causing the condition.

Where is it happening?

Geographic patterns may reveal differences in:

• Access
• Infrastructure
• Resources
• Exposure
• Institutional practices

When is it happening?

Examine:

• When the problem emerged
• Whether it is increasing or decreasing
• Seasonal patterns
• Important events or policy changes that occurred around the same time

A long-standing problem may reflect entrenched systems, resource constraints, policies, incentives, infrastructure, or other conditions rather than simply people's unwillingness to change.

How much?

Examine:

• Number of people or cases affected
• Rate or proportion
• Frequency
• Duration
• Severity
• Trends over time

Use appropriate denominators and comparison groups so the scale of the problem is not misleading.

Examine contributing conditions

Instead of asking only, "What is the root cause?" ask:

What conditions contribute to this problem, and how do they interact?

Consider:

• Policies and rules
• Organizational processes
• Funding
• Incentives
• Staffing
• Infrastructure
• Access
• Information and communication
• Social and economic conditions
• Historical conditions
• Trust and relationships
• Individual and organizational behavior

Use repeated “why” questions carefully

Asking "Why?" several times can help reveal assumptions and deeper contributing conditions.

For example:

Program appointments have a high no-show rate.

Why might that be happening?

Participants report transportation and scheduling difficulties.

Why are those difficulties affecting this program more than others?

Appointment times are concentrated during working hours and the site is not served directly by public transportation.

This exercise can identify useful lines of investigation.

It does not prove that the final answer is the one true root cause.

Several causal pathways may operate at the same time.

Use systems thinking when the problem is complex

For complex issues, consider mapping relationships among:

• Policies
• Organizations
• Resources
• Infrastructure
• Incentives
• Behaviors
• Community conditions
• Feedback loops

Tools may include:

• Causal diagrams
• Process maps
• System maps
• Timelines
• Stakeholder maps

Use the simplest tool that helps participants see relationships they were previously missing.

Examine forces maintaining and changing the situation

Force-field analysis can still be useful when the group wants to identify factors that maintain the current condition and factors that support change.

Instead of treating the exercise as an unrestricted list, ask participants to identify:

• Evidence supporting each factor
• How strongly the factor influences the situation
• Whether the organization can influence it
• How it interacts with other factors

Identify assets and protective factors

Ask:

• Where is the desired outcome already occurring?
• What is different there?
• What community strengths can be built upon?
• Which relationships or institutions already reduce the problem?

An analysis focused only on deficits can overlook practical solutions already operating in part of the system.

Analyze stakeholders without assigning simplistic blame

Instead of asking only "Who is causing the problem?" ask:

• Who is affected?
• Who influences important conditions?
• Who controls relevant resources?
• Who has formal decision authority?
• Who has relevant knowledge or experience?
• Who might help implement change?
• Who may experience costs or unintended effects?

Accountability still matters.

If a particular policy, organizational practice, decision, or harmful behavior materially contributes to the problem, identify it accurately.

Examine power and interests

Ask:

• Who currently defines the problem?
• Who controls the data?
• Who controls funding or authority?
• Whose knowledge has historically carried the greatest weight?
• Who has less ability to influence the response?
• Are conflicts of interest or incentives affecting how the problem is framed?

Identify uncertainty and competing explanations

At the end of the analysis, the group may still have several plausible explanations.

Document:

• What is well supported
• What is plausible but uncertain
• What information is missing
• What evidence would help distinguish among competing explanations

Do not force agreement merely to make the process appear complete.

Revisit the problem statement

Analysis may show that the original statement was:

• Too broad
• Too narrow
• Focused on a symptom
• Based on an unsupported assumption
• Missing an important population, place, or condition

Rewrite it when necessary.

Prepare a concise problem-analysis summary

Before moving to potential solutions, summarize:

• The problem statement
• Magnitude and trend
• Who is affected
• Relevant context
• Major contributing conditions
• Assets and protective factors
• Important differences among groups or places
• Areas of uncertainty
• Evidence still needed
• Relevant authority and organizational role

This summary gives participants a shared reference point when they begin generating and comparing possible responses.

Keep the analysis open to revision

Defining a problem is not a one-time event.

New information may emerge while an intervention is being designed, implemented, or evaluated.

If the evidence changes, revisit the analysis.

A responsible organization should be willing to change its understanding rather than continuing to act on a problem definition that the evidence no longer supports.

In Summary

Defining and analyzing a problem is a foundation for effective community and organizational action.

Begin by describing the condition rather than assuming the solution. Make clear what standard, goal, right, or community priority defines the difference between current and desired conditions.

Gather credible information from multiple appropriate sources. Distinguish observed evidence from interpretations, hypotheses, values, and unsupported assertions, and identify important limitations and uncertainties.

Decide what role your organization should play by considering severity, urgency, equity, authority, capacity, opportunity cost, community priorities, likely benefits, and potential harms.

When analyzing causes, avoid assuming that a complex community problem has one root cause. Examine interacting policies, systems, institutions, resources, behaviors, relationships, historical conditions, assets, and feedback effects.

Include affected communities and other relevant people in ways that are meaningful, accessible, and appropriate to their knowledge, responsibilities, and decision authority. Pay attention to power, trust, and whose interpretations have historically shaped the issue.

Finally, treat the problem definition as revisable. Monitoring, implementation, community feedback, and evaluation may reveal conditions that were not visible at the beginning.

Strong problem analysis does not guarantee a simple answer. It gives the organization a clearer, better-supported foundation for deciding what to do next.

You understand the nature of problems:

___They may be defined as the difference between what is and what might or should be.

___They may occur within or outside of the group.

___They occur at different levels of severity.

You have clarified the problem:

___You have started with what you know.

___You have decided what is missing.

___You have gathered information on the problem.

___You have defined the problem.

You have decided to solve the problem:

___It is important.

___It is feasible.

___You are the best people to solve the problem.

___You have weighed the negative impacts.

___You have chosen among possible problems.

You have analyzed the problem:

___You know what the problem is.

___You know why the problem exists.

___You know who is causing the problem.

___You know when the problem first occurred or became significant.

___You know how much, or to what extent, the problem is occurring.

Choosing which problem to solve

A small, rural substance use prevention group is trying to decide where to focus their youth related efforts. In the following chart, the group compared two problems to see which one is more important to the group.

	Problem 1: Many underage teens smoke cigarettes or chew tobacco	Problem 2: Many teenagers use illegal drugs (marijuana, cocaine, et cetera)
How frequently does the problem occur?	Very Frequently	Frequently
How many people are affected?	Most area high school students have smoked at least once; a significant percentage smoke regularly	In our rural community, few illicit drugs are available; this is a fairly small number
For what amount of time are they affected?	Regular smokers, often for life	Often life-long consequences
How severe is the effect?	Relatively severe	Can be tremendously severe
How important do group members perceive the problem to be?	Very Important	Less Important
How important is the problem perceived to be by others?	Less important; smoking and chewing are widely accepted here	Very Important
How likely is it that we can solve/significantly improve the problem?	Very Likely	Possible, but difficult
Are there any negative impacts?	None	None

Which problem will the coalition choose? That remains to be seen; this chart won't give a magic answer. But by using this or a similar device, it's easy to see all of the different aspects of the problem, and the group is now better equipped to make an informed choice.

Tool 1: Deciding on a problem statement

This exercise is adapted from an exercise on developing vision statements created by Lori Alvarado, DCCCA Center, Lawrence, KS. This activity works best in groups with less that 40 people.

• Ask everyone present at the meeting to write down his/her definition of the problem.
• Ask people to pair off and share their problem statements with each other. Together, the pair can create a new problem statement, incorporating ideas from both.
• Ask pairs to join together in groups of four, and again merge the statements into one.
• Continue joining the groups in larger and larger groups until everyone is together again, and you have one agreed upon statement.

Tool 2: Choosing which problem to solve

The following table can be used or adapted to help you decide which problem you want to try to solve if you have several on your plate at the same time. By answering each question, you can get a clearer idea of all of the aspects of solving a problem, and should be able to choose more easily and effectively. For a completed example of this chart, see the Examples section above.

	Problem 1	Problem 2
How frequently does the problem occur?
How many people are affected?
For what amount of time are they affected?
How severe is the effect?
How important do group members perceive the problem to be?
How important is the problem perceived to be by others?
How likely is it that we can solve/significantly improve the problem?
Are there any negative impacts?

A PowerPoint presentation summarizing the major points in the section.

What are "root causes?"

The term "root causes" is often used to describe conditions that help create or maintain a problem.

For relatively straightforward problems, it may be possible to identify a small number of underlying causes.

Many community problems, however, are more complex. They may develop through several interacting causes involving people, organizations, policies, resources, infrastructure, institutions, relationships, and broader social and economic conditions.

For that reason, it is often more useful to think in terms of underlying and contributing conditions rather than assuming that every problem has one root cause.

Understanding these conditions is an important part of the problem-solving process.

Cause analysis can help a group:

• Look beyond the most visible symptom
• Identify several places where change might be possible
• Examine individual, organizational, community, policy, and other system conditions
• Avoid assuming a preferred solution before understanding the problem
• Identify what additional evidence is needed

Cause analysis does not guarantee that the group will identify the correct response.

The explanations developed during the process should be treated as hypotheses to examine with evidence, community knowledge, implementation experience, and evaluation.

What is the "But why?" technique?

The "But why?" technique is a simple method for exploring conditions that may contribute to a community problem.

It is related to an approach often called the "Five Whys," although there is no required number of times that the question must be asked.

The technique begins with a clearly described condition.

Participants ask why that condition may be occurring.

For each proposed explanation, they ask another question such as:

• But why is that happening?
• What conditions make that possible?
• What evidence supports that explanation?
• What else could explain it?
• Could it have been prevented or reduced?
• What conditions would have to change?

The goal is not necessarily to arrive at one final answer.

One outcome may have several causes, and one contributing condition may lead to several additional questions.

The result may therefore look more like a branching map than a single chain.

A simple example

Suppose a community health program notices that evening appointments have a much higher no-show rate than daytime appointments.

The group might ask:

Condition: Evening appointments have a high no-show rate.

Q: Why might that be happening?
A: Some participants report difficulty getting to the site in the evening.

Q: Why is transportation more difficult in the evening?
A: Public transportation serving the site operates less frequently after 6:00 p.m.

Q: What evidence supports that?
A: Transit schedules and participant interviews show fewer evening routes and longer travel times.

But transportation may be only one pathway.

The group should also ask:

Q: What else could contribute to the no-show rate?
A: Some appointments overlap with work, caregiving responsibilities, or other obligations.

Q: Are there other possibilities?
A: Reminder messages may not reach everyone, and some participants may not know how to reschedule.

The analysis now identifies several possible intervention points rather than one supposed root cause.

Why should you identify underlying and contributing causes?

Taking action without understanding what contributes to a problem can lead to an intervention that addresses only a visible symptom or an incorrect assumption.

Cause analysis can help a group direct its resources toward conditions that meaningfully influence the outcome.

It can also reveal that several responses may be needed at the same time.

To distinguish immediate conditions from underlying ones

A community may need an immediate response while also addressing conditions that repeatedly produce the same problem.

For example, emergency food assistance can be essential for people who need food today.

Longer-term analysis might also examine:

• Food affordability
• Household income
• Transportation
• Availability of food retailers
• Eligibility and access to benefits
• Housing and other household costs
• Employment conditions

Immediate relief and efforts to change underlying conditions do not have to compete with one another.

To identify several possible intervention points

A problem may be influenced at several levels.

Depending on the issue, contributing conditions may involve:

• Individual knowledge, skills, behavior, or health
• Family, peer, or other interpersonal relationships
• Organizational practices
• Services and institutions
• Community resources and infrastructure
• Economic conditions
• Policies and laws
• Access to power and resources
• Physical environments
• Social norms and other contextual factors

Do not assume in advance that an individual behavior is the most important cause simply because it is easy to observe.

To avoid blaming people for conditions outside their control

Individual choices matter in many situations, but choices are made within social, economic, organizational, and physical environments.

For example, before concluding that people need more nutrition education, ask whether nutritious food is affordable, accessible, available, and practical within people's actual circumstances.

Before concluding that people need to make better use of a service, ask whether the service is available at appropriate times, physically and financially accessible, trustworthy, understandable, and responsive to community needs.

To identify structural and institutional conditions

Some problems are strongly influenced by:

• Policies
• Funding arrangements
• Institutional procedures
• Housing
• Transportation
• Employment conditions
• Education
• Discrimination
• Access to services
• Distribution of power and resources

These conditions may be less visible than individual behavior but can strongly shape what options people actually have.

To identify protective factors

Cause analysis should not focus only on what is going wrong.

Ask:

• Where is the desired outcome already occurring?
• What is different there?
• What strengths or resources are protecting against the problem?
• What existing practices should be preserved or expanded?

Understanding why a problem is less severe in some places or circumstances can reveal intervention possibilities that a deficit-only analysis would miss.

To improve community participation in analysis

People affected by a condition often have knowledge about barriers, resources, history, and everyday experience that organizations may not see in administrative data.

Meaningful participation can improve the analysis and help determine whether proposed explanations fit people's actual experiences.

Participation should not be framed as requiring community members to "own" a problem that may be influenced by institutions, policies, markets, or other actors outside their control.

Instead, clarify who has knowledge, who has decision authority, who controls relevant resources, and who can contribute to change.

When should you use the "But why?" technique?

The technique can be useful when:

• A group is describing symptoms but has not explored what contributes to them
• A proposed solution appears to assume a cause that has not been examined
• Participants have different explanations for why a condition exists
• The group wants to identify several possible intervention points
• An operational or organizational problem appears to involve a chain of contributing conditions

The technique is quick and inexpensive, but it should not be treated as sufficient for every problem.

Additional methods may include:

• Surveys
• Interviews
• Community listening sessions
• Administrative data
• Research evidence
• Observation
• Process mapping
• Causal diagrams
• System mapping
• Program evaluation

Use additional methods when the stakes are high, the problem is complex, participants disagree substantially about causes, or the group lacks evidence to support the proposed causal chain.

When immediate action is also necessary

Cause analysis should not delay urgent action needed to protect health, safety, rights, or basic needs.

A group can address an immediate harm while continuing to investigate why the condition occurred and how recurrence might be prevented.

How does the "But why?" technique work?

Technique Guide

1. Start with a clearly defined condition

Begin with a specific description of what is happening.

Avoid defining a population as the problem or embedding a preferred solution in the statement.

For example:

Participation in the program has declined by 25% during the past year.

is more useful than:

People do not care about the program.

The first statement describes a condition that can be investigated. The second assumes a cause.

2. Involve people with relevant knowledge

Depending on the issue, include people who:

• Experience the condition
• Have relevant community or lived knowledge
• Work directly with the program or system
• Have relevant professional or technical expertise
• Control resources or authority related to the problem
• May help implement change

Broad participation can improve the analysis, but it does not guarantee that every cause will be identified.

Consider power differences as well. Some participants may be less willing to challenge an explanation publicly when supervisors, funders, government officials, or other powerful participants are present.

Written, confidential, anonymous, small-group, or separate input may sometimes improve the quality of information.

3. Ask the first "Why?" question

Ask:

What conditions may be contributing to this?

Record several plausible answers rather than accepting the first explanation as the causal pathway.

4. Ask for evidence

For each proposed explanation, ask:

• What evidence supports this?
• Is this something we know, something participants have experienced, or a hypothesis we still need to test?
• Do other credible sources support it?
• Could another factor explain the same pattern?

This helps prevent a plausible story from becoming accepted as fact simply because it sounds convincing.

5. Continue along several branches

Each answer may lead to another question.

For example:

Condition: Evening appointment attendance is low.

Q: Why might attendance be low?
A: Some participants have transportation difficulties.

Q: Why are transportation difficulties especially important in the evening?
A: Transit service is less frequent after 6:00 p.m.

At the same time, another branch might be:

Q: What else may contribute?
A: Evening appointments overlap with work and caregiving responsibilities.

Q: Why are appointment options concentrated at those times?
A: Staffing and facility schedules limit the hours currently offered.

Another branch might examine reminders, rescheduling procedures, accessibility, or other conditions.

The purpose is to see the network of plausible contributing factors rather than forcing every observation into one chain.

6. Ask what could have prevented or reduced the condition

Prevention questions can reveal intervention points.

Ask:

• What could have prevented this?
• What could have reduced its likelihood or severity?
• What existing protective factors already reduce it in some places or circumstances?

7. Look beyond individual error or behavior

If the analysis reaches an answer such as:

Someone made a mistake.

continue asking:

• What conditions made the mistake more likely?
• Were instructions clear?
• Was training sufficient?
• Was workload reasonable?
• Did technology or equipment contribute?
• Did the process make errors easy to make or difficult to detect?

Individual accountability may still matter, but stopping at "human error" may hide system conditions that can be changed.

8. Examine several levels of the system

Depending on the issue, ask about:

• Individual conditions
• Interpersonal relationships
• Organizational processes
• Community resources
• Physical environment and infrastructure
• Economic conditions
• Policies and laws
• Distribution of power and resources

Not every problem requires analysis at every level. Use the levels that are relevant to the condition.

9. Look for relationships and feedback

Causes do not always operate in one direction.

A condition may create a response that later strengthens or weakens the original condition.

Ask:

• Does this factor affect another factor?
• Does that second factor eventually affect the first?
• Could an intervention create an unintended effect elsewhere?
• Does the importance of the factor change over time?

A systems map or causal diagram may be more useful than a simple chain when these relationships become complicated.

10. Identify what the group can influence

Once several contributing conditions have been identified, distinguish among factors the group can:

• Change directly
• Influence through partnership or advocacy
• Monitor but not directly control

This helps turn causal analysis into realistic intervention planning without pretending every underlying condition is within the group's authority.

11. Document uncertainty

At the end of the exercise, identify:

• Contributing conditions strongly supported by evidence
• Plausible conditions that need more investigation
• Explanations for which evidence is weak or conflicting
• Important information that is still missing

Do not force agreement on a causal explanation simply to complete the exercise.

12. Use additional analysis when necessary

The "But why?" technique is a starting point, not proof.

Follow it with other methods when necessary, including:

• Research
• Surveys
• Interviews
• Administrative data
• Observation
• Process mapping
• Systems mapping
• Evaluation

13. Compare possible intervention points

Cause analysis may reveal several possible places to act.

Compare them using criteria such as:

• Evidence
• Expected effectiveness
• Equity
• Safety
• Accessibility
• Feasibility
• Cost
• Organizational authority and capacity
• Sustainability
• Potential unintended consequences

Several interventions at different levels may be more appropriate than one solution directed at one supposed root cause.

14. Test the analysis during implementation

A causal analysis is a working explanation of how a problem operates.

Once action begins, monitor whether the expected changes actually occur.

Ask:

• Did changing the identified factor affect the outcome?
• Did another barrier become more important?
• Were there unintended effects?
• Did the problem affect different groups differently?
• Does the causal explanation need to be revised?

In Summary

The "But why?" technique is a useful way to move beyond an immediate symptom and begin exploring why a community problem may be occurring.

Its strength is its simplicity. Repeated questioning can reveal conditions that were not obvious when the problem was first described.

Its simplicity is also its limitation.

Complex community problems often result from several interacting causes rather than one root cause. A single chain of "why" questions can therefore produce an explanation that is too narrow or overly linear.

Use the technique to generate possible causal pathways, not to prove them. Ask what evidence supports each explanation, consider competing explanations, examine individual and system conditions, identify protective factors, and look for feedback and unintended consequences.

Include people affected by the condition along with others who hold relevant knowledge, responsibility, resources, or decision authority. Pay attention to power and create additional ways to contribute when people may not be comfortable challenging an explanation publicly.

Finally, connect cause analysis to action and learning. Compare possible intervention points, select responses using explicit criteria, monitor what happens during implementation, and revise the analysis when new evidence shows that the problem works differently than expected.

___You understand what root causes are

___You understand what the "but why?" technique is

___You understand why you should identify root causes

___You know when you should identify root causes

___You understand how the "but why?" technique works

___You know how to decide among the options you're left with from the "but why?" technique

___You know how to apply the "but why?" technique

"But why?" in Latin America

David Werner, a community health organizer in Latin America, used the "But why?" technique to get to the more fundamental, underlying causes of widespread ill health of villagers in Western Mexico:

"...(At first) I did not look far beyond the immediate causes of ill health. As I saw it, worms and diarrhea were caused by poor hygiene and contaminated water. Malnutrition was mainly caused by scarcity of food in a remote, mountainous area where drought, floods and violent winds made farming difficult and harvest uncertain.

Little by little, I became aware that many of their losses -- of children, or of land or of hope -- not only have immediate physical causes, but also underlying social causes. There is a photograph of a very thin little boy in the arms of his malnourished mother. The boy eventually died of hunger. The family was -- and still is -- very poor. Each year the father had to borrow maize from one of the big landholders in the area. For every liter of maize borrowed at planting time, he had to pay back three liters at harvest time. With these high interest rates, the family went into further debt. No matter how hard the father worked, each year more of his harvest went to pay what he owed to the landholder." - D. Werner, Helping Health Workers Learn, Front-7

 

The "But why?" method is not explicit in this story, but by asking "But why?" questions, Werner could help people analyze their problems, and prevent waste of tactics and resources. Using the "But why?" technique, he could see beyond the most obvious causes for the problems he was trying to eliminate. For instance, he learned that malnutrition may have more causes than simply lack of food.

Tool 1: Discussion Guide for Identifying Root Causes

A note to all readers/participants: This exercise is designed to help practice identifying underlying factors that are behind a community problem. We are calling these underlying factors "root causes." To identify "root causes," we will be using a technique called "But Why?"

Goal: To analyze a community problem by trying to determine its most fundamental reason, or "root causes."

Task 1: Select one member of your group to act as the "asker." This Person will be the one asking the "But why?" questions.

Task 2: Chose a issue to examine, a specific problem. Once the specific problem is identified and described, your "asker" will guide you in identifying what your group considers to be the "root causes" of that problem. The identification of root causes should be made by answering the "But why?" questions.

Task 3: After you have identified some key root causes for your priority problem, discuss what approaches might be undertaken to remove or counteract those root causes.

Possible Approach: _____________________________________________________

Possible Approach: _____________________________________________________

Possible Approach: _____________________________________________________

At this point, you should look at all possible approaches and select the one that fits your problem better, the one that is the best solution.

A PowerPoint presentation summarizing the major points in the section.

 

What are social determinants of health and development?

Health and development are influenced by far more than individual choices or access to medical care.

Social determinants of health are the conditions in which people are born, grow, learn, live, work, play, worship, and age, together with the wider systems and distribution of power, money, and resources that shape those conditions.

These conditions influence opportunities for health and well-being and help explain why some communities and populations experience better health outcomes than others.

Social determinants can include:

• Income and economic security
• Employment and working conditions
• Education access and quality
• Health care access and quality
• Housing
• Transportation
• Food access and affordability
• Neighborhood and environmental conditions
• Social support and community connection
• Discrimination and exclusion
• Public policies and institutional practices
• Access to political, economic, and social power

These determinants interact.

For example, unstable employment can affect income, housing, transportation, insurance or health care access, stress, and the amount of time available for family responsibilities. Poor transportation can affect access to work, school, food, health services, and community participation.

For many community health and development issues, there is no single social determinant or one root cause. Several conditions may operate together, and their importance may differ across communities and over time.

A practical framework

In the United States, one useful framework groups social determinants of health into five broad domains:

• Economic stability
• Education access and quality
• Health care access and quality
• Neighborhood and built environment
• Social and community context

These categories are useful for organizing analysis, but they should not be treated as isolated boxes.

Broader economic, social, environmental, and political systems can influence several domains at once.

Health equity

Differences in health are not automatically inequities.

Health inequities are differences that are linked to avoidable and unfair conditions or distributions of opportunity and resources.

Examining health equity means asking not only:

What is the average health outcome?

but also:

• Who experiences better or worse outcomes?
• What conditions contribute to those differences?
• Are some groups exposed to greater risks?
• Do some groups have fewer protective resources?
• Do the same health events have more serious consequences for some people because of economic, social, or institutional conditions?

Exposure, protection, and consequences

One way to examine social determinants is to consider how conditions affect:

1. Exposure. Are some people more likely to encounter environmental hazards, unsafe working conditions, violence, food insecurity, economic instability, or other risks?
2. Protection and access to resources. Do people have access to health care, safe housing, transportation, social support, legal protections, information, and other resources that can reduce risk?
3. Consequences. Does the same health or economic event create more serious effects for people with fewer financial reserves, less workplace flexibility, limited insurance, unstable housing, or other constraints?

These differences are produced by conditions, not by an inherent weakness of the people experiencing them.

Economic stability

Income, employment, job security, debt, benefits, and the cost of basic needs can affect health through many pathways.

Economic instability can influence:

• Housing stability
• Food security
• Transportation
• Access to health services and medication
• Exposure to stress
• Ability to take time away from work
• Educational opportunities

Avoid assuming that income alone explains an outcome. Examine how income interacts with costs, public benefits, household responsibilities, local services, discrimination, and other conditions.

Education access and quality

Education can affect health through employment opportunities, income, health literacy, social networks, access to information, and other pathways.

Relevant conditions can include:

• Early childhood opportunities
• School quality and resources
• Language access
• Disability access
• Safety
• Educational costs
• Opportunities for training and continuing education

More education does not automatically produce good health, and less formal education should not be treated as an individual deficiency. Examine the conditions connecting educational opportunity with health and development.

Health care access and quality

Health care is only one influence on health, but timely access to appropriate, high-quality services remains important.

Barriers may include:

• Cost
• Insurance or eligibility
• Distance and transportation
• Appointment availability
• Work schedules
• Disability access
• Language access
• Digital access
• Administrative complexity
• Quality of care
• Trust based on current or historical experiences with institutions

Neighborhood and built environment

Where people live can affect health through:

• Housing quality and stability
• Drinking water and sanitation
• Air quality
• Exposure to environmental hazards
• Transportation
• Street and pedestrian safety
• Parks and public spaces
• Food availability
• Broadband and other infrastructure
• Access to schools, services, employment, and health care

Describe these conditions directly rather than labeling communities as "blighted," "bad," or unhealthy.

Social and community context

Relationships and social conditions can influence health and development.

Relevant factors may include:

• Social support
• Community networks
• Civic participation
• Discrimination
• Social exclusion
• Community safety
• Trust
• Institutional relationships

Community connection can be protective, but do not assume that every family, neighborhood association, faith community, or other social network is equally available or beneficial to everyone.

Racism, discrimination, and exclusion

Discriminatory policies, practices, and treatment can affect access to:

• Employment
• Housing
• Education
• Health care
• Transportation
• Financial resources
• Public services
• Political and institutional influence

Discrimination can also produce chronic stress and affect trust in institutions.

Where inequities are linked to discrimination or institutional practice, identify those mechanisms directly rather than treating racial or ethnic identity itself as the cause.

Cultural context

Culture can shape communication, social relationships, food practices, beliefs about health, family roles, help-seeking, and other aspects of community life.

Culture should not be used as a convenient explanation for a health outcome without evidence.

Avoid assuming that everyone who shares a racial, ethnic, national, religious, or linguistic identity has the same beliefs or practices.

Use cultural humility:

• Ask rather than assume
• Recognize variation within communities
• Include relevant community knowledge
• Examine institutional barriers alongside individual practices

Language and communication access

People may experience barriers when important health, educational, employment, or public information is not available in a language or communication format they can use effectively.

Addressing the determinant may therefore involve improving:

• Interpretation
• Translation
• Accessible documents
• Plain-language communication
• Digital accessibility

The information and commercial environment

People's information environments now include television, news media, social media, online video, search systems, recommendation algorithms, advertising, influencers, messaging platforms, and AI-generated content.

These systems can influence:

• What health information people encounter
• Which products are promoted
• Perceptions of risk
• Social norms
• Trust in institutions and health information

Commercial conditions can also affect health through product design, pricing, marketing, availability, workplace practices, and business decisions.

Policy and governance

Laws, regulations, budgets, institutional rules, and public policies can shape health conditions at scale.

Policies may affect:

• Housing
• Employment and workplace protections
• Education
• Transportation
• Environmental exposure
• Food systems
• Health care
• Public benefits
• Civil rights and nondiscrimination

Policy choices may involve real tradeoffs among resources, costs, rights, economic interests, health, and other public priorities.

Analyze those tradeoffs directly rather than assuming that disagreement reflects bad motives.

Climate and environmental conditions

Environmental and climate conditions can affect health through heat, air quality, severe weather, infectious disease patterns, water availability, housing, food systems, displacement, and infrastructure.

These effects may be greater for people who have fewer resources to avoid or recover from hazards.

Why address social determinants of health and development?

Social determinants matter because interventions focused only on immediate symptoms may leave important conditions unchanged.

Addressing social determinants can:

• Prevent some health problems before they occur
• Reduce exposure to hazards
• Improve access to protective resources
• Reduce barriers to health care and other services
• Improve material and social conditions that influence health
• Reduce avoidable differences in health outcomes

This does not mean that immediate services should be withheld while organizations work on longer-term conditions.

A person who needs food, shelter, medical care, protection, or another urgent service needs an appropriate response now.

At the same time, organizations and communities can examine why the need keeps occurring and which conditions could be changed to reduce it.

Move beyond a single-root-cause model

Social determinants often operate through several interacting pathways.

For example, difficulty accessing preventive health care might involve:

• Cost
• Insurance
• Transportation
• Clinic location
• Work schedules
• Childcare
• Language access
• Disability access
• Appointment availability
• Trust

Several intervention points may therefore be more appropriate than one supposed root cause.

Improve prevention

Prevention often requires changing the conditions that repeatedly expose people to risk or limit access to protective resources.

For example, preventing waterborne disease involves not only knowledge about safe water but reliable infrastructure, water quality protections, sanitation, monitoring, and appropriate public-health response.

Reduce inequities

Overall health can improve while large differences between groups remain or even grow.

When evaluating a strategy, ask:

• Did average outcomes improve?
• Did people facing the greatest barriers benefit?
• Did gaps narrow, remain unchanged, or widen?
• Were new burdens or barriers created?

Who should address social determinants of community health and development?

Social determinants usually extend across sectors.

Health organizations alone cannot control housing, wages, transportation, education, environmental conditions, employment, or every other factor affecting health.

Depending on the issue, relevant participants and partners may include:

• People and communities directly affected
• Community-based organizations
• Public-health and health-care organizations
• Schools and educational institutions
• Housing organizations
• Transportation agencies
• Employers and workforce organizations
• Local, state, Tribal, territorial, or federal government
• Businesses
• Social-service organizations
• Researchers and evaluators
• Funders
• Advocacy organizations
• Other organizations with relevant authority, resources, expertise, or community relationships

Community engagement should be meaningful

People affected by an issue often hold knowledge that organizations and institutions do not.

Community engagement should therefore begin early enough to influence:

• How the problem is defined
• What priorities are identified
• Which strategies are considered
• How implementation occurs
• How success is evaluated

Engagement should not consist only of asking people for information after major decisions have already been made.

Be clear about power and decision authority

Collaboration does not automatically mean that everyone has identical authority.

Clarify:

• Who provides knowledge and experience
• Who makes recommendations
• Who controls funding or other resources
• Who has legal or institutional authority
• Who makes the final decision
• Who is responsible for implementation

Where shared governance is appropriate, establish it explicitly rather than implying shared power that does not actually exist.

Recognize community assets and self-determination

Communities are not empty settings waiting for outside organizations to provide capacity.

They already contain:

• Knowledge
• Relationships
• Organizations
• Leadership
• Informal support systems
• Skills
• Cultural and historical knowledge

External partners can contribute resources, technical expertise, connections, and support while respecting community priorities and existing strengths.

When should you address social determinants of community health and development?

Social conditions should be considered whenever they may meaningfully influence the issue.

They are particularly important to examine:

• When a health or development problem persists despite direct services
• When outcomes differ substantially among groups or places
• When people repeatedly encounter barriers to accessing services or opportunities
• When prevention is a major goal
• When policy, funding, or institutional change is being considered
• When environmental or economic conditions appear to influence the problem
• When an emergency reveals longstanding weaknesses in housing, transportation, communication, health care, food systems, or other infrastructure
• When a community is developing a long-term health or development strategy

When direct services are not enough

A service can be effective and still leave the conditions producing the need unchanged.

For example, a health organization may provide high-quality treatment while people continue to experience difficulty reaching the clinic because of transportation, cost, work schedules, or other barriers.

The appropriate response may include both the service itself and changes to the conditions affecting access.

When advocating for policy or funding

Policy and funding proposals should be based on a clear understanding of:

• The problem
• Who is affected
• Contributing conditions
• Expected benefits
• Costs and tradeoffs
• Possible unintended consequences
• How results will be evaluated

When focusing on prevention and community well-being

Prevention frequently requires action beyond individual education.

Knowledge matters, but so do the conditions that make healthier choices practical, affordable, safe, accessible, and sustainable.

How do you address social determinants of community health and development?

Addressing social determinants involves two broad tasks:

1. Understand which conditions influence the issue and how they interact.
2. Develop, implement, monitor, and adapt strategies that address conditions the organization or partnership can reasonably influence.

Identify relevant social determinants

Do not assume in advance which determinants are most important.

The same health outcome may have different contributing conditions in different communities.

Assess the community

A community assessment can combine:

• Community and lived experience
• Interviews
• Focus groups
• Surveys
• Administrative data
• Public-health data
• Geographic information
• Observation
• Research evidence
• Policy analysis
• Historical information
• Existing community assessments and plans

Talk with people who know the issue

Depending on the situation, this may include:

• People directly affected
• Community organizations
• Service providers
• Public officials
• Advocates and organizers
• Researchers
• Employers or businesses
• Other people or organizations with relevant knowledge

No individual should be expected to represent an entire racial, ethnic, religious, disability, neighborhood, professional, or other community simply because they belong to it.

Make engagement accessible

Consider:

• Language access
• Disability access
• Transportation
• Childcare or caregiving constraints
• Technology
• Meeting schedules
• Compensation where appropriate
• Confidential or anonymous participation where power differences create risk

Examine history

Current conditions may reflect earlier policies, investment patterns, institutional practices, economic changes, environmental decisions, or community experiences.

Ask:

• How did the present condition develop?
• What previous interventions were tried?
• What worked and what did not?
• Which groups experienced previous decisions differently?
• How have past experiences affected current trust?

Apply critical thinking

As you analyze the information:

• Check the accuracy and limitations of important evidence
• Distinguish evidence from interpretation
• Examine assumptions
• Consider competing explanations
• Identify important missing information
• Consider conflicts of interest and incentives
• Document uncertainty

Ask questions about distribution and power

Consider:

• Who is affected, and how?
• Where are outcomes better or worse?
• What conditions differ between those places or groups?
• Who controls relevant resources?
• Who has authority to change policies or practices?
• Who benefits from the current arrangement?
• Who bears the greatest costs or risks?
• What would action and inaction cost, and to whom?

Use the "But why?" technique carefully

Repeatedly asking why can help a group move beyond an immediate symptom.

Do not assume that the final answer in a chain is automatically the root cause.

Ask:

• What evidence supports this explanation?
• What else could contribute?
• Are several pathways operating at once?
• What protective factors are present?

For complex problems, process maps, causal diagrams, systems maps, or other tools may provide a more complete picture.

Develop strategies at appropriate levels

Social determinants can be addressed through many kinds of action.

Economic conditions

Depending on the issue and organizational authority, strategies may address:

• Employment opportunities
• Job quality and workplace conditions
• Income supports
• Benefits access
• Housing and food costs
• Financial barriers to services

Education and information

Education can be an important intervention when lack of useful information or skills contributes to an outcome.

It is less likely to be sufficient when the main barriers are structural.

For example, telling people how to use a service will not solve a problem if the service is unaffordable, inaccessible, unavailable, or does not meet their needs.

Health care access and quality

Strategies might address:

• Service availability
• Cost
• Location
• Transportation
• Scheduling
• Language and disability access
• Administrative barriers
• Quality and continuity of care

Social connection and community infrastructure

Communities may strengthen:

• Mutual support
• Community organizations
• Referral networks
• Civic participation
• Partnerships
• Community gathering spaces

Build on existing community relationships rather than assuming new organizations must always be created.

Access and administrative barriers

Organizations can examine whether their own systems create avoidable barriers through:

• Complicated eligibility rules
• Difficult application processes
• Excessive documentation requirements
• Limited hours
• Long wait times
• Inaccessible technology
• Lack of interpretation or translation
• Transportation barriers

Simplifying the process may sometimes be as important as expanding the service.

Environmental and occupational hazards

Reducing exposure may require:

• Enforcement of safety standards
• Infrastructure improvements
• Pollution control
• Safe water and sanitation
• Workplace protections
• Housing improvements
• Emergency preparedness

Use qualified technical expertise where interventions affect engineering, environmental safety, occupational health, utilities, or other specialized systems.

Policy and systems change

Policy can influence conditions for large numbers of people.

Potential actions may include:

• Changing organizational policy
• Improving implementation of existing policy
• Advocacy
• Administrative reform
• Funding changes
• Regulatory change
• Cross-sector agreements

Policy adoption is not the end of the process.

Monitor implementation, enforcement, access, and actual effects.

Use multisector collaboration when necessary

An organization may identify determinants it cannot directly control.

In that case, partnership may be necessary.

For example:

• A health organization may work with transportation agencies on access to care.
• A school system may work with housing and community organizations on student stability.
• Public-health agencies may work with planning departments on built-environment conditions.

Clarify responsibilities so collaboration does not mean that everyone is generally responsible and nobody is accountable for specific action.

Strengthen community capacity without treating communities as deficient

Capacity strengthening can include:

• Funding
• Technical assistance
• Leadership opportunities
• Data access
• Training requested by the community
• Stronger organizations and partnerships
• Support for community-led decision-making

Begin by identifying what capacity and assets already exist.

External organizations should not assume that community members need to be taught how to act in their own interests.

Start at a manageable scale when appropriate

A small organization may not be able to change every determinant affecting an issue.

It can still identify:

• Conditions it can change directly
• Conditions it can influence through partnership
• Longer-term policy goals

A focused pilot or staged approach may be appropriate when uncertainty is high or resources are limited.

Small steps should still connect to the broader analysis so that the organization does not mistake a limited intervention for a complete solution.

Monitor social determinants and health equity

Identify indicators that show whether relevant conditions are actually changing.

Depending on the strategy, monitor:

• Access
• Service use
• Economic conditions
• Housing stability
• Transportation
• Environmental exposure
• Education or employment outcomes
• Community experience
• Health outcomes

Where appropriate, examine whether outcomes differ among relevant groups or places rather than relying only on overall averages.

Evaluate effects and unintended consequences

Ask:

• Did the strategy change the determinant it was intended to change?
• Did health or development outcomes improve?
• Who benefited?
• Who did not?
• Did inequities narrow or widen?
• What unintended consequences occurred?
• What should be continued, changed, expanded, or stopped?

Adapt as conditions change

Social determinants are not static.

Economic conditions, policies, migration, climate, technology, services, institutions, and community priorities can change.

Continue to monitor the context and revise strategies when evidence shows that the original approach no longer fits.

Principles for collaborative action

Several principles can guide work on social determinants:

• Engage people affected by the issue early and meaningfully.
• Recognize multiple forms of knowledge, including community and lived knowledge, professional expertise, and research evidence.
• Build and maintain trust through transparent, reliable action.
• Recognize power differences and share decision-making where appropriate.
• Build on community assets and existing organizations.
• Match intervention scope to the evidence, problem, authority, and resources available.
• Work across sectors when the determinants extend beyond one organization's authority.
• Provide adequate resources for community participation and implementation.
• Monitor both overall outcomes and equity.
• Learn and adapt rather than assuming the original strategy will remain correct indefinitely.

In Summary

Social determinants of health and development are the social, economic, environmental, institutional, and policy conditions that shape people's opportunities for health and well-being.

They include conditions related to economic stability, education, health care, neighborhoods and the built environment, social and community context, and the broader systems that influence access to power, money, resources, protection, and opportunity.

These determinants interact. Complex health and development problems rarely have one social cause or one permanent solution.

Effective analysis therefore combines community knowledge, credible data, research, historical context, and an examination of policies, institutions, resources, power, and environmental conditions.

People directly affected by an issue should have meaningful opportunities to influence how it is understood and addressed. Engagement should be ongoing, accessible, trustworthy, and clear about decision authority.

Responses may include direct services, organizational changes, stronger access to resources, environmental improvements, economic strategies, community partnerships, policy change, and multisector action. Immediate assistance and longer-term structural action can occur together.

Finally, addressing social determinants requires monitoring and learning. Track whether relevant conditions change, who benefits, whether inequities narrow or widen, and whether unintended effects appear.

The goal is not to identify one root cause and declare the problem solved. It is to understand and improve the conditions that shape health, use the authority and resources available responsibly, and adapt as evidence and community conditions change.

What are social determinants of community health and development?

___Social determinants of community health and development issues are the social factors that determine and influence the issues.

___The three overarching factors are:

• Economic inequality
• Social connectedness
• Sense of efficacy

___The ways they most often play out are in:

• Differences in exposure
• Differences in vulnerability
• Differences in consequences for different populations

___More specific social determinants can include:

• Racial and ethnic bias
• Cultural differences
• Media influences
• Politics
• Living conditions
• Geography

Why address social determinants of community health and development?

___If you want to solve or prevent a problem for the long term, you have to deal with its root causes.

___If you address the root causes, you’re more likely to successfully address the issue for the short term as well.

___The social factors involved may have more resonance for those affected than the issue itself.

___It may be easier to approach an issue through its underlying social factors than to deal with it directly.

___Addressing the social determinants of community issues is crucial to understanding them fully, so that your strategy and tactics for dealing with them correspond to reality.

___Addressing social determinants presents a tremendous opportunity for learning and community leadership development.

Who should address social determinants of community health and development?

___Those affected by the issues (the targets of change).

___Those who can have an effect on the issues (the agents of change).

___Staff members from organizations that work directly with the target population and/or the issue.

___Respected community leaders and citizens.

___Those who will be asked to change, sacrifice, or take action in order to address the issue.

___Anyone else who has a stake in the issue.

When should you address social determinants of community health and development?

___When it’s clear that simply focusing on the issue isn’t enough.

___When you’re advocating for changes in laws, policies, or funding.

___When you’re seeking fundamental change.

___When you’re seeking a long-term solution to a long-term problem.

___When your focus is on community wellness and prevention.

How do you identify social determinants of community health and development?

___You assess the community.

___You ask people who know.

___You apply critical thinking principles to the issue.

___You ask the right questions.

How do you address social determinants of health and community development?

___You work to address larger social factors through environmental and policy conditions, including:

• Knowledge and skills
• Support within and between groups
• Modification of access to, barriers to, and opportunities for resources and services
• Consequences of actions
• Exposure to or protection from hazards
• Policy change

___You’re guided by these basic principles:

• People most affected should choose the issues and plan strategies for the work.
• True change in social determinants demands comprehensive interventions that address multiple and interrelated factors at multiple levels.
• Collaborative efforts should aim at bringing about change in multiple sectors and systems.
• Support organizations should build capacity in the community to control its own fate.
• Health and development efforts should involve collaborative partners as catalysts for change.
• Strategies should be self-sufficient and sustainable over the long term.
• Efforts should be aimed at goals that can be accomplished by the people in question with the resources at hand.
• Successes should be consolidated and maintained, so that new and greater challenges can be taken on.
• Efforts should continue indefinitely.

Example #1: Meet the Wonder Women of Indonesia

Rovina is one of hundreds of "wonder women" in Kopernik’s Wonder Women initiative that has empowered women to become clean energy micro-social-entrepreneurs, connecting life-changing solar lights, clean cookstoves, and water filters with last mile communities in some of Indonesia's poorest provinces.

More than 80 million people live without any electricity in Indonesia, and many more live with unreliable access to electricity.

Almost 100 million people rely on smoky, fuel-hungry three-stone fires for cooking.

And clean drinking water is often a costly luxury.

There is great demand for affordable, clean energy technologies, especially in the poorest provinces of eastern Indonesia, but geography and demography make energy access a huge challenge.

This is where Kopernik's Wonder Women Eastern Indonesia initiative comes in.

Equipping women with the skills and resources to become clean energy micro-social entrepreneurs is a viable, sustainable way of connecting these technologies with the people who need them the most.

Read more

 

 

Example #2: Community Health And Literacy Center: A Health, Literacy & Recreation Hub

The Community Health and Literacy Center, formed out of a collaboration between the Children’s Hospital of Philadelphia (CHOP) and the City as unexpected partners, worked together to bring a neglected neighborhood both improved access to health care and health, promoting recreation and literacy opportunities.

The center, which opened in the spring of 2016, is a first-of-its-kind hospital-city partnership. The project includes a CHOP pediatric clinic; a full-service community health center run by the city’s department of public health; a branch of the Free Library of Philadelphia; and a modern recreation center with a playground and green space, run by the city’s Department of Parks and Recreation. It offers welcoming outdoor space for the neighborhood and an indoor community meeting space. The location has excellent public transit access, with a subway stop on site. CHOP and the city are working to integrate services and programming as a way to have more of an impact on improving population health.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #3: Vita Health & Wellness District: Health at the Center of a Neighborhood Transformation

The Vita Health & Wellness District project was established through a partnership between the Stamford housing authority and Stamford hospital to revitalize an impoverished inner city area, in Stamford Connecticut, into a mixed-income community with expanded neighborhood services centered around a sustainable urban farm. Addressing the social determinants of health provide a framework for managing the neighborhood transformation in ways that would support and strengthen the existing community.

The Vita project is a great example of how a hospital can fulfill the Affordable Care Act’s mandate to engage its community by partnering to address the social determinants of health. The project also demonstrates how a forward-thinking community development organization can effectively partner with the health sector to pursue comprehensive community revitalization that could not have been achieved otherwise. These are still early days in what promises to be a fruitful and long-lasting partnership.

Read more about the Vita Health & Wellness District project on the Building Healthy Places Network blog.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #4: Rolling Hills Apartments: Weaving Together Opportunities for Healthier Lives for a Diverse Immigrant Community

Twin Cities LISC, a local community development financial institution, has partnered with local organizations and city agencies to create quality affordable housing with improved healthcare access, including constructing a Federally Qualified Health Center. LISC also employed community health advocates to weave together the isolated health-related efforts in the neighborhood of focus into a cohesive health agenda. More specifically, they connect and help support existing efforts, identify and help address gaps, and facilitate the conversations and activities that sustain collaboration.

Learn how social determinants of health are being addressed to build healthier lives for immigrants in St. Paul, Minnesota in this Community Close-Up from the Building Healthy Places Network.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #5: Revitalizing People and Place with a Healthy Food Hub Origin

Following the devastation of Hurricane Katrina in New Orleans, the founders of what became Broad Community Connections (BCC) began to attend community meetings, and investigate with their fellow community members how to rebuild a city in disarray. These discussions highlighted many of the problems that many central New Orleans resident had faced even before the storm, including but not limited to economic disadvantage, community disinvestment, health disparities, and lack of access to many needed goods and services. BCC was designed to revitalize Broad Street, a commercial thoroughfare running through the heart of the city and to connect several of the central city neighborhoods.

Founded in 2008, BCC set its sights on improving health and improving economic vitality in the area. Ultimately, the ReFresh project provided a high-quality grocery store to a low-income food desert and created a multi-faceted hub to improve healthy food access and local food systems, foster community connectivity, support youth development, and anchor economic development.

Read more about the ReFresh project in New Orleans on the Building Healthy Places Network blog.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #6: Under One Roof: Health Care and Social Services in the Same Place

The Chicanos Por La Causa (CPLC) is the largest community development corporation based in Arizona. CPLC is committed to building stronger, healthier communities as a lead advocate, coalition builder, and direct service provider. CPLC helps more than 200,000 people through programs in four areas–housing, economic development, education, and health and human services. CPLC recognizes that the needs of the families it serves are complex as a family rarely approaches the CDC with only one need. As a result, CPLC sought to establish cross-sector partnerships that would more effectively and holistically meet the needs of families.

Read more about CPLC on Rooflines - The Shelterforce Blog, from the National Housing Institute.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #7: Boston Children’s Hospital Community Asthma Initiative

The Community Asthma Initiative (CAI), an initiative of Boston Children’s Hospital, began addressing health disparities in Boston neighborhoods impacted by asthma in 2005. CAI provides an enhanced model of care, which includes asthma education and home visits for families with children ages 2–18 living in the Greater Boston area that were previously treated in the Emergency Department (ED) or hospitalized as a result of asthma. CAI works with partners and coalitions to address asthma health disparities by implementing changes in policies at the local and state levels. As of June 2014 there were reductions in the number of children with ED visits, hospitalizations, missed school days, and missed work days for parents.

Read more about the Community Asthma Initiative from the National Forum on Hospitals, Health Systems & Population Health.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #8: It’s Not Just About the Buildings: How Community Development Organizations are Promoting Residents’ Mental Health

Around the country, housing and community development groups are increasingly stepping up to partner with residents to improve community well-being by proactively strengthening residents’ emotional and mental health. Read more.

Example #9: Pilot Project Directs Healthcare Resources to Rural Missouri

A pilot project has been announced that plans to improve health outcomes in rural Missouri communities. It’s a collaborative effort between the Missouri Department of Social Services and the MO HealthNet Division.

The Transformation of Rural Community Health (ToRCH) project focuses on addressing social care challenges that impact residents’ ability to maintain their health and manage chronic conditions.

“(It’s) a groundbreaking initiative that empowers and encourages rural communities to collaborate to address healthcare-related social needs among their Medicaid population, with a focus on driving better health outcomes,” said Robert Knodell, Missouri Department of Social Services Director.

One key focus of the project is to tackle social determinants of health that influence overall wellbeing – safe housing, transportation, access to healthy foods, and physical activity opportunities. The U.S. Department of Health and Human Services explained that these needs influence the conditions where people are born, grow, learn, work, play, worship, and age.

“For too long, our payment systems have failed to reward hospitals for efforts to address some of the root causes of poor health,” said Kirk Mathews, MHD Chief Transformation Officer, “The ToRCH program allows hospitals to receive payment for proactively addressing issues that contribute to poor health outcomes. Under this model, hospitals are empowered to truly be in the ‘healthcare’ business in addition to the ‘sick care’ business.”

Six rural hospitals were selected last June as part of the pilot project, in Salem, Clinton, Sedalia, Rolla, Bolivar, and Richmond. The funding allows them to act as community hubs.

Click here to read the full article at the MissouriNet website.

A PowerPoint presentation summarizing the major points in the section.

• Before you start

• Generating solutions

• Evaluating solutions

• Making a decision

 

 

Once a group has defined and analyzed a problem, the next task is to decide what might be done about it.

The first idea that comes to mind is not necessarily the most effective, feasible, or appropriate response. There may also be several reasonable options, each with different benefits, costs, risks, and tradeoffs.

A useful solution-development process therefore separates several tasks:

• Generate a range of possible responses
• Clarify and improve the options
• Compare them using explicit criteria
• Use the appropriate decision process
• Document the decision, assumptions, and next steps

Group participation can broaden the range of ideas and knowledge available, but the group should also be clear about who is providing input, who has decision authority, and who will be responsible for implementation.

Before you start

Good idea generation depends less on creating a particular atmosphere than on creating conditions in which people can contribute meaningfully.

Before beginning, make sure participants understand:

• The problem as it is currently understood
• The intended outcome
• Important evidence and uncertainties
• What is within and outside the group's authority
• Important legal, ethical, safety, budgetary, or policy constraints
• How the final decision will be made

Create conditions for useful participation

People are more likely to offer developing or unconventional ideas when they do not expect ridicule, retaliation, or immediate dismissal.

Encourage participants to:

• Ask questions
• Suggest ideas that are not yet fully developed
• Challenge assumptions respectfully
• Build on another person's idea
• Identify concerns and uncertainties

This does not require every idea to be praised or ultimately accepted. Evaluation comes later, but respectful clarification is appropriate throughout the process.

Make participation accessible

Physical comfort matters because unnecessary discomfort can interfere with concentration and participation.

Depending on the setting, consider:

• Accessible meeting space
• Seating
• Restrooms
• Lighting and acoustics
• Temperature
• Breaks
• Water or refreshments where appropriate
• Language access
• Captioning or interpretation
• Accessible electronic or printed materials
• Remote participation where needed
• Technology that participants can use effectively

Do not assume that one environment or activity will make everyone equally comfortable.

Use introductions or relationship-building only when useful

If participants do not know one another, a brief introduction may help establish who is present and what knowledge or role each person brings.

Do not require personal disclosures, games, or unrelated icebreakers simply because the group is beginning a creative activity.

Review relevant evidence before generating solutions

Creativity is more useful when participants understand the problem.

Depending on the issue, review:

• Relevant data
• Community and lived experience
• Previous efforts
• Research evidence
• Available resources
• Policy or legal requirements
• Important uncertainties

If a group does not have enough information to evaluate possible responses responsibly, gather additional evidence before making a high-stakes decision.

Generating solutions

The purpose of idea generation is to develop a reasonable range of options before committing to one.

Different methods work well for different groups. The facilitator should choose a process that fits the number of participants, available time, accessibility needs, power relationships, and complexity of the problem.

Generate ideas individually

One useful approach is to give participants several minutes to think and write independently before group discussion begins.

This can give people time to develop ideas without immediately being influenced by the first suggestion or by the most vocal or highest-status participant.

Ideas can be written on:

• Paper or cards
• A shared document
• A digital whiteboard
• An anonymous form

Use a structured round

Participants can take turns offering one idea at a time.

Allow someone to pass rather than requiring every person to contribute on every round.

Continue until the allotted time ends or the group has no significant new ideas to add.

Use brainwriting

Brainwriting allows participants to develop ideas in writing and build on one another's suggestions.

For example:

1. Each participant writes one or more possible responses.
2. Ideas are shared with other participants.
3. Participants add questions, extensions, or related possibilities.
4. The ideas are collected and reviewed by the group.

This method can be useful when participants prefer written reflection, when the group is large, or when rapid spoken discussion would make participation difficult.

Use brainstorming

Brainstorming can help a group generate options quickly.

During the initial idea-generation stage:

• Focus on generating possibilities rather than choosing among them
• Avoid premature criticism
• Allow clarification when an idea is not understood
• Encourage participants to combine or build on ideas
• Record ideas where participants can review them

Brainstorming does not require pretending that every conceivable action is acceptable.

Ideas should remain within relevant:

• Legal requirements
• Ethical boundaries
• Safety requirements
• Respect for people's dignity and rights
• The legitimate scope of the group's work

Within those boundaries, avoid rejecting an idea simply because it is unfamiliar or different from what the organization usually does.

Ask what assumptions are limiting the options

A group may narrow the solution space without realizing it.

Ask:

• What are we assuming cannot change?
• Are we assuming we must create something new?
• Are we assuming our organization must do this alone?
• Are we assuming the current budget, process, location, schedule, or staffing model cannot change?
• Which constraints are real, and which are assumptions?

Look for existing approaches

Generating solutions does not mean every solution must be invented from scratch.

Ask:

• Is something already working within part of the community?
• Has another organization addressed a similar problem?
• Is there relevant research or practice guidance?
• Could an existing program be improved, expanded, or made more accessible?

Consider different types of response

Possible options might include:

• Improve an existing program or process
• Create a new intervention
• Change a policy or procedure
• Remove an unnecessary barrier
• Partner with another organization
• Refer the issue to an organization with greater authority or expertise
• Test a small pilot
• Implement the change in stages
• Stop an ineffective activity
• Continue the current approach while collecting additional information

Include the current approach or taking no additional action when it is a legitimate option. This gives the group a comparison point for judging whether a proposed change is actually better.

Use anonymous input when appropriate

Anonymous or confidential contribution may be useful when:

• Participants have different levels of authority
• A supervisor or funder is present
• People may experience consequences for challenging the current approach
• The issue is sensitive

Anonymous input does not eliminate every power difference, but it can provide another route for ideas or concerns that may not emerge publicly.

Know when to stop generating

More ideas are not always better indefinitely.

Stop when:

• The agreed time has ended
• Few genuinely new ideas are emerging
• The group has a sufficiently broad range of realistic options to evaluate

New alternatives can still be added during evaluation if an important option was overlooked.

Evaluating solutions

After generating a range of possibilities, clarify the options and compare them systematically.

The goal is not simply to identify which idea people like best.

The group should ask which option, combination of options, or staged approach best fits the problem, evidence, values, resources, responsibilities, and constraints.

Clarify each option

Before evaluating an idea, make sure participants understand what it actually proposes.

For each option, clarify:

• What would be done
• Who would be responsible
• Who would be affected
• What resources would be required
• What outcome the option is expected to influence

Establish evaluation criteria

Agree on important criteria before participants become strongly attached to one option.

Criteria may include:

• Evidence: What evidence suggests this approach could work?
• Expected effectiveness: How likely is it to improve the intended outcome?
• Feasibility: Can it be implemented with available or obtainable staff, time, resources, technology, partnerships, and authority?
• Cost: What resources will it require?
• Opportunity cost: What other work may receive fewer resources if this option is chosen?
• Equity: Who is likely to benefit, and who may be left out or experience additional burdens?
• Accessibility: Can the people who need the intervention actually use or participate in it?
• Safety: What risks could it create or reduce?
• Legal and ethical fit: Is the approach consistent with relevant rights, responsibilities, policies, laws, and ethical requirements?
• Community and participant impact: How do people affected by the proposal understand its likely benefits, barriers, and consequences?
• Organizational fit: Is it consistent with the organization's legitimate mission and responsibilities?
• Sustainability: What would be needed to maintain the approach if it proves useful?
• Unintended consequences: What additional positive or negative effects might occur?
• Reversibility: If the approach does not work as expected, how difficult would it be to modify or stop?
• Evaluation: How would the group know whether it was working?

Not every criterion will carry the same weight.

Identify which considerations are requirements, which are priorities, and which involve tradeoffs.

Examine evidence and uncertainty

For each option, distinguish:

• What is supported by strong evidence
• What is supported mainly by local experience or professional judgment
• What assumptions the option depends on
• What remains uncertain

Absence of perfect evidence does not always mean that no action should be taken.

It may mean that the response should be proportionate to the uncertainty and monitored carefully.

Examine who benefits and who bears burdens

Do not look only at the overall effect.

Ask:

• Who gains access, resources, protection, or opportunity?
• Who may face new costs, requirements, risks, or barriers?
• Are some effects concentrated among people with less decision-making power?
• Can harmful effects be prevented or reduced?

Consider implementation early

An option can appear promising on paper and still fail because the conditions for implementation are missing.

Ask:

• Who would lead implementation?
• What authority would they need?
• What staffing and training are required?
• What partners or approvals are needed?
• What dependencies could delay the work?
• How long would implementation take?

Consider a pilot

When an option is promising but uncertainty remains, a smaller or time-limited pilot may be appropriate.

Before beginning, specify:

• What the pilot is intended to test
• What outcomes will be monitored
• How long it will run
• What would justify continuing, expanding, modifying, or stopping it

Use a decision matrix where helpful

A group can place options in rows and criteria in columns and compare how well each option meets the criteria.

This can make tradeoffs easier to see.

If numbers or scores are used, remember that they summarize judgments. They should not create an impression of mathematical certainty where the underlying evidence or values remain uncertain.

Improve or combine options

Evaluation does not have to leave each idea unchanged.

The group may:

• Modify an option to reduce a risk
• Combine useful parts of several options
• Implement different strategies for different parts of the problem
• Stage actions over time

Remove options that do not meet necessary requirements

Some options may be eliminated because they:

• Violate a legal, ethical, or safety requirement
• Fall outside the organization's authority
• Require resources that cannot reasonably be obtained
• Are unlikely to address the problem
• Create harms that cannot be adequately reduced

For important decisions, record why major options were rejected.

Making a decision

Before deliberating among the final options, participants should understand who has authority to make the decision and what process will be used.

Common approaches include:

• An accountable person makes the decision
• An accountable person makes the decision after consultation
• A delegated team or committee decides
• The group votes according to established rules
• The group uses consensus
• The group uses consent or another established decision method

No single method is best for every decision.

The method should fit:

• Formal decision authority
• Governance requirements
• The importance and reversibility of the decision
• Available time
• The need for expertise or community participation
• Who will be accountable for the outcome

Decision by an accountable person

Sometimes one person is responsible for the final decision.

That does not prevent the person from seeking information and advice from others.

Be clear from the beginning that consultation is informing the decision rather than transferring final authority to the group.

Voting

Voting can be appropriate when the group has formal decision authority and voting rules are established.

Follow applicable requirements involving:

• Quorum
• Voting thresholds
• Conflicts of interest
• Abstentions

Avoid inventing a voting threshold only after the group sees how members are divided.

Consensus

Consensus can be useful when broad support is important and the group has enough time to examine disagreements carefully.

Define what consensus means before using it.

Depending on the group, it might mean:

• Unanimous agreement
• Agreement that everyone can support the decision
• No participant has a defined blocking objection

These are not the same standard.

Consensus should not require someone to hide a serious concern simply so the group can report agreement.

During consensus discussion

Encourage participants to:

• Listen carefully to reasoning they disagree with
• Explain the evidence or values behind their concerns
• Change their position when new evidence or reasoning warrants it
• Avoid changing their position merely to end the discussion
• Look for modifications that address legitimate concerns

A compromise or third option can sometimes resolve disagreement, but it is not automatically better simply because more people find it acceptable.

Structured ranking and nominal group technique

Structured methods can help when a group has many options or when some participants are likely to dominate open discussion.

One method is the nominal group technique.

A typical process includes:

1. Participants generate ideas silently and independently.
2. Ideas are shared in a structured round.
3. Participants clarify and discuss the options.
4. Participants privately rank or vote on priorities.
5. Results are summarized and used according to the group's established decision process.

A ranking can inform the decision without necessarily determining it automatically.

If the group intends the ranking to determine the final choice, establish that rule before participants rank the options.

What if the group cannot decide?

Whenever possible, establish the fallback process before deliberation begins.

If the group cannot reach the required decision threshold, it may:

• Use another authorized decision method
• Gather missing evidence
• Seek legal, financial, technical, or community input
• Modify the options
• Pilot one or more approaches
• Refer the decision to the person or body with appropriate authority
• Defer the decision when additional time would serve a clear purpose

Deferral should not become a way to avoid a difficult decision indefinitely.

Protect dissent and unresolved concerns

Disagreement does not automatically mean that the process failed.

A participant may identify a risk or consequence that the majority considers acceptable but that still deserves documentation.

Depending on the setting, record:

• Significant unresolved concerns
• Dissenting positions where relevant
• Information that must still be gathered

Document the decision

Once a decision is made, clarify:

• What was decided
• Who made the decision
• What decision method was used
• Which criteria were most important
• Major evidence and assumptions
• Important tradeoffs or unresolved concerns
• Who is responsible for implementation
• What happens next

Ask for process feedback

After an important decision, useful questions may include:

• Was the decision process clear?
• Did participants have appropriate opportunities to contribute?
• Were the important criteria and evidence considered?
• Are there material concerns that still need to be documented or addressed?
• Are responsibilities and next steps clear?

Do not require everyone to say that they are completely satisfied with the outcome.

A legitimate decision may still involve disagreement or tradeoffs.

In Summary

Generating and choosing solutions requires both creativity and disciplined judgment.

Begin with a clear understanding of the problem, relevant evidence, important constraints, decision authority, and the outcome the group hopes to achieve.

Generate several options before committing to one. Use methods that give people different ways to contribute, including individual reflection, written or anonymous input, structured rounds, brainstorming, and collaborative idea development.

Then evaluate the options using explicit criteria. Consider evidence, effectiveness, feasibility, cost, equity, accessibility, safety, legal and ethical requirements, organizational authority, sustainability, unintended consequences, and how results will be measured.

Choose a decision method that fits the situation. Consensus can be useful, but it is not automatically preferable to voting, delegated authority, consultation followed by an accountable decision, or another established process.

Finally, remember that selecting a solution does not complete the problem-solving process. Clarify responsibility, document assumptions and tradeoffs, plan implementation, monitor results, and be prepared to modify the approach when evidence shows that it is not working as expected.

___You understand that it's important to make people comfortable to stimulate creativity and to promote open discussion of ideas.

___You understand that you can make people comfortable both through team-building activities and by providing physical comfort.

You understand the different methods used to generate solutions:

___Simply go around the room and suggest ideas

___Send a piece of paper around the room

___Idea writing

___Brainstorming

You know how to evaluate solutions:

___You have judged each idea independently.

___You have determined whether each idea is practical, effective, cost-effective, easily put into practice, accepted by everyone involved, and consistent with other things done by the group.

___You have modified the solution where necessary.

You understand the different ways to make a decision:

___You can have one person decide, and announce the decision to the group.

___You can gather input from individuals, and then have one person decide.

___You can gather input from the group, and then decide.

___You can vote.

___You can try to build consensus among everyone at the meeting.

You know what to do if the discussion doesn't result in an agreement accepted by everyone:

___You can try one of the other decision-making possibilities listed above.

___You can try the nominal group technique.

___You can choose not to decide.

A PowerPoint presentation summarizing the major points in the section.

• Why should you plan your action?

• How do you plan your action?

• How do you implement your solution?

• Evaluating what's happened

• What can go wrong, and what to do about it

A group can spend substantial time defining a problem, examining its causes, generating possible responses, and choosing an approach. None of that guarantees that the decision will actually be carried out.

Implementation is the part of the problem-solving process in which a proposed solution becomes organized action.

It requires more than enthusiasm or agreement. People need to know what will happen, who is responsible, what resources and authority are available, when important steps are due, how progress will be monitored, and what the group will do when conditions change.

This section focuses on turning a selected approach into an action plan, implementing it, evaluating what happens, and adapting when the plan does not work as expected.

Why should you plan your action?

Planning creates a practical bridge between a decision and implementation.

A useful action plan can:

• Clarify the scope of the work
• Assign responsibility
• Identify required resources and authority
• Establish milestones and deadlines
• Identify dependencies among tasks
• Anticipate major risks and barriers
• Establish how progress and outcomes will be monitored
• Make follow-up easier

Planning cannot anticipate every problem.

Conditions may change, assumptions may prove wrong, resources may become unavailable, or implementation may create unexpected effects.

A good plan should therefore provide enough structure for coordinated action while allowing responsible adaptation.

Match the planning effort to the work

A small, low-risk action may need only a responsible person, deadline, and brief written record.

A larger or higher-risk intervention may require:

• A detailed action plan
• A budget
• Formal approvals
• Contracts or procurement
• Staff or volunteer training
• A communication plan
• An accessibility plan
• A data and evaluation plan
• Risk and contingency planning
• A longer implementation timeline

Do not create a complicated planning process for work that does not need one.

At the same time, do not rely on informal verbal agreements for a project whose success depends on many people, organizations, resources, or deadlines.

How do you plan your action?

Confirm what was decided

Before developing the implementation plan, make sure the selected approach is clearly described.

Ask:

• What problem or condition is this intended to address?
• What outcome do we expect?
• Who made or authorized the decision?
• What assumptions does the approach depend on?
• What important risks or uncertainties remain?

If the solution has changed so much during decision-making that it no longer clearly addresses the original problem, revisit the analysis before implementation begins.

Describe how the solution is expected to work

For a complex intervention, it can help to describe the connection between:

• Resources or inputs
• Activities
• Immediate outputs
• Short-term outcomes
• Longer-term outcomes
• Important contextual factors and assumptions

This can be written as a logic model, program roadmap, theory of change, or another format that clearly shows how the group expects its activities to produce results.

The purpose is not to create paperwork for its own sake. It is to make assumptions visible so they can be tested during implementation and evaluation.

Break the solution into action steps

Identify the work required to move from the decision to implementation.

Depending on the project, action steps may involve:

• Approvals and governance
• Staffing or volunteer roles
• Partnerships
• Funding
• Procurement
• Facilities
• Technology
• Accessibility
• Training
• Communications
• Participant recruitment or outreach
• Data collection
• Evaluation

Example

Suppose a community health program has found that evening appointments have a high no-show rate. After examining several causes and possible responses, the organization decides to pilot later transit support, more flexible appointment times, and a simpler rescheduling process.

Action steps might include:

• Confirm which transportation partner can support the pilot
• Identify the appointment times and participants included in the pilot
• Update scheduling and rescheduling procedures
• Make information available in accessible formats and appropriate languages
• Train staff on the revised process
• Establish baseline attendance data
• Define measures for attendance, access, participant experience, cost, and unintended effects
• Establish a review date and criteria for continuing, modifying, expanding, or stopping the pilot

This type of planning connects implementation directly to the problem analysis and to the evidence that will later be used to judge results.

For each action step, answer the key questions

What will be done?

Describe the task clearly enough that the responsible person knows what completion means.

Who owns it?

Identify one person or role with primary responsibility for making sure the task moves forward.

Other people may provide support, advice, approval, or information.

Make clear who:

• Is responsible for doing the work
• Is accountable for completion
• Must be consulted
• Needs to be informed

Do not assign someone responsibility without considering whether they have the authority, time, skills, resources, and role needed to carry it out.

What is the timeline?

Identify:

• Start date
• Deadline
• Important milestones
• Dependencies

Some activities cannot begin until another task is finished. Others can occur at the same time.

Make timelines realistic enough to support planning rather than simply choosing the earliest possible date.

What resources are needed?

Resources may include:

• Funding
• Staff or volunteer time
• Expertise
• Equipment
• Technology
• Facilities
• Data
• Training
• Partnerships

Identify where those resources will come from and what happens if they are not available.

What approvals or authority are required?

Determine whether the step requires:

• Leadership approval
• Board or committee action
• Government authorization
• Contract or procurement approval
• Legal or compliance review
• Partner agreement

Do not assign responsibility to someone who cannot legally or organizationally authorize the work.

What accessibility and inclusion requirements apply?

Consider accessibility during planning rather than adding it after implementation begins.

Depending on the activity, this may include:

• Physical access
• Language access
• Communication accommodations
• Accessible electronic materials
• Transportation
• Scheduling
• Technology access

What could interfere with the work?

Identify major risks and dependencies.

For each important risk, consider:

• How likely is it?
• What would the effect be?
• What warning signs should be monitored?
• What can reduce the likelihood or impact?
• What is the contingency plan?
• Who decides whether the contingency plan is activated?

How will progress be monitored?

Decide before implementation begins:

• What information will show whether the step is on track
• Who will collect or review that information
• How often it will be reviewed
• What would trigger follow-up or escalation

Establish a source of truth

Put the action plan in an approved location where the people responsible for the work can find the current version.

The plan may be maintained in:

• A shared action-plan document
• A spreadsheet
• A project-management system
• Another organizational system

Avoid keeping the only current version in one person's notes or email.

For complex work, document significant changes to scope, budget, responsibilities, timeline, or strategy.

How do you implement your solution?

Implementation is not simply carrying out a finished plan.

It is a period in which assumptions, capacity, partnerships, and real-world conditions are tested.

Confirm responsibilities

Before work begins, each responsible person should understand:

• Their task
• Deadline
• Available resources
• Decision authority
• Dependencies
• How to raise a problem or request assistance

Responsibility may be accepted voluntarily, assigned as part of a legitimate staff role, or established through another appropriate organizational process.

Do not pressure volunteers into responsibilities they have not agreed to take on.

Use appropriate communication channels

Identify how project participants will communicate about:

• Routine updates
• Questions
• Delays
• Decisions
• Urgent risks

Use appropriate organizational contact methods rather than requiring people to disclose personal telephone numbers or other private contact information.

Monitor implementation as it happens

Ask:

• Are activities occurring as planned?
• Are milestones being met?
• Are resources sufficient?
• Is the intervention reaching the intended participants?
• Is the quality of implementation acceptable?
• Are barriers or unintended effects appearing?

Monitoring allows the group to respond before a missed milestone becomes a major implementation failure.

Use meetings when they are useful

A follow-up meeting may be useful when people need to:

• Make a decision
• Resolve an interdependent problem
• Examine evidence together
• Coordinate significant changes

Routine status information may be shared asynchronously.

Do not schedule recurring meetings merely because meetings were part of the original plan.

Adapt responsibly

Some implementation changes can be made by the person responsible for the work. Others may affect budget, scope, legal requirements, evaluation, community commitments, or strategy and require additional approval.

Establish in advance:

• What can be adjusted routinely
• What requires approval
• Who has authority to approve it
• How significant changes will be documented

Evaluating what's happened

Evaluation should begin during planning, not after implementation is finished.

Before the work begins, identify what the group needs to learn and what evidence will answer those questions.

Evaluate the implementation process

Process or implementation evaluation asks whether the intervention was carried out as intended and what helped or hindered it.

Questions might include:

• Were planned activities completed?
• Were they completed on time?
• Who was reached?
• Who was not reached?
• What resources were used?
• What barriers affected delivery?
• What adaptations were made?
• Was implementation quality consistent with what was intended?

Evaluate outcomes

Outcome evaluation asks whether the intended results occurred.

Depending on the project, questions might include:

• Did the targeted condition improve?
• By how much?
• For whom?
• Over what period?
• Were results different across relevant groups or locations?
• What unintended positive or negative effects occurred?

An observed improvement does not automatically prove that the intervention caused it. Other events or conditions may also have influenced the result.

Use credible evidence

The appropriate evidence depends on the question and stakes.

Sources may include:

• Administrative data
• Program records
• Surveys
• Interviews
• Observations
• Financial information
• Community and participant feedback
• Other appropriate measures

Define baseline measures before implementation when change over time is important.

Evaluate equity and access

Overall improvement may hide important differences.

Ask:

• Who participated?
• Who benefited?
• Who encountered barriers?
• Did the intervention reduce, maintain, or increase important disparities?

Gather feedback about the process

Feedback from staff, volunteers, partners, participants, and other relevant people can help identify:

• Confusing procedures
• Accessibility problems
• Workload issues
• Unanticipated barriers
• Useful adaptations

Feedback can be collected through written, digital, verbal, anonymous, interview, or other accessible methods.

Satisfaction may be useful information, but it should not be confused with evidence that the intervention achieved its intended outcome.

Act on the findings

Evaluation should inform decisions.

The group may decide to:

• Continue the approach
• Modify it
• Expand it
• Reduce its scope
• Test another approach
• Stop it

Document the evidence and reasoning behind significant changes.

What can go wrong, and what to do about it

Implementation rarely proceeds exactly as planned.

When a problem appears, diagnose it before choosing the response.

The person assigned to a task does not have the right capacity or support

Ask:

• Were role requirements clear?
• Does the person have the time, authority, skills, and resources needed?
• Would training or a co-owner help?
• Would another role be a better fit?

Discuss role fit respectfully rather than labeling someone as the "wrong person."

No one accepts responsibility for a task

Ask why.

• Is the task necessary?
• Is the workload realistic?
• Are the required skills available?
• Is the responsibility appropriately a volunteer role?
• Does it need to be assigned to staff or contracted expertise?
• Are adequate resources or compensation available where appropriate?

Do not pressure someone privately to take on a responsibility merely because nobody volunteered publicly.

Participation or energy declines

Low participation may reflect:

• Excessive workload
• Competing responsibilities
• Unclear progress
• Insufficient resources
• Frustration with the process
• Lack of clarity about the purpose

Identify the cause before assuming that people simply need more motivation.

Recognizing progress can be useful, but celebration does not substitute for resolving an implementation barrier.

The work is taking longer than expected

Examine:

• Whether the original estimate was realistic
• Which tasks are delayed
• Whether a dependency is blocking progress
• Whether staffing or resources are sufficient
• Whether unnecessary scope has been added
• Whether lower-priority work should be deferred

Adding more people does not automatically make work faster and may increase coordination needs.

Community members or partners oppose the approach

Do not assume opposition should be defeated or appeased.

Determine what the concern is.

It may involve:

• A legitimate harm or unintended consequence
• Accessibility
• Rights or legal concerns
• Cost or burden
• Different community priorities
• Insufficient engagement
• Missing information
• Misinformation about the project

Respond according to the substance of the concern.

The appropriate response may be explanation, additional engagement, modification, mitigation, further evidence, or reconsideration of the approach.

A new opportunity or alternative appears

Avoid switching direction solely because something new appears attractive.

Compare:

• Evidence
• Expected benefits
• Risks
• Transition costs
• Existing commitments
• Strategic fit
• Effect on the implementation timeline

Use the established decision authority to approve significant changes.

The solution is not being implemented as planned

This is an implementation problem.

Ask:

• Which activities are not occurring?
• Why?
• Are resources, staffing, training, or systems inadequate?
• Is the original plan unrealistic?
• Should the implementation approach be adapted?

The solution is being implemented but outcomes are not improving

This may indicate a different problem.

Ask:

• Was the causal analysis correct?
• Has enough time passed for the expected outcome?
• Is the intervention reaching enough of the intended population?
• Is the intervention strong enough to affect the outcome?
• Have outside conditions changed?
• Are the measures capturing the outcome accurately?

Do not assume that waiting longer will eventually make an ineffective intervention work.

The intervention creates unintended harm

Some problems require immediate modification, pause, or termination.

Establish criteria in advance where possible for:

• Pausing implementation
• Escalating a safety concern
• Modifying the intervention
• Ending the intervention

Legal, ethical, safety, and safeguarding obligations should take priority over preserving the original plan.

The intervention appears successful

Success also requires analysis before expansion.

Ask:

• Is the evidence strong enough to support the conclusion?
• Under what conditions did the approach work?
• For whom did it work?
• What resources made the result possible?
• Can those conditions be maintained at a larger scale?
• Were there unintended consequences?

Scaling a successful pilot may require a different implementation plan rather than simply doing more of the same thing.

In Summary

Choosing a solution is not the end of problem solving. Implementation is where the group's assumptions are tested against real conditions.

Begin with a clear action plan. Identify tasks, owners, authority, resources, timelines, milestones, dependencies, accessibility requirements, risks, and communication methods.

Plan monitoring and evaluation before implementation begins. Track both whether the intervention is being delivered as intended and whether the expected outcomes occur. Use credible evidence, examine who is reached and who benefits, and watch for unintended consequences.

When implementation problems occur, diagnose them rather than assuming that people simply lack motivation. Delays, opposition, weak results, or declining participation may reveal problems with resources, workload, accessibility, assumptions, strategy, or context.

Finally, use what you learn. Continue approaches that are working, improve those that can be strengthened, and modify or stop those that are ineffective or harmful.

Effective implementation is not rigid execution of a plan. It is coordinated action supported by clear responsibility, evidence, monitoring, communication, and the willingness to adapt when conditions or results show that a different approach is needed.

You understand why you should plan your action:

___To provide the framework on which your solution will hang.

___To be sure you have taken care of all the details.

___To save time, energy, and resources.

You have planned your action:

___You have broken down your solution into individual action steps.

___You have decided to what extent each action step will occur.

___You have decided who will do the work.

___You have decided when each action step will take place.

___You have decided what resources you will need and where you will get them.

___You have decided what you will do if something goes wrong.

___You know which steps need to happen first.

You have implemented your solution:

___You have made sure everyone is clear and in agreement about the process.

___The facilitator has asked for new questions.

___Everyone knows how to contact each other.

___You have set another meeting date.

You have evaluated what happened:

___You have evaluated the success of the meeting.

___You have evaluated the success of the solution.

You know what to do if something goes wrong:

___You know what to do if the wrong person volunteers for the job.

___You know what to do if no one volunteers for the job.

___You know what to do if enthusiasm fails.

___You know what to do if the solution is taking too much time.

___You know what to do if the solution arouses community opposition.

___You know what to do if a seemingly new and better opportunity arises.

___You know what to do if the solution doesn't seem to be working.

Tool #1: Action planning sheet

Use the following table to list each of your action steps in the first row, and answer the following questions for each.

	Action Step 1	Action Step 2:	Action Step 3:
How much, or to what extent, will this action occur?
Who will do it?
When will it take place?
What resources do we need? Where will we get them?
What is the backup plan?
In what order will these steps occur? Does it matter?

Tool #2: Feedback form

At the end of the meeting, the facilitator and recorder can pass out the following sheets to be filled in anonymously by meeting participants.

Participant Feedback Form

Date of meeting:

Overall, how useful did you find the meeting?

What did you like best about the meeting?

What did you like least about the meeting?

Was the proper amount of time spent on each subject?

If not, which subjects took too long?

Which weren't given enough time?

What should be different about future meetings?

Additional comments:

We appreciate your help and feedback at and about today's meeting. The facilitator will address concerns brought up on these feedback sheets and send a letter to all participants in the next two weeks.

A PowerPoint presentation summarizing the major points in the section.