Chapter 19. Choosing and Adapting Community Interventions | Community Tool Box

• What is a promising practice or intervention?

• Where do you find out about existing promising practices or interventions?

• How do you identify a true promising practice or intervention?

• How do you choose the particular practice or intervention that's right for your community?

The West Perry Youth Initiative (WPYI) has completed a careful assessment of youth issues involving all sectors of the community. The findings were revealing: young people and other community members alike were concerned by the number of young people who brought weapons to school and by the number of violent incidents that many youth encountered. The initiative therefore identified youth violence prevention as the area it most needed to address.

So far, so good. But a problem identified is not the same as a problem solved. Everyone knows that you can't just wave a magic wand and make youth violence in the community disappear. It's a complex issue that involves young people, parents and caregivers, schools, law enforcement, community resources, community attitudes, access to weapons, and many other factors. The initiative and the community have to choose an intervention that will work.

One way to deal with this issue is to look at what other communities have done to try to prevent youth violence. But the question then becomes "How do we know that a particular model will have the effect we're looking for?" WPYI has some choices here:

• It could just do what most other communities are doing, without worrying about how well it works. (This may sound silly, but a surprising number of organizations in a variety of fields adopt this approach.)
• It could invent something from scratch. After all, there was a lot of community involvement in the assessment and planning process. Surely, if we put all those brains together, we can come up with some good ideas.
• It could look for some practices and interventions that are already being used elsewhere that seem to be successful in the ways that WPYI has in mind.

This chapter is about finding out what kinds of practices and interventions are possible, choosing what's appropriate for your purposes and your community, and adapting it to the particular needs, strengths, and character of your community and priority population. In this opening section of the chapter, we'll discuss how to tell whether a practice or intervention is one that has a chance of fulfilling your purposes.

What is a promising practice or intervention?

Promising practices and interventions are those that have the potential to effectively address the issues of concern in your community. They are usually (though not always, as we'll see) approaches that seem to have worked elsewhere, as judged by standards that make sense for your community and your issue.

What's the difference between a practice and an intervention?

A practice is a particular way of doing things. It may encompass a whole program or it may simply refer to a single method or approach. Vaccinating infants according to recommended schedules in order to provide appropriate protection against disease is an example of a practice. Another example might be using a low-barrier approach in an emergency shelter so that people experiencing homelessness can access safe shelter while staff maintain clear procedures for protecting the safety and well-being of everyone using the service.

An intervention is usually a whole program or initiative meant to achieve an overall result. In the first example above, for instance, the practice is vaccinating infants according to an appropriate schedule. The intervention used to support this practice might include outreach to parents and caregivers, convenient vaccination opportunities, reminder systems, transportation assistance, and coordination with other health care services.

In the shelter example, an intervention might include street outreach, access to safe overnight shelter, connections to permanent housing, behavioral health services, transportation, and other supports. Individual practices within that intervention would be chosen to promote both accessibility and safety.

Practices are the tools that interventions use to get the job done. Sometimes a whole intervention may also be considered a practice. An adult literacy or workforce development program, for instance, might be seen as one practice within a larger initiative addressing economic opportunity. A substance use treatment program with several components might be treated as a single practice if those components work together as an integrated model.

Untried practices and interventions

Promising practices and interventions may also be untried, but based on something solid. Sometimes, there is no model for what you want to do, or at least no satisfactory one. In that case, there are places to look for ideas.

• Theory. You may have read about a new idea, or may know an academic whose research is in the area you're concerned with. Trying out a practice or intervention grounded in theory is a way both to come up with a strategy that has a good chance of working and to test the theory as well.

• Past experience. You may have tried or seen something that worked well in a similar situation, or you may have evidence from what you've done before that certain methods are likely to work well under certain circumstances. That's a reasonable basis for action.
• Analysis of the problem, especially one that comes from a broad community discussion. If lots of people are involved in looking at the issue, including members of the priority population and the community at large, solutions are more likely to reflect real causes, community strengths, history, and cultural realities.

New practices and interventions have to start somewhere. Sometimes they start from entirely new ideas or new perceptions of an issue. You may be in a situation where that's appropriate. One caution, however: there are few ideas that are totally new. If you do have a new idea, check around and see if it or something similar has been tried before. If it has, you may be able to get some suggestions about how to make it work and how to avoid pitfalls.

Where do you find out about existing promising practices or interventions?

The discussion above, of course, brings up the question of where to look for promising practices and interventions. There are a number of possibilities, and the ideal is to use as many of them as you can. The best strategy for learning about promising practices and interventions is to find and contact directly the programs or initiatives using the practices or interventions you're interested in.

Some sources of information about promising practices and interventions:

Networking.

Talk to everyone you know. Directors and staff from other agencies, coalition members, community partners, and others may know about things happening locally, statewide, nationally, or internationally. They may be able to provide introductions, or at least information so that you can contact programs or initiatives and learn about what they're doing.

Online sources.

Online sources can provide access to research, program descriptions, evaluation reports, toolkits, databases, and examples of practices being used in other communities. Look for credible sources, consider the quality and date of the evidence, and, when possible, contact the organizations implementing practices you are interested in.

Libraries.

Public libraries are open to all. Colleges and universities may also provide community or alumni access to their collections. Much of the material referred to above may be available through libraries, and librarians can be extremely helpful in finding what you're looking for. They are skilled at identifying credible sources, locating research, and helping users navigate both print and digital information.

State and national advocacy and professional organizations.

These organizations often identify promising practices, publish journal articles, host conferences, and maintain online resource collections. You can contact the organization or explore its website to find out what's available.

International, state and federal agencies.

UNESCO, HUD, public health agencies, government departments, and other public institutions often publish promising practices, program evaluations, guidance, and examples from initiatives they fund. These resources may be available online or through agency publications.

Foundations and other private funders.

These funders may identify promising practices or describe projects they support. Many publish reports, evaluations, case studies, and project descriptions online.

Academia.

Local colleges and universities may have researchers studying the issue you're concerned with, or may know others who are. Graduate students and faculty may also be interested in working with community organizations through research projects, practicum experiences, evaluation work, or master's and doctoral projects. Start by contacting the university department most closely connected to the work you do - education, environmental science, psychology, public health, social work, urban planning, etc.

Word of mouth from the community.

Faith leaders, members of service organizations, business leaders, community organizers, and other community members may know through their networks about intervention models being used elsewhere. Members of the priority population may also know of programs or initiatives similar to the one you want to start and may be able to offer valuable perspectives on what has or has not worked.

How do you identify a true promising practice or intervention?

Once you've looked at a number of promising or "best" practices and talked to some people about their programs, how do you decide what really works, and what might work for you? First, you need to determine what the practices you've been looking at are effective for. Then, the question is what criteria do you use to identify promising practices and interventions. In other words, how do you know they actually work? Finally, what are some of the common elements of successful practices and interventions, elements that you can incorporate into whatever you decide to do?

Best practice for what?

Particular promising practices may or may not be relevant to your goals. Some organizations, agencies, or government departments identify practices according to how effectively they address a specific problem or condition. For example, a practice addressing child maltreatment might focus on identifying immediate safety concerns, protecting children from further harm, and responding appropriately when maltreatment occurs. These responses are essential, but by themselves they may not address all of the conditions that contribute to the problem.

Another type of promising practice focuses on prevention. In the case of child maltreatment, a preventive intervention might combine effective responses to current harm with family supports, accessible behavioral and mental health services, parenting resources, economic and social supports, community education, and other strategies that strengthen protective factors for children and families.

Finally, some promising practices focus on promoting positive behaviors, relationships, or community conditions. These approaches build strengths rather than focusing only on stopping harmful outcomes. For example, sexual health initiatives may promote consent, healthy relationships, condom use, STI prevention, and safer sexual practices. Similarly, many health initiatives emphasize creating conditions that support physical activity, nutritious food, stress management, social connection, and access to preventive care.

As you look for promising practices, be clear about what kind of approach you're interested in and have the resources to support. Are you addressing an immediate problem or condition? Are you focusing on prevention by addressing contributing factors before harm occurs? Or are you promoting strengths, protective factors, and conditions that support well-being? Many effective interventions combine elements of all three.

There's another element to the question of what a promising practice is meant to do: what is the real problem or issue that your community needs to address?

Criteria for identifying promising practices and interventions

There are essentially two ways you can look at a practice or intervention: quantitatively and qualitatively.

The quantitative view uses numbers to analyze and understand the impact of particular practices or interventions on participants and communities. These numbers may be used in simple or complex ways. They could state the number of people served, the number who accomplished something specific, or changes in community-level outcomes. They can also be used in statistical analysis to draw more complex conclusions about the effects of a program.

Even simple numbers can provide useful information about how well a practice or intervention is working, but numbers should be interpreted carefully. Growth in participation may indicate that a program is valued and accessible, but participation alone does not prove that the program is accomplishing its goals.

Quantitative analysis can provide an important indication of whether change has occurred as a result of a program. It is often what public funders and public officials request as evidence of effectiveness. At the same time, quantitative analysis by itself may not explain why an intervention succeeds, why people participate or leave, or how participants experience the program.

Qualitative analysis looks at what actually happens when a particular practice or intervention is used. It may include interviews, observations, stories, focus groups, participant feedback, case studies, photographs, or detailed analysis of trends and experiences over time.

The quantitative analysis of the program may show that there are fewer violent incidents and that more young people are participating in programs that build skills for preventing and resolving conflict. The qualitative analysis may show that broader changes are taking place in relationships, attitudes, trust, and the overall climate of the community. Using both quantitative and qualitative data can provide a more complete picture of whether and how the program is working.

The lesson here is that the combination of quantitative and qualitative analysis is what's likely to give you the best picture of reality and make it possible to identify a promising practice or intervention. That's not the end of the lesson, however. Let's go back to that program that seems to serve a small number of people extremely well. What can we learn from that example?

If we make the standards for a "best practice" too strict, we're apt to reject some possibilities that may have potential. Remember, things work differently in different places and in different circumstances. If your standards are "nothing but the Mercedes," you'll never buy that Subaru that can get you home in the snow while your Mercedes is spinning its wheels in the parking lot.

When you look for promising practices and interventions, start by casting a wide net. Something that works only adequately in another community may work extremely well in yours with thoughtful adaptation. By the same token, something that works well someplace else may not be appropriate for you.

Another element of your search should be finding out what didn't work. You may have a terrific idea with a hidden flaw that has already been discovered elsewhere. Or there may have been an attempt to do something similar in your community before, with poor results because the approach did not fit local circumstances, culture, or priorities. Knowing your history can save you vast amounts of time, energy, and frustration. It's one of the most important criteria for assessing promising practices and interventions.

General characteristics of a successful program

One way to approach the search for promising practices and interventions is to look at the general elements of programs that seem to work. Lisbeth Schorr, in her book Common Purpose: Strengthening Families and Neighborhoods to Rebuild America (New York: Anchor Books, Doubleday, 1997), discusses what works in improving outcomes specifically for children and families. She identifies "Seven Attributes of Highly Effective Programs":

• Successful programs are comprehensive, flexible, responsive, and persevering. They address many aspects of an issue rather than a single one; they can, and do, change according to the needs and strengths of participants and the community; and they remain committed for as long as it takes to accomplish their purpose.
• Successful programs see children in the context of families. Children don't exist in a vacuum, and understanding their families, caregivers, relationships, and environments can be important to understanding their experiences and supporting positive outcomes.
• Successful programs understand families as parts of neighborhoods and communities. Families don't exist in a vacuum, either. Effective interventions consider the community conditions that affect families, draw on local strengths and knowledge, include people with community connections among staff and leadership, and help strengthen local leadership and capacity.
• Successful programs have a long-term preventive orientation, a clear mission, and continue to evolve over time. Successful programs address underlying causes rather than only responding to immediate symptoms, and realize that meaningful change may take years. They know what they're trying to accomplish, while remaining flexible about how they pursue that mission as new information, community priorities, and participant experiences emerge.

As Thomas Peters and Robert Waterman pointed out in In Search of Excellence, the key here is to be tight about your mission, but loose about how to achieve it. The mission itself - what you aim to accomplish in the long run - is non-negotiable. How you go about accomplishing it, however, should be flexible and responsive to the realities of the situation. It may change continually in response to new information, changes in the community, and the experiences of participants.

• Successful programs are managed by effective and committed individuals with clearly identifiable skills. Schorr identifies some of those skills as willingness to experiment and take risks, tolerate ambiguity, seek evidence of results, collaborate, and allow staff appropriate discretion.

Other skills that must be added here are the practical managerial skills that assure that bills are paid, that there's a reasonable budget in place and that it isn't exceeded, that funders receive the reports and other information they require, and that staff issues are dealt with quickly, fairly, and well. No matter how collaborative and community-based an organization is, someone still has to keep the organization functioning.

• Staffs of successful programs are trained and supported to provide high quality, responsive service. Just as participants and communities have to be considered in context, so do staff members of organizations. They need an organizational climate that supports their work and values ongoing learning and professional development.
• Successful programs operate in settings that encourage practitioners to build strong relationships based on mutual trust and respect. Strong programs treat participants with dignity, recognize their knowledge and lived experience, and avoid relationships that position staff as inherently more important or knowledgeable. Current and potential participants should feel welcomed, respected, and included as partners in the work.

In addition to Schorr's seven attributes, there are two more that might be added:

• Successful programs are collaborative both internally and externally. Internal collaboration refers to the inclusion of both staff and participants in the planning, implementation, and decision-making of the program. External collaboration means involving a broad range of agencies, officials, schools, community organizations, and others connected to the issue. This can make it easier to coordinate services and address the issue from multiple angles.
• Successful programs and their staffs generally have, both institutionally and individually, a set of relationships and core values that strengthen their sense of shared purpose, and give them confidence that disappointments and setbacks can be overcome. These values often manifest themselves as a passion for the work and for social justice, and translate into relationships with participants that support personal development, agency, and leadership.

All of these nine attributes might apply to a program of any sort: how do they help you sort out promising practices for what you want to accomplish? In fact, these general characteristics are some of the promising practices you need to pay the most attention to. They provide an overall structure for a program that works. How you decide to approach your specific issue should depend on the priorities and strengths of your community, what the priority population identifies as useful and appropriate, a participatory planning process, the talents and skills of your staff, and the resources available.

The nine attributes here paint a picture of a program that is responsive, flexible, equitable, collaborative, well-managed, effective, aware of context, supportive of staff members and their development, and committed for the long term to a clear mission. If you can adopt these general characteristics, the chances are your intervention will do well. To make it the best it can be, it's necessary to find - or create or adapt - the specific practices and/or interventions that are right for your community.

How do you choose the particular practice or intervention that's right for your community?

All of these steps assume community involvement, ideally in both planning and implementing an intervention.

• Conduct a community-based assessment and planning process to be sure that you're addressing the issues that are most appropriate and pressing for the community. If your intervention is to work, it has to address the real issues and priorities identified by the community. An assets and needs assessment and planning process will help you identify those issues and think about how to approach them most effectively.
• Decide whether you'll address the issue directly, or whether you'll try to change the conditions that contribute to it. It may be that working on underlying causes will be more successful than addressing the issue only at the individual level; and that could mean a totally different kind of intervention.
• Find (or create, if that's necessary) practices or interventions that have successfully addressed the issue in the way you want to address it. It's important to realize that not every successful program is successful in the way that you're interested in. If your focus is community empowerment, for instance, a highly centralized program that provides few opportunities for community participation may not be what you're looking for. If you want to address root causes, a program that focuses only on immediate symptoms may not be a good fit. Make sure that a practice or intervention matches both your immediate goals and the principles behind them.
• Determine what elements of a promising intervention will work in your community, and which ones need to be changed. In other words, adapt the intervention, or parts of it, so that it fits your community's needs, strengths, culture, and circumstances. Not all the pieces of an urban program will work in a rural area, for instance, where transportation, childcare, access to services, geography, and everyday life may be very different. The community and the priority population should have meaningful opportunities to shape an adopted practice or intervention and make it work for them. If no two communities are exactly alike, interventions may also need to look different while preserving the core elements that make them effective.

Everett Rogers, in his book Diffusion of Innovations (New York: Free Press, 1995), writes of the concept of "reinvention." Individuals and organizations, when adopting a new practice or idea, often make it their own by changing it - sometimes slightly, sometimes substantially - to meet their particular needs. These "reinvented" innovations may work better and be more likely to be sustained because they are better adapted to local circumstances and because the people using them have helped shape them.

• Implement the intervention, making adjustments as you go along. It's probably helpful to start out with the expectation that you'll have to make changes as you learn more about the fit between the practices you've adopted or created and the priority population. That attitude will make it easier to make those changes, and thus to become more effective over time.
• Evaluate your work and results regularly, understanding that no matter how well any intervention works, it can always be improved. It's important to examine your work and outcomes continually, whether formally or informally, so that you'll have more than intuition to tell you whether you're achieving your goals or not. It's perhaps even more important to keep the idea of a dynamic program always before you, so that no matter how well you're doing, you'll still be willing to try something new if it looks promising.

In the rest of this part of the section, we'll concentrate on finding and choosing the appropriate practice and intervention for your community.

Difficulties in finding practices or interventions you can use:

One possibility, of course, is finding the best program around and simply copying it exactly in your community. That should be fairly simple to do, shouldn't it? Actually, no... it's not. Copying - replication is the term that's most often used - doesn't always work well. Lisbeth Schorr, again, has some ideas on this subject:

• Excellent programs often don't travel well. You may know that some fine wines can't be sold far from where they're made, because the shaking they go through when they're being shipped changes their character. Community interventions can change character when they're transported, too.
  • You can't necessarily take something that works in one community and expect it to work the same way in another, entirely different, community. An intervention's success depends on the needs, strengths, culture, and circumstances of its community. A successful intervention from elsewhere may need to be adapted to fit a new setting.
  • Even where an intervention was tremendously effective, people may not be able to tell you exactly what they did. Some programs keep careful records of nearly everything; others keep almost none. Some programs are based on clear theoretical and philosophical foundations; others "just grew" out of their founders' experience and intuition. So you may not be able to replicate a program exactly simply because no one can tell you what "exactly" is.
  • A successful intervention - especially one which is hard to describe - may depend largely on the talents, relationships, or experience of a particular individual or small group. Sometimes, such a program can't be reproduced exactly because those relationships and local circumstances are unique.
• Even if you can replicate it exactly, you can't expect people to accept and embrace a program if it's imposed upon them from above. They should have meaningful opportunities to participate in its planning, adaptation, and, where possible, implementation in order to develop shared ownership.
• No intervention or practice that involves people - either staff or participants - is perfect. People, organizations, and communities change over time, so even a strong program will probably need to adapt as circumstances, priorities, and participants change.

A successful adult literacy program found itself adapting continually as the circumstances and goals of its learners changed. Changes in the local economy, housing and employment conditions, immigration policy, community resources, and other factors affected who participated in the program. At different times, participants included young people who had left school before graduating, adults seeking employment, people with substance use disorders, people learning English, and survivors of domestic violence. Different participants brought different strengths, goals, experiences, and support needs. Staff members continually adjusted their educational methods, services, and relationships with learners in response.

• The difference between a successful and an unsuccessful intervention can be subtle. It may be as simple as the way a participant is greeted the first time they walk through the door, whether the space is welcoming and accessible, or whether people feel respected and included. Often, the subtleties aren't even part of the formal intervention itself. Small shifts in the economic climate, transportation access, public assistance requirements, or other conditions can affect participation in ways that may not be immediately obvious. As a result, replicating a successful program may be more complicated than it looks, no matter how well documented the program and its practices are.
• If you can't replicate an intervention's resources as well as its practices, you're probably headed for trouble. Programs that are asked to reproduce successful models with substantially fewer staff, funding, facilities, or other resources may have difficulty achieving the same results. Successful adaptation requires realistic expectations about the resources needed to support quality implementation.

Keys to success in replication

Just as there are difficulties in replicating successful programs, there are also some factors that will help replication work. They depend largely on characteristics of the original intervention (the first six of these are also from the work of Lisbeth Schorr):

• Ideas that are sound and well-developed through experience. Interventions that are solid, evidence-informed, and based on well-tested concepts are more likely to transfer successfully to other settings.
• Ideas that can be taught and can inspire local leadership. The ideas behind the intervention need to be understandable and practical, while also giving community members and organizations meaningful opportunities to shape, lead, and sustain the work.
• A sense of mission, of belonging to something larger. The program has to carry a vision that transcends the immediate project and connects people with a greater purpose. This goes back to the sense of passion for the work and for social justice mentioned earlier. A program may be easier to sustain when people see how their work contributes to larger community goals.
• Access to people who have successfully implemented the program. As emphasized from the beginning of this section, the best way to find out about a program is to consult the people who are actually carrying it out. They can give you the details that no one else can and help you understand the relational and contextual elements that may affect success.
• Supportive and thoughtful consultation. This consultation might come from colleagues in other organizations; funding organizations; members of the community and priority population; people with lived experience; or a consultant with relevant expertise.
• Technical assistance that recognizes there are new things to be discovered.
• Local involvement in initial planning for, finding and choosing, adapting, and implementing the intervention. This will help to develop local ownership, leadership, and stewardship of the intervention.
• Awareness on the part of funders that trying to replicate a program that's been successful elsewhere doesn't guarantee immediate success. Even strong models need time to be adapted to local conditions, cultures, and community priorities. Funders can support success by allowing organizations time to build relationships, learn, adapt, and improve.
• Adequate resources - people, money, supplies, and time - to achieve your goals. Match the scope of your intervention to the resources you actually have.

Elements of successful replications of effective programs

Just as there are factors in the programs themselves, there are also elements in the replication process that lead to successful replication. Some elements of successful replications:

• They combine the replication of the essence of a successful intervention with the adaptation of many of its components to a new setting or population. Every program needs to be adapted to its community, its specific priority population, the skills and concerns of staff members, local culture, available resources, and other conditions.
• They have had the continuous backing of an intermediary organization. This might be a local coalition, a grassroots group, a particular agency - some entity that could offer expertise, mobilize support, lend legitimacy and influence, and connect the intervention with appropriate local networks.
• They recognize the importance of systems and institutional context. They seek settings where the intervention is welcomed and where there is real commitment to its success.
• They recognize the importance of people. They understand that participants, community members, staff, and partners need to see value in the intervention and have meaningful opportunities to contribute to its success.
• They judge success by the outcomes for individuals and communities. What actually happens - whether participants meet their goals, whether community conditions improve, and whether the changes people hoped for occur - is the standard for whether these interventions consider themselves effective.
• They tackle, directly and strategically, the obstacles to large-scale change. Successful interventions look beyond the immediate issue to underlying causes and community conditions. Part of a successful youth violence prevention program, for instance, might focus on strengthening supportive relationships, creating safe opportunities for young people, supporting family and caregiver involvement, addressing access to weapons, improving community conditions, and developing effective responses to violence.

In Summary

Choosing a promising practice or intervention for your purposes may not be a simple matter. What works in another community may not work in yours, and it may be difficult to determine exactly how a particular successful intervention operates or which parts of it are essential.

There are, however, some general elements that good programs seem to have in common:

• Responsiveness
• Flexibility
• An equitable philosophy
• Commitment to collaboration
• Good management
• Effectiveness
• Awareness of the context of the issue and the priority population
• Commitment for the long term to a clear mission

In addition to these general characteristics, there are some factors that identify successful replications. They include the adaptation of program features to local needs, strengths, and cultures; backing by an intermediary organization; an understanding of the importance of community and human context; judging success by individual and community outcomes; adequate resources; meaningful community participation; and a focus on root causes.

The process of choosing may be difficult, but it doesn't have to be a guessing game. If you follow the guidelines in this section, examine the available evidence, and listen to community members - especially people most directly affected by the issue - you can choose and adapt practices that support meaningful and lasting community change.

What is a promising practice or intervention?

___You know that a practice is a particular way of doing things.

___You know that an intervention is usually a whole program or initiative meant to achieve an overall result.

___You use theory, past experience, and/or analysis of the problem to help you create or judge untried practices and interventions.

Where do you find out about existing promising practices or interventions?

You use these sources to find out about existing promising practices or interventions:

___Networking.

___State and national advocacy and professional organizations.

___International, state and federal agencies.

___Foundations and other private funders.

___Academia.

___Libraries.

___The Internet.

___Word of mouth from the community.

How do you identify a true promising practice or intervention?

___You have decided whether you're searching for a best practice for treatment, prevention, or promotion.

___You know how to use both quantitative and qualitative data to judge promising practices and interventions.

You recognize the attributes of successful programs:

___Successful programs are comprehensive, flexible, responsive, and persevering.

___Successful programs see children in the context of families, and families as parts of neighborhoods and communities - in other words, they consider their work in context.

___Successful programs have a long-term preventive orientation, a clear mission, and continue to evolve over time.

___Successful programs are managed by competent and committed individuals with clearly identifiable skills.

___Staffs of successful programs are trained and supported to provide high quality, responsive service.

___Successful programs operate in settings that encourage practitioners to build strong relationships based on mutual trust and respect.

___Successful programs are collaborative both internally and externally.

___Successful programs and their staffs generally have, both institutionally and individually, a set of relationships and core values that strengthen their sense of shared purpose, and give them faith that disappointments and setbacks can be overcome.

How do you choose the practice or intervention that's right for your community?

You follow the basic steps to choosing a promising practice or intervention:

___You conduct a community-based assessment and planning process to be sure that you're addressing the issues that are most appropriate and pressing for the community.

___You decide whether you'll address the issue directly, or whether you'll try to change the conditions that make it possible.

___You find (or create, if that's necessary) practices or interventions that have successfully addressed the issue in the way you want to address it.

___You determine what elements of a promising intervention will work in your community, and which ones need to be changed.

___You implement the intervention, making adjustments as you go along.

___You evaluate your work and results regularly, understanding that no matter how well any intervention works, it can always be improved.

You pay attention to the difficulties in finding practices or interventions you can use:

___Excellent programs often don't travel well.

___You can't expect people to accept and embrace a program if it's imposed upon them from above.

___No intervention or practice that involves people - either staff or participants - is perfect.

___The difference between a successful and an unsuccessful intervention can be subtle.

___If you can't replicate an intervention's resources as well as its practices, you're probably headed for trouble.

You try to assure successful replication by:

___Choosing a program based on ideas that are sound and well-developed through experience.

___Choosing a program based on ideas that can be taught and can inspire local leadership.

___Choosing a program that conveys a sense of mission, of belonging to something larger.

___Making sure you have access to people who have successfully implemented the program.

___Making sure you have supportive and wise consultation.

___Making sure you have technical assistance that recognizes there are new things to be discovered.

___Including local involvement in initial planning for, finding and choosing, and implementing the intervention.

___Making sure funders know that trying to replicate a program that's been successful elsewhere doesn't guarantee success overnight, or even at all.

___Matching your goals to your available resources.

You structure the replication process for success by:

___Combining the replication of the essence of a successful intervention with the adaptation of many of its components to a new setting or population.

___Obtaining the continuous backing of an intermediary organization.

___Recognizing the importance of the systems and institutional context.

___Recognizing the importance of people.

___Judging success by the outcomes for individuals and communities.

___You tackle, directly and strategically, the obstacles to large-scale change.

Tool: A Self-Assessment to Help You Find and Choose Promising Practices

Starting the search

Answering these questions will help start your search for the best promising practice for your community.

• What is the broad area of interest (e.g., health promotion, independent living )?
• What specific problem are you working on (e.g., substance use, obesity)?
• What population will benefit from your effort (e.g., Hispanics, youth, rural groups)
• What type of intervention or community change (i.e., change in program, policy, or practice) are you seeking? Is it listed in your strategic plan?
• In what sector of the community will this take place (e.g., business, youth groups, churches)?
• Are you interested in a targeting an intervention at a high-risk group or a comprehensive approach, or both?

Choosing your approach

Answering these questions will help you choose the best promising practice for your community.

• Does the promising practice meet all of the criteria set by your search?
• Some programs can be complicated, which means an organization that can support the effort is needed. Are there organizations in your community that can support the effort? If not, can you create such an organization?
• What is the evidence that the promising practice will have some impact?
• Will you be able to replicate the practice? If not, how will you modify it for your community?
• What resources do you have or will you be able to generate to support the practice? Will a pared back version satisfy your needs?
• Is the practice compatible with your community's beliefs, attitudes and values (e.g., will your community support condom distribution)?
• Have you looked at different versions of the practice in the examples and stories provided in the Community Tool Box or in other resources? Have you contacted others who have implemented the practice?
• How will this promising practice work for you? What would make it a success for your community?

A PowerPoint presentation summarizing the major points in the section.

Have you ever wondered why some people in our communities have better outcomes than others? Why some children do well in school while other children - equally capable - face greater barriers? Why people in the same community may experience unequal health outcomes? Have you wanted to help change these outcomes?

There are many different and interrelated causes of problems and desired outcomes. If your organization can understand these causes, it can focus its intervention to better contribute to community improvement. This can help your organization and community work toward the conditions and outcomes you envision.

So, where do you begin in trying to make these changes? We believe one very good way to go about it is to consider the risk and protective factors that may contribute to a particular problem or desired outcome.

What are risk and protective factors? They are aspects of a person, group, environment, or life experience that make it more likely (risk factors) or less likely (protective factors) that people will experience a given problem or achieve a desired outcome. For example, smoking is a risk factor for cardiovascular disease. Regular physical activity can be a protective factor for cardiovascular health.

Risk and protective factors are key to figuring out how to address community health and development issues. It's a matter of taking a step back from the problem, looking at the behaviors, experiences, systems, and conditions that contribute to it, and then figuring out how those conditions can be changed or strengthened.

For example, in an effort to prevent harmful substance use, an approach that uses risk and protective factors to direct interventions might increase young people's access to positive activities, supportive adults and peers, accurate information, coping and decision-making skills, and environments that support healthy choices.

We suggest that you consider risk and protective factors as one of your early steps when you are writing or revising the strategic plan for your initiative.

In this section, you will learn more about risk and protective factors and their role in identifying the changes in your community that your organization wants to make. Specifically, we are going to look at:

• A more in-depth understanding of risk and protective factors
• When to look at the risk and protective factors for the issue that's important to you
• How to identify the specific risk and protective factors for your focus area
• How these factors can help your organization identify the people and communities who may benefit most and select strategies for making a difference

Ready? Then let's dive in!

What are risk and protective factors?

As we said above, risk and protective factors are aspects of a person or group, their environment, and their life experiences that make it more likely (risk factors) or less likely (protective factors) that people will develop a given problem or achieve a desired outcome. Risk factors increase likelihood; they do not determine what will happen to a particular person or community.

Often, risk and protective factors can be considered flip sides of the same coin. For example, a family history of alcohol use disorder may be a risk factor for developing problems related to alcohol. On the other hand, growing up in a family where parents and caregivers talk openly about alcohol, model healthy choices, and provide consistent support may be protective. Research suggests that the accumulation of risk factors can increase the likelihood of adverse outcomes in health, education, and development.

Another term used for protective factors is "assets." So-called "asset-based" approaches put the emphasis on strengths and resources that support positive outcomes. These assets may exist within individuals, families, organizations, neighborhoods, cultures, or broader community systems.

We generally group both risk and protective factors into two broad categories: those that occur in the environment, both socially and physically, and those that relate to individual characteristics and experiences. These categories interact with one another and should not be considered in isolation. Let's look at personal factors first.

Personal Factors

Personal factors are characteristics, knowledge, experiences, skills, and circumstances that differ among individuals. They include an individual's knowledge, skills, experience, history, health, and genetic makeup. Here is more specific information on the types of personal factors that may contribute to risk and protection:

Knowledge and Skill:

• Knowledge, including knowledge about available choices, possible consequences, and available resources
• Beliefs, such as ideas about the causes of problems or the consequences of choices
• Skills, including being able to navigate one's environment, communicate, make decisions, and set and accomplish goals
• Education and training, such as formal education, community-based learning, or specialized training

Experience and History

• Experience, such as experiences of care and support, maltreatment or neglect, overcoming barriers, or successfully attaining goals
• Cultural norms and practices, including values, traditions, and expectations that may influence behavior and well-being
• Social and structural position, including experiences of discrimination, exclusion, privilege, or access to opportunity

Biology/genetics

• Existing health, including current health status and health conditions
• Cognitive, mental health, and physical functioning, including disability-related factors and access needs
• Chronic health conditions, including needs for ongoing care, accommodations, or other supports
• Age and sex or gender, when these are relevant to the particular health or development issue
• Genetic predisposition or family history, such as a family history of diabetes, cardiovascular disease, or alcohol use disorder

Environmental Factors

Environmental factors are conditions that affect people within a community rather than being unique to one individual. The environment includes the conditions in which people live, learn, work, play, and interact - their households, neighborhoods, schools, workplaces, and larger communities. These may include aspects of the social environment, including relationships, social support, norms, policies, and community connections. They also include aspects of the physical environment, including access to resources, exposure to hazards, transportation, housing, and other living conditions. Environmental factors fall into the following categories:

Support and services

• Availability and continuity of social support and relationships, such as with family, friends, neighbors, mentors, and others
• Availability of appropriate services, including services that are accessible, responsive, and appropriate to community needs
• Availability of resources, including human, organizational, financial, and material resources

Access, barriers, and opportunities

• Physical access and barriers, including distance, transportation, accessibility, and physical access to services
• Communication access and barriers, including language access, interpreters, translation, accessible communication formats, and technology
• Competing requirements for participation, including work, caregiving, school, transportation, or other responsibilities that can make participation difficult

Consequences of efforts

• Social encouragement and discouragement, such as whether family, peers, institutions, or community norms support particular behaviors
• Incentives and disincentives, including monetary and material gain or loss and access to desired benefits
• Time costs and delays, including the time and effort required to take action, meet needs, and access services

Policies and living conditions

• Policies, such as those affecting access to benefits, enforcement of laws, workplace conditions, and eligibility for services
• Financial barriers and resources, including whether people have sufficient resources for needed goods and services and how resources are distributed
• Exposure to hazards, including toxic chemicals, air pollution, unsafe environments, or other environmental risks
• Living conditions, such as the availability and quality of housing, food, clothing, heating and cooling, transportation, and clean drinking water
• Economic hardship and inequities in resources and opportunity, including difficulty meeting basic needs and unequal access to income, services, and other resources

General principles about risk and protective factors

Before going further, let's look briefly at some general principles about risk and protective factors. These apply across risk and protective factors and across personal, social, physical, and environmental conditions. Research has consistently shown us that:

• Many risk and protective factors are related to multiple community outcomes. That is, they may influence more than one community health and development concern. As such, they can give you a useful place to start in developing your own lists of risk and protective factors. For example, economic hardship and limited access to resources can affect health care access, educational opportunities, nutrition, housing, and other outcomes. On the other hand, a young person having a strong relationship with a caring adult can be an important protective factor across a number of health and development outcomes.

• Not all risk and protective factors are equally influential. Some factors may have a stronger relationship with a particular outcome than others. For example, peer substance use may be an important factor to consider in adolescent substance use prevention. It's important to consider the relative importance of each risk and protective factor because this will help you prioritize your actions later on.
• Risk and protective factors can accumulate and interact. Greater exposure to multiple risk factors may increase the likelihood of an adverse outcome, while multiple protective factors and assets may help support positive outcomes. For example, cardiovascular risk may be influenced by the combination of tobacco use, physical inactivity, blood pressure, cholesterol, nutrition, health care access, and other factors rather than by any single factor alone.

When do you want to learn about the risk and protective factors for your issue?

So, you believe risk and protective factors are important, but are unsure when your initiative should address them. The answer depends in great part on the stage of development of your group - how long you've been around, what you are doing now, your resources, and so on.

Generally speaking, the rule is the earlier, the better. If your organization is already up and running, you might want to look at risk and protective factors before you revise the strategic plan for your initiative. That's something you will probably want to review regularly as conditions, priorities, and available information change.

If you are planning a new initiative or if your organization is starting a new program - perhaps your Youth Coalition recently received a grant to reduce adolescent pregnancy - then the time to start is after you have developed your long-term goals, but before you've developed the road map, or "model of change," that will get you to them.

If your organization is using the "VMOSA" (Vision, Mission, Objectives, Strategies, and Action Plan) approach to planning, you will want to look at risk and protective factors after you've developed your vision and mission, but before you get to the more specific goals outlined in the objectives, and definitely before you develop your strategies. This is because risk and protective factors will sometimes influence your objectives, but they generally fit hand in glove with your strategies, as well as the desired community and system changes that implement those strategies. Let's look at a specific example.

This is the point at which the coalition may want to study risk and protective factors. The LVHCC found that strong relationships with parents, caregivers, and other supportive adults were protective factors for child health and development, while school disengagement was associated with poorer outcomes. Further study suggested that some students faced barriers such as limited academic support, language-access needs, and insufficient culturally and linguistically responsive resources. Altogether, the coalition identified a range of risk and protective factors for child health and well-being. These findings led the coalition to develop a number of objectives and strategies, including the examples below.

• Two of our several objectives are: 1) Within two years, increase meaningful parent, caregiver, and adult interaction with children under 2 years of age by 40%; and 2) Within four years, increase the percentage of young people graduating from high school by 25%.

Remember: Your objectives are specific, measurable results of the work done by your organization. They include the practical details, including how much of what will be accomplished by when.

• Two of our strategies for supporting children and young people in school include: 1) Involving caring adults in talking with or reading to young children; and 2) Increasing the number of bilingual or multilingual teachers and other language-access supports in area schools.

Remember: Your strategies explain how you are going to achieve your goals; they are broad ways to address the mission. Most organizations use multiple and complementary strategies, for example providing information and enhancing skills, improving access and reducing barriers, strengthening services and supports, and changing policies or environmental conditions.

How do you identify risk and protective factors and use them to select people, communities, and strategies for your intervention?

Once you have an understanding of risk and protective factors, as well as when you should include them in your planning, the time is right to identify the particular risk and protective factors that your organization will address. The following few pages offer one possible way to go about doing this.

Review data and information about candidate risk and protective factors for the issue your community is facing.

You can do this by either gathering data that is already available or compiling your own if what you need doesn't seem to have been collected. And of course, you can also combine these two options by using the general data that already exist and supplementing them with information gathered by your organization and community partners.

Let's look briefly at both of these options - gathering and compiling data - and how you might go about each of them.

Gathering available data.

If information is already available, use it. Data on risk and protective factors may already be available for many of the issues of importance to your community. This includes topics such as substance use, cardiovascular diseases, adolescent pregnancy, child maltreatment, access to health care, school success, and a host of other community problems or goals.

To find this information, you can start with ideas given in this section for both general and issue-specific risk and protective factors. From there, you can search credible online sources, check your local library, or contact state agencies, local health or education departments, community organizations, or universities.

If you already know the risk and protective factors for the problem or goal you are working on, you're halfway home. The next step is to find current, reliable data to understand which risk and protective factors are most important in your community and how local conditions compare with appropriate benchmarks.

Historical example: Percentage of Kansans with selected risk factors for cardiovascular diseases

The table below is retained as a historical example of how state and national data can be compared. For current planning, use the most recent reliable data available.

	Kansas	National
Physical Inactivity	50%	56%
Obesity	26%	24%
Smoking	22%	23%
Hypertension	21%	21%
High Cholesterol	18%	18%

Source: 1992 Behavior Risk Factor Surveillance System, Kansas Department of Health and Environment

Developing your own information.

Sometimes, however, there just isn't information available on the topic that you are researching. Or, you might have general information on risk and protective factors, but also want to know which specific factors are important in your community, how people experience them, or the extent to which they exist locally. Then, you'll need to use other methods to develop the information you need. Although they are discussed more fully in other sections of the Community Tool Box, let's touch here briefly on several possibilities.

• The "But why?" technique. This is a method often used to identify underlying factors that contribute to a community issue. The "But why?" technique examines a problem by asking what caused it. Each time an answer is given, a follow-up "But why?" is asked. For example:

From the brainstorming done here, you might identify factors such as competing work and caregiving responsibilities, limited access to affordable childcare, and the need for more flexible educational or family supports. This technique is especially useful early on for developing possibilities that can then be explored through conversations with people affected, focus groups, surveys, or existing data.

Focus groups

Focus groups can also give you a better understanding of the issue. They are small-group discussions designed to gather participants' experiences, perspectives, and ideas. Depending on the purpose, a focus group may bring together people who share certain experiences or characteristics when doing so helps participants feel comfortable speaking openly. The composition of the group should be based on the questions you are asking rather than assumptions about who will or will not feel comfortable together.

One advantage of focus groups is that they can provide context, lived experience, and a deeper understanding of how people feel about an issue. Although a survey can provide systematic information about patterns across a larger group, focus groups can help explain what those patterns mean to community members and why they may exist.

Surveys

If you have the resources and would like to make your results more systematic, you can conduct a survey to find out which risk and protective factors are important in your community. It's possible that you will want to test some of the information you found using the "But why?" technique, compare local information with broader data, or develop or adapt a survey to address these topics.

Select risk and protective factors to be addressed by your comprehensive intervention.

Now that you have determined what the likely risk and protective factors for your issue are, the next step is to decide to what extent each of these factors should influence your strategic plan. There may be some factors on which you want to spend a great deal of time and resources, and others that you may not want to address directly, at least at the beginning. Two key questions can help you sort out how much weight you want to give to each risk and protective factor:

• Does it strongly influence the issue? Is a given risk or protective factor strongly associated with the outcome you hope to change, or is the relationship weaker? For example, peer substance use may be an important factor to consider in adolescent substance use prevention. The relative importance of a risk or protective factor can often be explored through existing research, local data, community experience, surveys, and other forms of evidence.
• How changeable is it? Most factors fall into one of three broad categories, or "degrees of changeability":
  • Some risk and protective factors can be changed substantially. For example, high cholesterol may often be improved through changes in nutrition and physical activity and, when appropriate, medication and clinical care.
  • Some risk and protective factors may be modified but not completely eliminated. An example might be access to alcohol or other substances among young people. Communities may be able to reduce access through policy, enforcement, retailer practices, education, family engagement, and other strategies, even if complete elimination is unrealistic.
  • Finally, some factors cannot be changed directly. Family history and genetic predisposition, for example, may influence the likelihood of developing some health conditions, including alcohol use disorder. These factors should not be used to label people or assume an outcome is inevitable. Instead, they can help identify opportunities to strengthen protective factors, supportive relationships, prevention resources, and early access to appropriate services.

One way to decide which factors to prioritize is to consider those that appear to have a strong relationship with the outcome and that your organization or partnership has a realistic and equitable opportunity to influence.

By answering the two questions above, you can start to decide the appropriate mix of risk and protective factors that you want to address. The next step is to decide how many of these factors your initiative has the resources and partnerships to pursue effectively.

It is quite common for an organization to address a mixture of risk and protective factors. How extensive your list is may be determined in large part by the people, partnerships, time, funding, and other resources available. Most organizations will not be able to address every factor at once, and some factors will have a higher priority than others. You will therefore have to make thoughtful choices about priorities.

But remember: positive outcomes can be supported by strengthening multiple protective factors and community assets. If your organization cannot address all of the factors needed to make a meaningful difference, consider forming a partnership with other groups that can contribute complementary strengths and resources.

Once you have considered all of this, make a list of the risk and protective factors your initiative will try to change or strengthen. You will want to have this list handy as you move to the next step.

Use information about risk and protective factors to identify people and communities who may benefit most.

Once you have decided which risk and protective factors are important and potentially changeable, your next step is to identify the people and communities who may benefit most from your intervention. This may include people who experience greater exposure to particular risk factors, have less access to protective resources, or are affected by systems and conditions connected to the issue.

Be careful not to use risk information in ways that stigmatize people or imply that an outcome is inevitable. Risk and protective factors can help identify where resources, opportunities, policy changes, or additional support may be useful, but they should be considered alongside community strengths, lived experience, and the priorities identified by people most affected.

Other considerations include cost, reach, feasibility, equity, and the likely benefit of different approaches. These choices have ethical implications. People or communities with the greatest barriers should not automatically receive less attention simply because reaching or serving them may require additional resources.

If the intervention you are planning is fairly new and there isn't yet much evidence about how it will work in your community, you might begin with a well-defined pilot group while involving community members in planning and evaluation. A pilot can help you learn and improve before expanding the effort, but participants should not be selected simply because they make success easier to demonstrate.

The table below shows how candidate personal and environmental factors can be used to help identify people and communities who may benefit from the intervention.

Use the information about the types of risk and protective factors to select promising strategies or components for the comprehensive intervention.

At this point, you have decided what you want to change or strengthen - the specific risk and protective factors your organization has chosen. You have also identified who may benefit most and who should be involved. The next step is to organize all of this information to help you develop your initiative's strategies - how you are going to get things done.

The table below shows how risk and protective factors, the people and communities involved, and strategies are all interrelated.

Using risk and protective factors to select people, communities, and strategies (components) for a comprehensive intervention

	What Candidate Risk and Protective Factors	Who People or Communities Who May Benefit	How Strategies for the Comprehensive Intervention
Personal	Knowledge and skills Knowledge Beliefs Skills Education and training	People who would benefit from additional information, education, training, or skill-building opportunities	Provide accessible information and opportunities to build knowledge and skills; engage participants and community partners in designing relevant approaches
Personal	Experience and history Experience Cultural norms and practices	People who have experienced maltreatment, discrimination, exclusion, or other barriers to achieving their goals People whose social or cultural environments may include factors that increase or reduce risk	Strengthen services, relationships, and support Expand opportunities and address barriers
Personal	Biology and genetics Existing health Cognitive, mental health, and physical functioning Chronic health conditions Age and sex or gender Genetic predisposition or family history	People living with health conditions or disabilities who may benefit from accessible services, accommodations, prevention, or other supports	Strengthen accessible services, supports, accommodations, and preventive resources
Environmental	Support and services Availability and continuity of social support and relationships Availability of appropriate services Availability of resources	People experiencing social isolation, unmet support needs, or limited access to appropriate services and resources	Strengthen services, relationships, resources, and support
Environmental	Access, barriers, and opportunities Physical access and barriers Communication access and barriers Competing requirements for participation	People facing barriers to services, participation, communication, transportation, accessibility, or opportunity	Improve access, reduce barriers, and expand opportunities
Environmental	Consequences of efforts Social encouragement and discouragement Incentives and disincentives Time costs and delays	People whose participation or choices are affected by social expectations, limited incentives or resources, work or caregiving responsibilities, time, or other competing demands	Adjust incentives, supports, expectations, and conditions to make desired actions more feasible
Environmental	Policies and living conditions Policies Financial barriers and resources Exposure to hazards Living conditions Economic hardship and inequities in resources and opportunity	People and communities experiencing economic hardship, inequitable access to resources, unsafe or unhealthy conditions, or disparities in outcomes	Modify policies, systems, resource allocation, and environmental conditions

For a concrete example of the above, consider the following example from an organization working to improve quality of life in an urban neighborhood. It lays out just a few of the group's identified risk and protective factors, the people and partners connected to them, and possible strategies. After each risk or protective factor, its category from the table above is listed in parentheses.

Risk and Protective Factors for a High Quality of Life in the Neighborhood	People, Communities, or Partners Involved	Strategies (Components of the Intervention)
Limited incentives for businesses to invest in the neighborhood (Consequences - incentives/disincentives)	Local residents, small and large business owners, economic development organizations, and public officials	Change incentives and conditions - consider targeted incentives, technical assistance, or other strategies that support businesses that meet community priorities and contribute to local economic opportunity
Lead paint and other housing hazards (Policies and living conditions - exposure to environmental hazards)	Residents of affected housing, property owners and managers, housing organizations, building inspectors, and public health agencies	Modify policies and practices - enact and enforce appropriate housing safety requirements Work with residents, property owners, building inspectors, and health departments to identify and address housing hazards
Community experience, leadership, and knowledge of overcoming barriers (Experience - protective factor/asset)	Local residents, neighborhood leaders, and community organizations	Strengthen community leadership - support resident-led advocacy, leadership development, shared decision-making, and opportunities for community members to shape policies and neighborhood improvements

In Summary

Having a solid understanding of risk and protective factors, along with the people and communities most affected by them, gives you an excellent base from which to develop strategies for your initiative. By reducing or changing important risk factors, strengthening protective factors and community assets, and addressing the systems and conditions that shape people's opportunities, your organization and its partners can work more effectively toward the outcomes the community has identified.

 

___You have a good understanding of risk and protective factors, including the different categories of factors, what affects these factors, and when they should be addressed by your organization.

___You have gathered available data on risk and protective factors for the issue your community is facing.

You have decided what technique(s) will best help your information on local risk and protective factors:

___The "but why" technique

___Focus groups

___Surveys

___You have developed your own information on risk and protective factors, using the mean(s) you decided were most appropriate ("but why," focus groups, and/or surveys ).

___You have selected the risk and protective factors your intervention will address.

___You have used information about who is affected by multiple risk factors to select your "targets of change."

___You have used the information about risk and protective factors and targets of change to select promising strategies for the comprehensive intervention.

Example 1: Risk and protective factors that may be related to disparities in health outcomes associated with race and ethnicity

Here, risk and protective factors are separated into three broad categories by who is affected by, or can affect, that factor.

This example is adapted from Promoting Health for All: An Action Planning Guide for Improving Access and Eliminating Disparities in Community Health. See Resources for a full citation.

Knowledge and skill (personal)
Consumers/Local Residents	Health Care Providers	Broader Agents/Allies
Knowledge (e.g., of preventative health practices, self-care, resources for health care) Beliefs (ie, about causes and consequences of health behaviors and outcomes, e.g., effects of diet, physical activity) Skill (e.g., in accessing available services, advocating for needed services, language spoken) Education and training (e.g., years of formal education)	Knowledge (e.g., of local culture, client health needs) Belief (e.g., about what consumers value) Skill (e.g., cultural competence, languages spoken) Education and training (e.g., extent and adequacy of training)	Knowledge (e.g., of the problem of access/disparities) Beliefs (e.g., about how our health is bound up in that of others)
Experience and history (personal)
Consumers/Local Residents	Health Care Providers	Broader Agents/Allies
Experience with health systems (e.g., discrimination in seeking services) Experiences of prior health care (e.g., pain, no improvement) Cultural norms and religious practices (e.g., diet, healing practices)	Experience with service provision (e.g., respect shown to consumers) History of working with consumers (e.g., hostility, no improvement)	Community norms for racial and ethnic harmony (e.g., history of race/ethnic relations ) History of collaboration in public problem solving (e.g., involving those most affected and those most responsible)
Biology/Genetics
Consumers/Local Residents
Type and degree of existing health (e.g., pre-existing conditions, risk markers ) Cognitive, mental or physical ability (e.g., mobility impairment, psychiatric disability, cognitive ability) Chronic illness (and requirements for care) Gender (e.g., women or men may be more at risk for particular health outcomes) Age (e.g., infants, adolescents, or older adults may be more at risk for particular health outcomes) Genetic predisposition (e.g., diabetes)
Support and services (environmental)
Consumer/Local Residents	Health Care Providers	Broader Agents/Allies
	Availability and continuity of services and support (e.g., continuity of care from providers; peer support)	Social support and ties (e.g., through neighbors, faith communities)
Access, barriers, and opportunities (environmental)
Consumer/Local Residents	Health Care Providers	Broader Agents/Allies
Communication access/barriers (e.g., languages spoken) Physical access/barriers (e.g., transportation)	Communication access/barriers (e.g., available interpreters) Physical access/barriers (e.g., distance and physical access to facilities) Human resources (e.g., too few providers for need; availability of providers from ethnic community)
Consequences of efforts (environmental)
Consumer/Local Residents	Health Care Providers	Broader Agents/Allies
Competing requirements to participation (e.g., child care, work)	Time costs (e.g., waiting time for service, convenient hours of service)
Policies and living conditions (environmental)
Consumer/Local Residents	Health Care Providers	Broader Agents/Allies
Living conditions (e.g., homelessness, adequate housing, heat/cooling, clean drinking water) Poverty/financial resources (e.g., not enough money for basic needs, for needed health services)	Financial barriers and resources (e.g., not enough money for needed health care, for prevention) Policies (e.g., requirements for insurance coverage, co-payments, refusal of service)	Public accommodations for participation (e.g., available child care, transportation ) Employer accommodations and policies (e.g., workplace health services, flextime policies to permit participation, health insurance policies) Government policies (e.g., distributive policies that assure access to care) Poverty and deprivation (e.g., policies supporting economic development, education, and housing in neighborhoods of concentrated poverty)

 

Example 2: Substance use among young people

Information in this example comes from Drs. David Hawkins' and Richard Catalano's book Communities that Care. See Resources for a full citation.

Researchers David Hawkins and Richard Catalano have done extensive research on the risk and protective factors associated with substance use, particularly among young people in the United States. They determined that the risk and protective factors in the environment include all of the following. (Note that the heading itself gives the risk factor with the corresponding protective factor following in parentheses.)

• Economic deprivation (affluence)
  Those who live in deteriorating neighborhoods with little or no hope of a better future are much more likely to abuse alcohol and other drugs than those who live in more affluent communities.
• Community disorganization (organization)
  There are more problems related to substance use in areas where there is little sense of community; where people don't feel as if they are part of a greater whole.
• Transitions and mobility (stability)
  The more young people move to new environments, the more likely they are to use drugs. These transitions can be as typical as changing from middle school to high school, but changes are more likely to increase risks when they are more significant, such as frequent moves to new cities or towns.
• Availability of substances (lack of availability)
  The easier it is for people to get a hold of illegal substances such as drugs, the more likely they are to use them.
• Community norms saying it's "okay" to use drugs and alcohol (community views that say it's not okay)
  An example of this might be students in a college town, where excessive drinking among younger students is seen as a type of rite of passage to adulthood and not as a public health problem.

Hawkins and Catalano also determined that some of the individual or personal risk and protective factors for substance use include the following things. Again, protective factors are in parentheses.

• Family history of drug abuse (family history of appropriate use or nonuse)
  Children who have parents who are alcoholic or who abuse drugs are much more likely to have drug problems themselves. This is true for both girls and boys, but is a higher risk for boys, for whom a genetic link for alcoholism has been established.
• Family management problems (family strengths)
  These include a lack of clear expectations of what a child is supposed to do, a lack of someone to pay attention to what a child is doing, and inconsistent or overly harsh discipline.
• Academic failure (academic success)
  Children may fail in school for a variety of reasons, but it appears that just not succeeding increases the likelihood of substance use problems.
• Antisocial behavior (strong, positive social skills)
  This may include aggressive behavior among small children, misbehaving in school, skipping school, or getting into fights with other children.
• Friends who use drugs (friends who don't approve of drugs)
  This is one of the risk factors that has consistently predicted the use of drugs. Children whose friends use drugs are much more likely to do so than those whose peers don't use drugs, even if they don't generally experience other risk factors.

Some of the protective factors (this time, with the associated risk factors in parentheses) Hawkins and Catalano have found for substance use include:

• Bonding (lack of caring adults)
  Research has consistently shown that close relationships with non-drug users are one of the cornerstones of keeping adolescents from experimenting with drugs. Young people who have adults who care about them, and who help strengthen their values or beliefs of what is strong, ethical behavior are likely to have a clear idea about what is right, and the strength to behave in an appropriate manner.
• Skills (lack of competence)
  Children need to have skills to feel like they are contributing members of their family. If children are given the chance to help out with responsibilities, and are also given adequate training for those responsibilities (for example, they are taught to cook dinner, or to help tend the family garden), they will feel useful and successful. They will be less likely to start abusing alcohol or other drugs in search of the positive recognition they aren't getting at home.
• Healthy beliefs and clear standards (mixed messages)
  Living in a community, attending a school, and being part of a family where beliefs and standards are clearly against the use of drugs is a strong protective factor against experimentation. On the other hand, if children receive mixed messages, this could become a risk factor. For example, the message to a child is clear when the family goes out to eat, and the waitress asks if the family would prefer the smoking or nonsmoking section. If mom says, "Non smoking, please, we worry about our children inhaling second hand smoke," the message against cigarettes is clear to the children, even if the reply wasn't directed to them. On the other hand, a father who instructs his children not to use alcohol over his fourth beer sends a message that is much less clear.

Example 3: Determination of which risk and protective factors to focus on for teen substance use

Members of a small anti-drug coalition in rural Mississippi wanted to decide which risk and protective factors they should address. Using the table below, several people sat down and discussed which risk and protective factors were both important and changeable. Then, they ranked what they had said. The smaller the number they used, the more important the risk or protective factor (or, the easier it was to change.)

This is what they found:

Risk or protective factor	Importance		Changeability		Final value
Family history of drug abuse	1	+	3	=	4
Community norms saying it's "okay" to use drugs and alcohol	1	+	1	=	2
Transitions and mobility	2	+	3	=	5
Availability of substances	1	+	2	=	3

When all of the information was in front of them, they realized that their choices were easier to make. Although they all agreed that a family history of drug abuse was a very important risk factor, they realized that, given their limited budget, there wasn't a whole lot they could do about that risk factor right now. Similarly, with the category "transitions and mobility," they all agreed it was at least somewhat important, but again, there wasn't a whole lot they could do. Besides, the community was relatively stable; there weren't a lot of people moving in and out, and so this factor seemed a little less important.

However, all of the members felt that changing community norms and lessening the availability of substances were important risk factors that they could do quite a bit about. They could talk to people, start media campaigns, and conduct "stings " on stores that were selling alcohol to people under 21. The members decided to concentrate on these two risk factors as part of their current strategic plan. They also decided to come together again and reevaluate their work in six months.

Example 4: Risk and Protective Factors for Sexual Violence Prevention

This infographic highlights the connections between risk and protective factors and social determinants of health at the various levels of the social ecology, and can be used to link sexual violence prevention with anti-oppression and related public health issues in order to create more effective change.

 

Download a PDF of this chart.

 

 

Tool 1: Determining which risk or protective factors to focus on

In the table below, list all of the risk and protective factors that you have determined in the first column. In the next column, rate the importance of the factor, with one "1" being very important, two "2" being moderately important, and three "3" being slightly important. Note that more than one factor can have the same number. Do the same in the column labeled "Changeability," with one "1" being completely changeable, two "2" being partially changeable, and three "3" for factors you are unable to change. Finally, in the last column, add up the numbers you have gotten in each row. The factor(s) which has/have the lowest final value is/are the risk and protective factors you should start with, those with the second lowest value should come second, and so on.

Risk or protective factor	Importance		Changeability		Final value
		+		=
		+		=
		+		=
		+		=
		+		=
		+		=
		+		=
		+		=

 

 

Tool 2: Understanding the factors that contribute to the problem

Download this editable worksheet here.

A PowerPoint presentation summarizing the major points in the section.

What is risk reduction? What are protective factors?

You know your group wants to work on preventing a particular health problem in your community. Many effective prevention efforts work both to reduce risk factors and strengthen protective factors. But what's risk reduction? And what are protective factors?

Risk reduction means identifying the factors and conditions that increase the likelihood of the problem you're trying to prevent and then working to reduce or change those factors. For example, if you're working to prevent lung cancer, reducing tobacco use and exposure to tobacco smoke may be important parts of your strategy.

Protective factors are strengths, resources, relationships, conditions, and experiences that can reduce risk or support positive outcomes. For instance, if you work with a coalition to reduce cardiovascular disease, protective factors might include access to nutritious food, opportunities for physical activity, supportive social relationships, and high-quality preventive health care. Protective factors can help reduce the effects of risk factors and create conditions that support health and well-being. To demonstrate this, let's look at an example adapted from the work of researchers Hawkins and Catalano on risk and protective factors.

Example: Risk and protective factors for substance use among young people

 Risk factors:

• Economic hardship and limited access to resources
• Community instability or limited social connection
• Frequent transitions and mobility
• Availability of alcohol and other substances
• Community norms that normalize or encourage substance use
• Family history of substance use disorders or problematic substance use
• Limited family support, communication, or consistent expectations
• Academic difficulties or school disengagement
• Persistent behavioral challenges or involvement in harmful behavior
• Peers who use substances

Protective factors:

• Strong family, peer, school, and community connections
• Social, emotional, decision-making, and coping skills
• Clear and supportive expectations around substance use
• Stable employment and economic opportunity
• Availability of substance-free activities and opportunities for young people
• Supportive role models and mentors

By looking at the above lists, you should be able to identify several risk and protective factors that relate to one another. Clear and supportive expectations around substance use may help counter community norms that normalize substance use, for example. Strong relationships and community connections may also provide stability and support during periods of transition.

As you might have guessed by now, once you've figured out what the risk and protective factors are for the issue you're dealing with, the next step is to develop ways to reduce risk and strengthen protective factors. It's not enough simply to say, "Okay, we need to reduce sexual activity without adequate protection against STIs and unintended pregnancy among 18-to-24-year-olds." You'll need to develop strategies that address the factors contributing to that risk and specific tactics for carrying out those strategies.

Who should be involved in selection of risk reduction strategies?

Deciding on risk reduction strategies is something you shouldn't do completely on your own. While your organization may come up with some strong ideas, it's important to bring community members into the process, including people most affected by the issue and people who can contribute knowledge, relationships, resources, services, or decision-making authority. A community-wide approach works best in many cases.

Including members of the community in this process is advised because:

• It can help shape community norms and conditions that are connected to risk and protective factors. For example, HIV and STI prevention efforts may involve community members in promoting safer sexual practices, consent, access to condoms and testing, accurate health information, and supportive norms around sexual health.
• It creates a wider base of support for positive change. Involving people from a variety of groups, organizations, programs, and community networks can broaden participation and strengthen the effort.
• It can give you a better understanding of the strengths and resources available in the community. No single organization knows everything about community resources. Involving people from community organizations, government, social services, businesses, schools, health systems, neighborhood groups, and other sectors can help identify existing assets, relationships, and opportunities.
• It can help build broader community support for your initiative. When community members participate meaningfully in planning and decision-making, they are more likely to see the effort as something they helped shape and may share information and support through their own networks.
• It is more likely to support long-term change. Strategies developed through strong community partnerships can become integrated into organizations, relationships, policies, and community systems in ways that support sustainability.

Who are good people and groups to think about including?

• Local law enforcement and other public safety partners, when relevant
• Faith and spiritual leaders
• Local government officials and public agencies
• School administrators, teachers, students, parents and caregivers, school board members, and other education partners, especially when the effort involves young people
• Health and human service organizations
• Local media and communications organizations
• Young people, parents, caregivers, and families
• Local business owners, employers, and workers
• Community members representing a range of neighborhoods, backgrounds, experiences, and perspectives

You should also include people who are most directly affected by the issue in the process. Why is their participation important?

Including people most directly affected is important because:

• Meaningful participation can help establish and strengthen trust. Some communities have understandable reasons for mistrusting public health organizations or other institutions because of past or ongoing discrimination, exclusion, or mistreatment. Historical abuses such as the U.S. Public Health Service Syphilis Study at Tuskegee illustrate why transparency, accountability, respect, and meaningful community involvement are essential.
• People most affected by an issue bring essential strengths, knowledge, relationships, and lived experience. Community members often understand local conditions, barriers, assets, and possible solutions in ways that outside organizations may not. Their leadership can make an initiative more relevant and effective.
• It can give your group a better understanding of community priorities and what is likely to work. People with lived experience can identify barriers, strengths, unintended consequences, and opportunities that may not be apparent to planners or service providers.
• It can also increase community awareness of your organization and effort. Ongoing communication and participation can help community members understand what the initiative is doing and provide feedback as the work develops.

How to select risk reduction strategies

Now you have identified the risk and protective factors for your coalition, you have people together, and you're ready to start coming up with strategies and tactics. Where do you begin?

Take advantage of existing information.

First of all, you don't want to reinvent the wheel. There's a great deal of existing information that community health coalitions can use. Know your community's history. Has this initiative or something similar been tried here before? Even an effort that didn't achieve its goals may offer valuable lessons. Take advantage of existing knowledge on risk reduction and protective factors before developing strategies and tactics from scratch. Here are some ways you can do this:

Research to find out what other groups with missions similar to your own have done. A library search, credible online sources, research databases, program evaluations, and conversations with other organizations can yield a wealth of information. For example, a successful healthy food access program in another community might provide useful ideas for your own effort. Exchanging information with people doing similar work can benefit everyone involved.

Network, network, network. Get to know people who work with groups like yours. Conferences, workshops, professional networks, and community learning opportunities can connect you with people who have useful experience. Establish relationships with your peers so that you can exchange information, stories, lessons, and suggestions. Here are a few ways you can connect with people doing similar work:

• Attend conferences, workshops, webinars, and community learning events
• Get involved in regional and national coalitions or professional networks
• Join relevant email groups, online communities, professional associations, or other networks for people working on similar issues

A word of caution, however - don't assume that what has worked in other communities will necessarily work in your own. When you examine a possible strategy that has been used elsewhere, consider how well it fits your community's culture, laws, resources, priorities, history, and existing services. A syringe services program, for example, may require different outreach, partnerships, and implementation strategies in different communities.

Finally, conduct your own research and see what original strategies you can develop with community members and partners. A little ingenuity goes a long way. While many strong strategies can be adapted from other sources, don't be afraid to modify them when needed or develop new approaches based on local knowledge and experience.

Characteristics of effective risk reduction strategies

Here are some things that are usually present in an effective risk reduction strategy:

• First and foremost, an effective risk reduction strategy also works to strengthen protective factors. Focusing on strengths, resources, relationships, and supportive conditions can help avoid stigmatizing people based on risk factors or behaviors.
• The goals, methods to be used for data collection, evaluation, and feedback, and specific roles and duties of staff, volunteers, community partners, and other participants should be clearly defined. Outlining these things ahead of time can reduce confusion later in the process.
• The strategy approaches risk reduction in a way that's appropriate and responsive to the people and communities involved. Consider age, developmental stage, culture, language, accessibility, lived experience, community priorities, and the level and type of risk involved. For example, peer education can be effective with young people because peers may bring credibility, shared experience, and ways of communicating that complement information provided by adults and professionals.
• Many effective risk reduction strategies include early prevention and support. For example, providing people with access to nutritious food, health care, and other supports before and during pregnancy can promote healthy outcomes. Likewise, age-appropriate education about healthy relationships, consent, contraception, and STI prevention can help young people make informed decisions before problems arise.
• The strategy makes thoughtful and realistic use of available resources, including funding, staff time, partnerships, materials, facilities, and community capacity. If an approach cannot be sustained with available resources, consider adapting it or working with partners who can contribute additional support.
• If addressing more than one risk factor, it's usually helpful to use more than one strategy. Complex issues rarely have a single cause or solution. Domestic violence, for example, may be addressed through a combination of survivor-centered services, prevention education, economic and housing supports, programs that promote healthy relationships, accountability for people who cause harm, and policies and community norms that support safety and respect.

Questions to ask when evaluating prevention strategies you're considering:

• Does the strategy address important and well-supported risk factors?
• How will the strategy reduce risk and/or strengthen protective factors and community assets?
• Is the strategy likely to reach and meaningfully engage the people and communities it is intended to benefit?
• Is the strategy designed in a way that allows its implementation and effectiveness to be evaluated?

Common types of risk reduction strategies

Risk reduction strategies are often grouped into approaches that support individual behavior and approaches that change organizational, community, environmental, or policy conditions. Effective efforts often use both.

Strategies related to supporting individual behavior include:

• Incentives or disincentives - changing the costs, benefits, or supports associated with particular behaviors (for example, tobacco taxes that discourage tobacco use or free and low-cost cessation supports that make quitting more accessible)
• Increasing or reducing the time, effort, or other barriers associated with desired actions
• Providing support, such as peer education, coaching, counseling, navigation, or other forms of assistance
• Developing mentoring and supportive relationship programs
• Enhancing resources - raising funds, improving materials, strengthening connections with other programs and services, and increasing awareness of resources that are available
• Changing programs or services to reduce barriers and make them more accessible and responsive to the people using them
• Changing policies by creating, modifying, or ending policies as appropriate
• Providing information through approaches such as communication campaigns, community outreach, peer education, and counseling
• Modeling positive behaviors, relationships, or practices, including through peer education and mentoring
• Building skills through education, peer learning, coaching, counseling, practice, and other approaches
• Providing feedback on progress and opportunities for participants to reflect on and adjust their goals

Strategies related to organizational and community development include:

• Public awareness and communication campaigns, using tactics such as information campaigns, community outreach, peer education, and other appropriate communication methods
• Community assessment, learning, and monitoring
• Building coalitions and partnerships with other community groups
• Changing access to products and services, such as reducing youth access to tobacco products or expanding access to preventive health services
• Developing resources that strengthen family, peer, and community support
• Implementing and enforcing existing policies and laws fairly and consistently
• Advocacy and nonviolent civic action, including public education, community organizing, and other forms of collective participation
• Changing policies and laws through appropriate advocacy, outreach, public participation, and decision-making processes

Common tactics used in risk reduction

There are many tactics that can be used in risk reduction. Here are a few of the most common - but remember that the tactics you use should fit your goals, community, resources, and the people you hope to engage.

• Information and communication campaigns - This is one of the most commonly used tactics in risk reduction. Campaigns can help people understand health risks, protective factors, available resources, and actions they can take. Communication methods might include social media, websites, advertisements, posters, brochures, community newsletters, radio or television messages, speakers, text messaging, and informational hotlines.
• Street and place-based outreach - Outreach workers or peer outreach specialists connect directly with people in neighborhoods and other places where community members spend time. Activities might include conversations, canvassing, information tables, distributing supplies, harm-reduction resources, referrals, and connections to services. Consistent outreach can help build trust and make information and resources more accessible.
• Community outreach - Community outreach often takes place through workshops, presentations, listening sessions, community events, or other group settings. These activities can share information, build relationships, gather community input, and connect people with resources. They are often most effective when combined with other ongoing strategies.
• Peer education - Peer education involves people with shared experiences, identities, or community connections providing information, support, and opportunities for learning. Peer educators may bring credibility and lived experience that help make communication more relevant and accessible. They can participate in one-on-one conversations, group education, outreach, mentoring, navigation, or other activities.
• Risk reduction counseling - Risk reduction counseling is collaborative, nonjudgmental support for people who may experience increased risk. A counselor, peer specialist, health worker, or other trained person works with participants to understand their goals, identify risks and protective factors, explore realistic options, and develop skills and strategies that support safer and healthier choices. Counseling may take place one-on-one or in small groups.
• Direct action - Direct action refers to organized public actions intended to draw attention to an issue or advocate for change. Examples may include demonstrations, symbolic actions, public events, sit-ins, boycotts, or other forms of nonviolent civic participation. Because these tactics may attract significant public attention or involve legal, safety, and accessibility considerations, organizations should plan carefully and consider how the action fits within their broader goals and strategy. If using direct action tactics, think through the purpose, participants, safety, communication, and possible consequences in advance.

In Summary

This section provides an understanding of how you can design strategies and tactics to reduce risk and strengthen protective factors and community assets. Pay close attention to evidence and lessons from other communities, particularly those that share relevant characteristics with your own, while recognizing that strategies may need to be adapted to local strengths, priorities, resources, and circumstances. Community members - especially people most directly affected by the issue - should help shape those adaptations. You may find that a combination of locally developed ideas and approaches adapted from other sources works best for your community.

You understand that:

___Risk reduction involves finding out what in your community leads to the problem you're trying to prevent and then working to cut down on those factors.

___Protective factors are those things that keep whatever it is you're trying to prevent from occurring.

___A strategy is a broad step in a plan to accomplish a specific goal.

___A tactic is a specific step you take to complete a strategy.

You understand the following reasons for including members of the community in the process of selecting risk reduction strategies:

___It can help change community norms and values, which are often tied to risk and protective factors.

___It creates a wider base of support for changing behavior.

___It can give you a better sense of what resources are available to you in the community.

___It can help galvanize public support for your initiative.

___It is more likely to lead to long-term changes.

You have considered including people from the following groups in the process of selecting risk reduction strategies:

___Local law enforcement

___Religious leaders

___Local government officials

___School administrators, teachers, PTA members, school board members

___Health and human services agencies

___Local media representatives

___Youth and parents

___Local businesspeople

___Members of the target population you serve

You understand the following reasons for including members of the target population in the process of selecting risk reduction strategies:

___Giving the target population a say helps establish trust

___Affected communities are often stronger and more resourceful than we give them credit for

___It can give your group a better understanding of what the community needs

___It can also increase community awareness of who you are and what you do

Selecting risk reduction strategies:

___Research to find out what other groups with missions similar to your own have done

___Attend conferences and workshops

___Get involved in regional and national coalitions

___Sign on to an email list for people who do the same type of work you do

___When you examine a possible strategy that has been used in another community, think about how it would work with your own community

___Conduct your own research and see what original strategies you can come up with on your own

You understand the following characteristics of an effective risk reduction strategy:

___The strategy works to increase protective factors

___The goals, methods to be used for data collection, evaluation, and feedback, and specific roles and duties of all staff, volunteers, and any other personnel are clearly defined

___The strategy approaches risk reduction in a manner appropriate to your target population

___The strategy employs early intervention

___The strategy makes the best possible use of available resources

___If addressing multiple risk factors, it's probably best to use multiple strategies

You've asked the following questions when evaluating prevention strategies you're considering:

___Does the strategy address known risk factors?

___How will the strategy reduce risk and/or increase protective factors?

___Is the strategy likely to reach your target population?

___Is the strategy set up in a way in which it can be evaluated?

You're familiar with risk reduction strategies related to changing individual behavior:

___incentives or disincentives

___increasing (or reducing) time and effort for target behaviors

___providing support

___arranging mentors

___enhancing resources

___changing environmental design to remove barriers or enhance accessibility

___changing policy (creating, modifying, or terminating)

___providing information

___modeling

___skills training

___providing feedback on progress

You're familiar with risk reduction strategies related to organizational and community development include:

___public awareness and media campaigns

___community assessment and monitoring

___coalition building

___modifying access to products and services

___integrating and coordinating local agencies and resources

___developing resources to enhance family and peer support

___enforcement of existing policies and laws

___advocacy and nonviolent protest

___changing policies and laws

You understand some of the common tactics used in risk reduction:

___Information campaigns

___Street outreach

___Community outreach

___Peer education

___Risk reduction counseling

___Direct action

Tool #1: Supporting Youth at Risk: A Policy Toolkit for Middle-Income Countries

From the introduction of the Policy Toolkit, published in 2008:

Today, there are 1.5 billion people between the ages of 12 and 24 worldwide, with 1.3 billion of them living in developing countries—making the young the largest segment of developing country population in recorded history. More important, young people constitute a disproportionately large part of the world’s poor. While they represent 50 percent of the developing country population, they represent nearly 60 percent of the poor in those countries.1 Young people can be a source of growth and development for their countries, but a subset of young people—those known as youth at risk—are a source of the inequality, poverty, exclusion, and much of the crime and violence that plagues every region in the world, thereby imposing enormous costs on themselves, their families, and society at large.

The World Bank has produced this Policy Toolkit in response to a growing demand from our government clients and partners for advice on how to create and implement effective policies for at-risk youth. We have highlighted 22 policies (six core policies, nine promising policies, and seven general policies) that have been effective in addressing the following five key risk areas for young people around the world:

• Youth unemployment, underemployment, and lack of formal sector employment
• Early school leaving
• Risky sexual behavior leading to early childbearing and HIV/AIDS
• Crime and violence
• Substance use

The objective of this Toolkit is to serve as a practical guide for policy makers in middle-income countries—as well as professionals working within the area of youth development—on how to develop and implement an effective policy portfolio to foster healthy and positive youth development.

Supporting Youth at Risk: A Policy Toolkit for Middle-Income Countries

A PowerPoint presentation summarizing the major points in the section.

• What do we mean by "adaptation?"

• What do we mean by "different cultures and communities?"

• Why should you adapt interventions?

• When should you adapt interventions?

• An important question: Does an intervention always need to be adapted?

• How should you adapt interventions?

• Some special situations: "What should I do if...?"

What do we mean by "adaptation"?

Suppose you have conducted a community intervention and it is successful. Naturally, you might think about building upon your success and conducting the intervention elsewhere -- in a context that could be different culturally, or have an entirely different population.

For example, suppose you have organized a successful park clean-up, or voter registration drive, or home-visiting program for the elderly. The park becomes clean; the voters are registered; and visits are being made. Now there's the chance to do the same in another setting, with a different population. Will your success be repeated?

The key questions here are (1) whether that intervention will be successful elsewhere, and especially (2) how it can be made most successful. The best answers are (1) "maybe," and (2) "with careful thinking and planning."

The basic idea is that interventions are not always one-size-fits-all. When the setting is different, they may need to be adapted. Fortunately, there are principles of adaptation and guidelines for making any adaptation successful. That is the main focus of this Tool Box section.

What do we mean by "different cultural traditions?"

"Culture" is a big word which covers a lot of ground. A very brief definition is that culture refers to a set of behaviors, habits, roles, and norms that apply to a particular group. We could also use the term "traditions" to mean essentially the same thing. These terms overlap. For our purposes, though, we are less concerned with official definitions than with communicating the basic idea.

Within this broad definition, many groups qualify as cultures. Racial groups come easily to mind as one frequent example. European, African, Hispanic, Asian, and Indigenous cultures do sometimes differ (and often differ within themselves). Ethnic groups may have within themselves different cultures, and sub-cultures, as well. It's important to take these differences into account.

Cultural traditions, and cultural differences, can extend well beyond race and ethnicity. They can be based on age, gender, social class, religion, region, sexual orientation, employment, family background, or even neighborhood -- or any combination of these factors. A potluck supper, or blood-pressure screening, or immunization drive might be a terrific success in one setting; while in another setting the same event could fall flat on its face. Why? Different cultural traditions, broadly defined, might have something to do with it. A successful adaptation might not have been made.

Why should you adapt interventions to fit different cultural traditions?

Possibly the most important reason you might want to adapt your intervention to different cultures is because your intervention has worked already and you would like it to work again. A well-adapted intervention can:

• Show respect for another culture's values and identity
• Improve your ability to connect with your target community
• Increase the relevance of your actions
• Decrease the possibility of unwanted surprises
• Increase the involvement and participation of members of other cultural groups
• Increase support for your program by those cultural group members, even if they don't participate or get directly involved
• Increase the chances for success of your intervention (and its community impact)
• Build future trust and cooperation across cultural lines -- which should raise the prospects for more successful interventions in the future.

These are all excellent reasons to proceed, if the conditions are right.

When should you adapt interventions to fit different cultural traditions?

Here are six useful criteria:

1. When you think you have a good idea
2. When you have actually tested that idea, and found it to be successful
3. When you are actively interested in trying out the idea in a different cultural setting
4. When you have the needed time, money, and person-power to go forward
5. Members of the different cultural group are known to be interested in your intervention. (In some cases, they may even ask you to conduct it in their setting.
6. Members of that cultural group are actively willing to collaborate with you in making that intervention a success.

An Important Question: Does An Intervention Always Need to Be Adapted?

No, not every single time. There are certainly cases where little or no adaptation is necessary. For example:

• A (Caucasian) grant-writing specialist was asked to give a grant-writing workshop to a Spanish-speaking group. Hardly any adaptation was needed in this case. The basics of grant-writing vary little across cultures. Cultural differences were not a factor here.
• Another specialist gave a demonstration on the Internet to a group of newly-arrived immigrants from different countries. Their goal was to learn how to use the Internet. They wanted to learn very specific skills. For this purpose, their culture didn't matter.

At other times, cultural differences do indeed matter:

• An AIDS prevention organization wanted to do prevention education in its local Spanish-speaking community. Community members were not inclined to or not able to come to public meetings. But they would and did go to meet their neighbors at another neighbor's house. The education here took place through charlas, or "house chats," a medium well-suited to that particular culture.
• A Black minister discussed how Black groups and White groups operated differently in meetings, at least as far as he was concerned: "See, white folk come to a meeting, they want to take care of business, they want the small talk very limited. They've got an agenda, boom, boom, boom, boom, boom, off to their next meeting. The black meetings take more stroking. You do more social backslapping, talk, talk, talk, talk, talk. And then you eventually get down to business." If this minister is right, cultural adaptation would be very important.

These examples involve racial or ethnic differences, but could be extended to other cultural differences as well. Our general point is that it's difficult to know in advance how much cultural adaptation will be necessary. So it's best to assume that at least some adaptation might be necessary, and to proceed cautiously.

Just how should you proceed? The "how-to" heading which follows may be helpful.

How should you adapt interventions to fit different cultural traditions?

Here is one step-by-step approach you can use as a guide. (If you are working within an organization, the same steps will apply to your organization as well.)

• Ask yourself, honestly: "Is the intervention is worth adapting?" It may be good; but is it good enough? Is its potential value high enough to justify the effort you will be putting in? A sincere and thoughtful answer to this question, well before you start, can save you a lot of time and trouble later on.
• Suppose you decide the intervention is worth adapting. Do you want to do the adaptation? Much of the success of your adaptation -- or of any intervention -- will depend upon your personal desire. There may be other things you would rather do. So unless you can answer this question with a definite "yes," think very carefully before moving ahead.
• You may decide that you want to do it. But here's another question: Is it really your role to direct the adaptation? Maybe it is; maybe no one else is ready to come forward at all. (If so, ask why.) But maybe the intervention would work better if you didn't direct it. Maybe others should take on the lead responsibility -- which could both make the intervention more successful and empower those others as well. Maybe your best place is on the edges, or in the background.
• Check your readiness. If you do have a role, are you culturally ready to take it on? You might want to ask yourself these questions:
  • What are your own cultural values and beliefs? How might they be different from those of the target community?
  • Do you have experience working with the cultural group in question, or with similar groups?
  • If so, what lessons can you draw from those experiences that might be useful here?
  • Are you personally ready to take on the potential work of doing the adaptation?
• Check the readiness of your target group - "readiness" works both ways:
  • Is the cultural group in question ready to work with you?
  • Is it also able to work with you? Does it have the skills and resources that might be necessary?
  • How is it likely to react to your own cultural tradition? (You will be bringing that tradition to the intervention whether you want to or not.)
• Depending on your answers to these questions, you may be ready to go ahead. If so, make the commitment to do the adaptation. Your external commitment, as well as your internal desire, will be an important ingredient in your success.
• Set specific objectives for the adapted intervention. What, specifically, do you want it to accomplish?

And now you are ready to go to work in the outside world. The next steps follow:

Do some research, especially if you don't know much about the cultural group in question. Learn as much as you can -- about its cultural beliefs and practices, about its social norms and political concerns, about its history -- before you plunge in.

What kinds of questions should you ask?

Where can you get those questions answered? You might start with your local library, which can supply you with:

• Census data
• Maps
• Government documents
• Local reports and statistics
• Hometown newspapers, including back issues
• Articles on the cultural group you will be working with. (Have others tried the same intervention with this cultural group? Through careful research, you may be able to find out what they did, and what happened as a result.)

Talk to people in that cultural setting. Talk to a variety of people if you can. These people can include:

• Known experts on that culture, usually through professional reputation
• Key members of that particular culture who are especially knowledgeable -- either because they have lived for a long time in that cultural setting, or are well-connected to others in that setting, or both. These key members (sometimes called "informants " or "gatekeepers") can help you a lot when it comes time to begin the intervention itself.

Who are these people, specifically? They could be:

• Local government officials
• Business professionals
• Teachers or college professors
• Professional researchers
• People who have worked in similar communities, on similar problems
• Well-informed people, without any particular title
• Community service workers
• Ministers and other religious leaders
• Newspaper editors

Note that each of these people can themselves be asked for other leads.

Talking with others usually means spending time one-on-one. Alternatively, you can also talk with others in a group. This can be more efficient and effective, even if some individual responses might be lost.

Spend some time in the cultural setting, if you haven't done so already. Have a cup of coffee at a local coffeehouse; take a walk in the neighborhood; sit in a park; go to a public event (or get yourself invited to a private one). The simple act of being in the setting can be an excellent teacher, and can give you insights otherwise hard to come by. Of course, while you are there, you can also talk to people (see #9 above); note that both "talking" and "spending time" are also forms of research (see #8).

When you have done your cultural homework, and learned as much as you feel you can, propose your intervention idea to some people in that setting. (This can also be done one-on-one or in a group; see #9 above.) The people you approach should be those you have developed a comfortable and trusting relationship with. If they are also influential people in that setting, that's an added advantage.

When you do propose, do so gently and gradually. Rather than say, "I'm planning to do X," try something like, "I have an idea that's been on my mind. Can I tell you about it, and then I'd be interested in what you think." Be tactful. Key your words to the experiences of your listener. Take advantage of the cultural lessons you have learned.

After you propose, ask for feedback. Does your listener think the intervention is a good idea? Will it work? What changes should be made? What should happen next? When you ask for feedback, don't ask just as a formality. Take that feedback carefully into account. Make the changes that are suggested (or have a good reason why, if you don't).

If many different informants tell you that your idea has little value for people in that setting, or hasn't a prayer of working, pay attention to those red flags. This may not be the right time or the right place to adapt this particular intervention. If so, it's much better to realize this now than later. But don't be too discouraged; some other intervention idea, perhaps not very different from what you had in mind, may emerge from your discussions. It might turn out to be a better idea for all concerned.

If your feedback is sufficiently positive, then you may be ready to move ahead. The next step is to find some people in that cultural community who will work together with you to make the intervention happen. Some of these people could be the same community members you have spoken to before (and it's certainly okay to have this in the back of your mind when you set out.) And some of them should definitely be people who will be affected by the intervention -- if it's a teen pregnancy prevention program, for example, you want to include teens, and quite possibly teen mothers and fathers.

In other words, at this stage, you want collaborators. In addition, you want to bring these collaborators together into an informal group -- often called a working group or an advisory group. This group will normally take the lead responsibility for adapting and carrying out the intervention.

At this point, you should begin planning and execution, just as you would with any other intervention; those same basic procedures apply now as well. Here you can draw upon your past successful experiences. Your collaborators -- your working group -- will decide what might need to be changed from the original intervention, and what does not. It will agree upon a course of action, establish timelines, conduct any pilot tests, and divide up responsibilities as it sees fit. These steps are common to all interventions, whether or not they are adapted.

Some special situations: "What should I do if...?"

If conflicts arise?

If they do, don't be surprised. Conflicts are natural, especially if two groups do not have a history of working together successfully. Relationships need to be formed. Trust needs to be developed, and trust takes time.

A useful guideline here is not to suppress conflict, but to see that it gets expressed when it occurs, openly and respectfully. Setting this tone at the beginning may help. Some regular check-in meetings to monitor both progress and feelings may help as well. Lay some ground rules for dealing with conflict, so that it doesn't get blown out of proportion. One additional possibility is some form of cultural training (see below).

If cultural groups really don't understand each other?

When two cultural groups are newly dealing with each other - especially when neither has much experience working with the other - and when the intervention is larger or might last for a long time, then some form of cultural training might be called for. Trainers from one cultural group can work to train the other, and vice versa. (Sometimes, trainers from both groups can conduct the training together.) The specifics of such training will vary with the situation; but you might want to work out some training details before the intervention is well under way.

If materials need translation?

You have materials in one language that you want translated into another. A good idea? Maybe so, but first consider whether relevant materials already do exist (and have been tested) in that second language. It could be a big time-saver if you can find them. Consider also whether it's better to translate than to create new materials from scratch. Creating new material takes time, but there's a possible gain in freshness and relevance.

If you do decide to translate, try to find an experienced translator in that cultural community. And if you can, try to have the translated material reviewed by others, and back-translated into the first language by another person; these techniques will give you a check on translation accuracy.

If the adaptation involves several different cultural groups

Suppose you are adapting an intervention not just to one cultural group, but to several different groups at the same time. It can happen; you could be working in a multi-ethnic setting, or across multi-generational or multi-denominational lines. Here you have an extra challenge on your hands, one of many that makes community work so interesting.

Your best response here is to look for elements that all the cultural groups have in common. They could involve needs for better housing, for example, or street safety, or better education for one's children. Are there such elements in your case? Then adapt your intervention keeping them in the foreground; or adjust your intervention to address those common goals. Once again, make sure all groups involved have a seat at the table; ask for feedback; listen to it.

Many multi-cultural organizations have done just that. And successful multi-cultural work, which builds connectedness and trust and achievement across several different cultures at the same time, is among the most exciting community work we can do.

In Summary

These two closing statements sum up the key points of this section:

• First, to paraphrase the well-known community organizer Saul Alinsky, always work within the experience of your target group. See things through their eyes. Act accordingly. To do so, you must have a good idea about how those people understand and relate to the world. This takes understanding on your part, not to mention sensitivity, flexibility, and patience. It isn't always easy. Working with different cultural groups or in culturally diverse communities presents a challenge even to experienced professionals.
• Second, even with the right attitude and the right approach, success is not guaranteed. For a variety of reasons, you may not get the local collaboration you want or need. Other obstacles may get in the way. But when success does happen, the rewards can be great. You will have developed a program that is culturally relevant to the community's needs, perhaps with benefits that have never been present before. And you may have set an excellent precedent for future work with that cultural community, a precedent that can long outlast your own departure from the scene.

___You understand what it means to adapt interventions for different cultural traditions.

___You understand why you should adapt interventions.

___You understand when you should adapt interventions.

___You understand when you don't need to adapt an intervention.

___You understand how to adapt interventions to different cultural traditions:

___You have determined that the intervention is worth adapting.

___You have decided that you want to do the adaptation.

___You have decided that it is your role to direct the adaptation.

___You are culturally ready to take on the role.

___You have checked the readiness of your target group.

___You have made the commitment to do the adaptation.

___You have set specific objectives.

___You have done some research.

___You have talked to people in that cultural setting.

___You have spent some time in that cultural setting.

___You have proposed your intervention.

___You have asked for feedback.

___You have incorporated that feedback (or have a good reason why you didn't).

___You have found some people in that cultural community who will work together with you.

___You have planned and executed your intervention.

___You know what to do in the following situations:

       ___If conflicts arise

       ___If cultural groups really don't understand each other

       ___If materials need translation

       ___If the adaptation involves several different cultural groups

Questions to Consider in your Search for Information about the Community

Historical Issues

• What is the history of the community?
• What name or names do the cultural groups use to refer to themselves?
• What is the significance of the different names?
• What are the major differences between cultural groups in your target community, particularly across generational, educational, socio-economic and geographic lines?
• What have been the major historical events which describe the target group's experiences in the United States?
• What were and are the major conflicts between or among the cultural groups in the target community? What were the outcomes?
• What were and are the major conflicts within each group? What were the outcomes?

Economic and Political Issues

• What are the different socio-economic levels of groups within the community?
• What is the political status of each group in the community (e.g. undocumented, refugee, legal immigrant, citizen)?
• What are the different literacy levels within groups? Are they literate/illiterate in English and/or their own language?
• What are the different education levels within groups?
• How is their health status affected by their economic and political status? What are the predominant health problems?
• How often is medical care used by these different groups? What types of care?
• What are the organizations that successfully serve the different groups within the target community? Are they governmental, religious, community, social service, political or ethnic in nature?

Culture and Tradition-Specific Issues

• What are the values of the different groups in the community?
• How do various members of each cultural group define health and illness?
• What are some of the more common health beliefs and practices of community groups, both in general and with respect to specific problems?
• What are the predominant family structures within the community's cultural groups? Patriarchal, matriarchal, single parent household, extended families, etc.?
• What are some of the traditional roles of different family members in these cultural groups, particularly where health care is concerned?
• Who are the formal and informal leaders in the community, and what role do they have in the area of health promotion?
• How many languages and dialects are spoken?
• What are the formal and informal channels of communication within and between different groups?

Medical Orientation

• What are the group's general beliefs about the cause, prevention, diagnosis and treatment of disease?
• What are the group's attitudes towards "Western" medicine?
• In general, what has been the experience of different groups when trying to access the health care system?
• To what extent is there use of traditional medicine or healers?
• Where do people go for health information?

Diet

• What are traditional foods, and what role do they play in health, religion, and social activities?
• How has diet here in the U.S. changed over time as compared to in their country of origin?
• Is there access to foods that constitute traditional diet? Are there acceptable substitutes?

Religion

• What are the different religions practiced within the cultural groups in the community?
• How is practice of their religion influenced by their culture?
• What is the size of membership, and who are the members?
• Who are the religious leaders, and what is their role in the larger community?
• Are there conflicts among or within the various religious groups?
• What involvement do various religious groups have in the area of health education and promotion?
• Do religious beliefs conflict with the philosophy of health promotion? Can the beliefs be incorporated into your program?

A PowerPoint presentation summarizing the major points in the section.

You run a community violence prevention program, working with gang-involved and justice-involved youth. The youth trust you, and sometimes divulge information to you. The police also know you work with gang-involved youth, and often ask you for specific information about particular youth. What are you obligated to tell them, or to keep from them?

The right of a person to know what happens to information he reveals in the course of a community intervention falls under the heading of ethics. A participant in a community program -- a health clinic, an adult literacy class, a youth leadership initiative -- has a right to certain expectations relating to how she and the information she passes on are treated. The community has expectations as well about the reliability, competence, and honesty of a program that benefits its citizens. In this section, we'll discuss what some of those expectations are, and your and your organization's or initiative's moral and legal obligations to those you serve.

What do we mean by ethics?

Ethics is a code of thinking and behavior governed by a combination of personal, moral, legal, and social standards of what is right. Although the definition of "right" varies with situations and cultures, its meaning in the context of a community intervention involves a number of guiding principles with which most community activists and service providers would probably agree:

Do no harm. Hippocrates put this in words over 2,000 years ago, and it's still Rule Number One.

• Respect people as ends, not means: consider and treat everyone as a unique individual who matters, not as a number in a political or social or clinical calculation.
• Respect participants' ability to play a role in determining what they need. Don't assume that professional staff or program planners necessarily know what's best for a community or individual.
• Respect everyone's human, civil, and legal rights. This encompasses such issues as non-discrimination and cultural sensitivity.
• Do what is best for everyone under the circumstances. You're not necessarily going to be able to help everyone all the time, but you can try to get as close as possible.

• Don't abuse your position or exploit a participant to gain a personal advantage or to exercise power over another person. This refers to taking advantage of participants or others for political, social, sexual, or financial gain.
• Don't attempt an intervention in areas in which you're not trained and/or competent. This goes along with "do no harm," but it's not always possible. Just as there are times when no intervention may be preferable to doing something counterproductive, there may be times when any intervention is better than none at all. In those circumstances, you may have to learn as you go, getting all the help you can and hoping you don't do anything harmful. It's important to distinguish between doing what you can and getting in over your head to the point where what you're doing becomes truly unethical and harmful.
• Actively strive to improve or correct, to the extent possible, the situations of participants in your program and the community. In other words, it's incumbent on you to try to create the best and most effective program possible to meet the needs of participants, and to address underlying conditions or situations in a way that will benefit the community as a whole.

Why is ethical behavior important in community interventions?

In addition to its simply being the right thing to do, always acting ethically brings some particular advantages with it. It makes your program more effective; it cements your standing in the community; it allows you to occupy the moral high ground when arguing the merits of your program, and to exercise moral leadership in the community; and it assures that you remain in good standing legally and professionally.

• Program effectiveness. Consistent ethical behavior can lead to a more effective program. Considering ethical principles in all aspects of a community intervention will lead you to finding the most effective and community-centered methods, and will bring dividends in participation, community support and funding possibilities.
• Standing in the community. An organization that has a reputation for ethical action is far more likely to be respected by both participants and the community as a whole than one that has been known to be unethical in the past. An organization that's recognized as ethical is also apt to be seen as competent, and to be trusted to treat people with respect and to do what it says it will do. That community trust makes it easier to recruit staff, volunteers, Board members, and participants, and to raise money and public support.
• Moral credibility and leadership. If you work for the betterment of the world -- whether you see that as social change, social justice, the alleviation of suffering, the fostering of human dignity, or simply the provision of services -- it's consistent to act as you wish the rest of the world to act. Ethical action reflects why you started your community intervention in the first place. You have a moral obligation to yourself, the individuals you work with, and the community to be ethical in all you do, and to expect the same from others. If you fulfill that obligation, and everyone knows it, your voice will have greater impact when you speak out for what you believe is right, or against what you believe is wrong, and others will follow you.

• Professional and legal issues. Many of the health and human service professions often involved in community interventions are held to specific codes of ethics by their professional certification or licensure organizations. The American Medical Association, the American Bar Association, the American Psychological Association, the National Association of Social Workers -- these and many other professional associations have detailed ethical standards their members are expected to adhere to. If members of the profession violate these standards, they can be disciplined, or even lose their licenses to practice.

  Lawyers who mishandle funds entrusted to them, for instance, or who otherwise violate the law, are often suspended or disbarred. A Massachusetts obstetrician who was found to be sexually abusing patients immediately lost his license to practice medicine (and had to flee the state to avoid prosecution).

  Professional codes of ethics generally cover everything from the use of accepted methods to professional development to billing practices. People in a particular field are expected to be familiar with their professional code, and to adhere to it under all circumstances.

  The law requires certain standards of many professionals as well. Doctors and lawyers can be sued for malpractice if their substandard handling of a case results in harm to a patient or client. In rare cases (where someone feels that a competent therapist might have been able to prevent a suicide, for instance), a mental health professional might also be sued for malpractice. Medical professionals, psychologists, psychiatrists, and psychotherapists can lose their licenses, and may be sued -- or prosecuted for criminal sexual assault -- if they have sexual relations with clients, even in cases where the clients consent. Organizations and individual administrators may find themselves in legal trouble if they abuse participants or if they misuse or misappropriate money. In most situations, ethical and legal behavior go hand in hand.

Who is subject to a code of ethics in community interventions?

The short answer is that everyone -- who works in a community program of any kind, or who deals with other people in a professional or paraprofessional capacity -- is subject to a code of ethics in community interventions. There are, however, a number of formal ethical codes -- usually set down by professional organizations, but sometimes by law -- that apply to people in particular professional or other positions.

Here are some examples of people expected to adhere to a formal code of ethics:

• Medical professionals (i.e. doctors, nurses, EMTs). This category also includes such non-traditional medical workers as chiropractors and acupuncturists.
• Mental health professionals (i.e. psychiatrists, psychologists, psychotherapists, counselors)
• Social workers
• Clergy
• Public officials
• Educators
• Youth workers
• People who work with young children, or in child protective services
• Lawyers and paralegals
• Mediators
• Administrators of all types of community programs or their sponsoring organizations
• Non-professional line staff (home health aides, overnight staff at residential facilities and shelters)

What are the ethical issues that need to be considered, and how do they play out in community interventions?

Ethical behavior in community interventions relates to the treatment of people, information, and money, and to the general actions of the workers and the organization or initiative, even when they're not dealing directly with the community. Not all of the areas discussed below are covered by a specific legal or ethical code for every profession or community service, but are nonetheless related to ethical behavior for just about any program or organization. All should at least be considered as you define ethics for yourself and your program.

Confidentiality

Probably the most familiar of ethical issues -- perhaps because it's the one most often violated -- is the expectation that communications and information from participants in the course of a community intervention or program (including conversations, written or taped records, notes, test results, etc.) will be kept confidential. Programs' legal responsibilities in this area may vary, but as a general rule, confidentiality is the best policy. It protects both participants and the organization from invasion of privacy, and establishes a bond of trust between the participant and the program. Depending upon the program, the staff member's position, and the participant's needs, confidentiality may encompass a range of possibilities:

• No one but the individual working with a particular participant will have access to information about or records of that participant without her permission. At this level of confidentiality, records and notes are usually kept under lock and key, and computer records should be protected by electronic coding or passwords.

• Information is confidential within a program, but may be shared among staff members for purposes of consultation and delivering better services to the participant. Teachers in an adult literacy program, for instance, may confer about a student with a particular learning disability or problem.

• Information is confidential within a program or to a particular staff member, but may be shared with staff members of other programs in which the participant is involved, either to improve services for the participant, or to contribute to the other organization's reporting data. This kind of arrangement usually requires that participants be told about it from the beginning, and that they sign release forms giving the program permission to share records and information under appropriate circumstances.
• Information is confidential within a program, but is submitted to funding sources as documentation of services provided. This situation can lead to problems if participants have been promised complete confidentiality. In that case, especially if threatened with withdrawal of funds, the program has to decide whether the money is more important than participants' anonymity, or what level of anonymity is sufficient. Some organizations simply provide the requested documentation without informing participants, on the assumption that funders are not likely either to have actual contact with participants or to misuse an individual record; others feel they must honor their promise, and can't release anything without participants' permission.

• Information is not confidential, or is only confidential under certain circumstances. Participation in a program may be court-mandated or mandated by an agency as a condition of receiving benefits or services. Often, in those cases, participation implies an agreement to the sharing of records and information, and may even be a matter of public record.

In all circumstances, ethical treatment of participants demands that they be informed about the program's confidentiality policies. In most cases, they then have the choice of not participating if they are unhappy with those policies; in the case of court-mandated participation, at least they'll know what to expect. All of which brings us to the next two issues, which may intertwine with confidentiality and each other: consent and disclosure.

Consent

There are really three faces of consent: program participants giving program staff consent to share their records or information with others for purposes of service provision; participants giving informed consent to submit to particular medical or other services, treatment, research, or program conditions; and community members consenting to the location or operation of an intervention in their neighborhood.

• Consent to sharing of information. As we found in the discussion of confidentiality above, most participant records and information collected by program staff can only be passed on with the consent of the participant. In general, this consent is embodied in a standard form signed by the participant, granting permission to a program in which he was formerly or is currently enrolled to share his information with another organization, in which he is also a former or current participant. In some programs, a participant might sign a blanket form on entrance, but a separate form is usually needed for each separate instance of information sharing outside the program itself.
• Informed consent for services, treatment, research, or program conditions. In some situations, services might be significantly different from participants' expectations (being asked to enter residential drug treatment as a result of psychotherapy, for example). In others -- medical diagnoses, for instance -- there are no "normal" expectations. A third possibility involves participants enrolling in a community intervention which is also a study. In any of these instances, ethical practice demands that people be fully informed -- and can ask and have answered any questions -- about what they are about to take part in. An informed consent form is usually the vehicle by which participants give their permission to be involved in these interventions.

• Community consent. It's difficult to draw lines here, or to find the absolute ethical standard. Is it ethically necessary to gain the consent of a neighborhood to place a halfway house or homeless shelter there, for instance? What if neighbors' attitudes stop at "Not in my back yard"? Do you need the consent of a group -- or its president or director -- to survey its members? Do you need the consent of a majority of the members of a jobs-for-youth program to enforce a substance-free policy?

Both confidentiality and consent bring up the issue of privacy, one that has been much discussed in the past 20 years or so. Technology has made information far more accessible to far more people, and individual privacy has consequently become far more threatened. Much of what is discussed above and below has been the subject of legal wrangling or legislation (as in the case of the Buckley Amendment). While the question of the right to privacy, constitutional or otherwise, is much too broad to go into here in any detail, it is always lurking behind any decision about releasing information.

Disclosure

Like consent, disclosure in this context has more than one meaning.

• Disclosure to participants of the conditions of the program they're in -- program policies of confidentiality and when it might be breached, what kinds of services are available and what kinds are not, any time limits on the program, whether it will cost anything, etc. Participants have a right to know if they will be part of a research study if they enter the program, and to understand the purpose of that study, as explained above. Some organizations or individuals put these disclosures in writing, and make sure that every participant has a copy and that he understands what's written on it. It is ethically important both that participants know exactly what they're getting into, and that they be treated as adults who can decide what makes sense for them.

• Disclosure of participant information to other individuals, agencies, etc. The rules here are essentially those for confidentiality: information, except in cases of mandated reporting, potential harm to self or others, or court testimony, can only be disclosed with the participant's permission. Exceptions to this rule have to be spelled out to participants as they enter the program, so they can decide whether the services are worth any loss of privacy or anonymity.
• Disclosure -- by the program and by the affected individuals -- of any conflict of interest that the program represents to any staff or Board members. Disclosure here includes individuals disclosing potential conflicts to the program or organization, and the program disclosing potential conflicts to funders and other interested parties.

Competence

By offering services of any kind, an organization is essentially making a contract with participants to do the job it says it will do. Implied in that contract is that those actually doing the work, and the organization as a whole, are competent to accomplish their goals under reasonable circumstances.

It is obvious that no program or individual will succeed 100% of the time. Participants may be unready -- think about the long-term failure rates of many substance use treatment programs -- or resistant. Some community interventions may succeed less than half the time, and that may be the best anyone can do. But whatever the success rate, participants and the community have a right to expect that the program knows what it's doing and will make its best faith effort to provide effective services. That means that community services need to be offered by folks who are competent at what they do.

Competence means more than simply having the appropriate training and experience. A competent organization hires competent staff members, provides supervision and staff development, and does everything it can to assure that the services it offers are the best available. If service appears to be ineffective or harmful, it is the ethical responsibility of the program to seek out or develop and try more effective methods. If a staff member, even with help from supervisors and others, isn't able to do the job, that should be documented and she should be dismissed.

There are legal implications here as well. As explained earlier in this section, in some cases, service providers can lose their licenses or be sued for malpractice if they are found to be incompetent. It is up to a program to make sure that no one on its staff places himself in that position.

Conflict of interest.

A conflict of interest is a situation in which someone's personal (financial, political, professional, social, sexual, family, etc.) interests could influence his judgment or actions in a financial or other decision, in carrying out his job, or in his relationships with participants. In community interventions, conflicts of interest may change -- to the community's disadvantage -- how a program is run or how its money is spent.

Conflicts of interest are virtually always unethical, to the point where the mere appearance of a conflict needs to be avoided. Even if decisions or actions are not actually influenced by personal interest, people in conflict of interest situations in their public or professional lives should do everything possible to resolve them.

If you find yourself in such a situation, the ethical remedy is two-pronged:

•  Point it out to whoever needs to know -- your employer, a funder, the community, the participant you're working with -- and discuss possible solutions.
• Eliminate the conflict situation. Depending upon the situation, solutions might involve excusing yourself from taking part in a particular decision, refusing funding from a particular source, ceasing to work with a particular participant, or even changing jobs.

Some examples of conflict of interest (with possible solutions in parentheses):

• A decision by a program director to purchase office equipment for the program from a company his wife owns: the director has both a personal and a financial stake in the decision. (The director could remove himself and/or his wife's company from the purchasing process.)
• A staff member entering into a sexual relationship with an intern or someone they supervise. The supervisor has power over the other's employment and/or professional evaluation, which puts pressure on the subordinate to enter into and/or continue the relationship, even if he or she is reluctant, and may keep the supervisor from making objective decisions about the subordinate. (If the relationship is mutual and the attraction strong on both sides, this can present a very difficult situation. If the supervisor simply transfers her supervisory responsibility to someone else, there still remains her power in the program or organization itself. The best solution is probably to remove herself and wait until the internship period ends before approaching an intimate relationship.)
• A researcher financing a study with money from a company that stands to benefit from a particular result of that study. The researcher's conclusions could be influenced by what the company wants. (The ideal here is not to finance a study with funding from anyone who has a vested interest in the outcome.)
• A counselor or therapist providing services to a family member or ex-lover. The issues that exist between the two may reduce both the objectivity of the therapist and the effectiveness of the therapy. (Suggest one or more other therapists, and don't provide those services.)
• A youth program staff member working with a youth with whose family she has a personal conflict. (The staff member should remove herself from direct contact with that particular teen: her attitude toward his family is apt to influence her attitude toward and work with him.)
• A doctor in a community clinic owning an interest in a specialty medical practice to which he refers patients from the clinic. (The doctor could offer a number of choices for referral, not specifying which one she had an interest in.)

Grossly unethical behavior.

This is behavior far beyond the bounds of the normally accepted ethical standards of society. In some cases, grossly unethical behavior may stem from taking advantage of a conflict of interest situation. In others, it may be a simple case of dishonesty or lack of moral scruples. Both individuals and organizations can be guilty of some instances of it, and in both cases it is often a result of someone managing to justify the unjustifiable. Community programs need to be clear about their own ethical standards, and to hold individuals to them and to any other standards their professions demand. In most cases, staff members guilty of grossly unethical behavior should be dismissed as quickly as possible, and prosecuted where that is appropriate. Some of the more familiar types of grossly unethical behavior include:

• Having sexual relationships -- even consensual sexual relationships -- with people with whom you have a professional relationship in which you hold the power. Doctor -patient, therapist-client, teacher-student, supervisor-intern, and youth worker-teen are all examples of such relationships. In some of these cases, a sexual relationship both violates the professional's code of ethics (and is therefore grounds for losing professional certification), and may be the base for a sexual harassment or sexual assault lawsuit as well.
• Exploiting for financial gain people with whom you have a professional relationship. Moving someone to the head of a waiting list in return for free services he can provide (car repair, for instance), or accepting gifts or money -- essentially bribes -- to do something out of the ordinary (e.g. accept someone who normally wouldn't qualify for your program).
• Defrauding funders: billing for non-existent services, or inventing problems in order to deliver unnecessary services.
• Denying necessary medical services to those uninsured and unable to pay.
• Discriminating in service delivery by race, gender, ethnicity, etc.

• Outright criminal behavior: redirecting program funds for personal use, for instance, or sexually abusing children in a day care center. This can also include criminal behavior that a staff member engages in on his own time -- e.g., selling drugs or robbing a warehouse

General ethical responsibilities.

Ethical behavior for a community intervention is more than simply following particular professional codes and keeping your nose clean. It means actively striving to do what is right for participants and for the community, and treating everyone -- participants, staff members, funders, the community at large -- in an ethical way. By doing what you do in the community, you take on a number of responsibilities:

Responsibility to funders. You are responsible for being fiscally accountable, for using funds properly, and for trying to do what you promised to do when you took the money.

Responsibility to staff members. You are responsible for making sure everyone is treated fairly in all dealings with the program; that everyone is paid for the work she does; that everyone has a reasonable amount of control over her job; and that everyone has the opportunity to continue to develop her skills and effectiveness through staff development and/or supervision. You are also responsible for protecting staff from harm to the extent possible, and for warning and training them if some physical or other danger is part of their jobs.

You owe it to a youth gang outreach worker, for instance, to train him in such areas as the boundaries of different gang territories, colors or clothing that send particular signals, conflict resolution techniques, how to talk to gang members without creating problems, etc. You also owe him a clear explanation of the risks of the job and of how much and what kind of support he can expect from the program.

Responsibility to participants. You are responsible for trying, throughout the life of the program, to provide the best and most effective services possible. This means constantly searching for better methods and ideas; paying attention to participant feedback; building on program successes; and acknowledging, learning from, and correcting program weaknesses. You are also responsible for respecting participants' rights, and for treating all with the respect due them, not only as program participants, but also as human beings.

Responsibility to the community. You are responsible for trying to understand and meet the needs of the community; for being responsive to community attitudes and opinions (without compromising your own mission or philosophy); and for trying, through your intervention, to improve the quality of life in some way for both program participants and the community as a whole.

The participatory nature of community interventions that these obligations imply can also raise ethical questions. It usually makes both ethical and practical sense to involve the target population and/or the community at large in planning a community program. There are many good reasons for this involvement -- fostering community ownership of the program, having the input of people with a sense of community history, respecting people enough to pay attention to what they say they need, etc. -- but there can be drawbacks as well. What if you think the community's ideas are completely wrongheaded, or they want more control over the program than you'd feel comfortable with? What are the ethical solutions to these situations?

The reality is that there aren't specific answers to most ethical questions. It's important to consider the questions, but to understand that taking what you see as the ethical path can sometimes land you in a briar patch. It helps to have clear sense of what you believe is right, and to also consider carefully what will actually benefit the situation and the people involved.

In the case of community participants giving wrongheaded advice, for instance, is the principle of respecting the community's wishes more or less important than that of creating the most effective way to meet community needs? And which will be more likely to actually get the job done in the community? The answers will probably vary in different places and times.

In Summary

Ethical considerations are extremely important in community interventions. A program that itself behaves unethically or allows its staff to do so is both ignoring its mission and risking its credibility and effectiveness in the community.

Because ethical issues are not always cut and dried, community programs should work out their own ethical guidelines and policies before questions actually arise. If you can agree on standards for primary ethical issues -- confidentiality, consent, disclosure, competence, conflict of interest, grossly unethical behavior, and the overall ethical stance and actions of the program -- and create policies which will help you uphold those standards, you're on your way to community respect and outstanding service delivery.

___You know what ethics means

___You understand that ethical behavior is important in community interventions for:

• Program effectiveness
• Standing in the community
• Moral credibility and leadership
• Professional and legal issues

Ethical issues that need to be considered

___You have decided on the confidentiality level of your program participant's information

___You have informed your participants of this

___You asked for consent to share information if necessary

___You have used disclosure in situations where deemed necessary.

___Your organization is competent to accomplish its goals under reasonable circumstances.

___You have taken steps to eliminate conflict situations when they arise.

___You know how to prevent and deal with grossly unethical behavior from individuals and organizations.

___You know what your ethical responsibilities to your funders, staff members, participants and the community are.

A PowerPoint presentation summarizing the major points in the section.

• What is a best practice?

• Why promote the adoption and use of best practices?

• When should you promote the adoption and use of best practices?

• Who should be involved in promoting the adoption and use of best practices?

• Where do you find best practices?

• How do you promote the adoption and use of best practices?

The Parkville Heart Health Coalition was concerned. A survey of families in the area had shown that most elementary school children spent much of their time watching TV or playing video games. Engrossed in these activities, the kids weren’t getting the exercise they needed.

Research had shown that introducing children to “lifetime” sports – tennis, swimming, hiking, skiing – was one of the best ways to instill in them a long-term commitment to regular physical activity. Members of the Coalition recognized this as a “best practice,” a proven solution to their problem. They realized, however, that they needed the cooperation of the schools, as well as local officials, to teach and promote these sports, as well as provide facilities for them. How could they go about convincing these indispensable partners to invest the necessary time, money, and energy? Was there a best practice for persuading a community to adopt good solutions?

Best or promising practices can help you solve community problems, and save you the trouble of reinventing the wheel. If someone else has already found an effective way to resolve your issue or advance your cause, it makes sense to use it.

The first section of this chapter discussed how to recognize and choose promising practices for health and community development. Sometimes, however, those are only the preliminary steps. Once they’re completed, there may remain the task of getting those practices actually adopted and used in the community. In this section, we explore how to do just that, as well as looking at what a “best practice” is, and how to go about finding one appropriate for your needs.

What is a best practice?

A best practice may be a particular method, or it may be a whole program or intervention. “Best practice” status is sometimes conferred either officially – by a government body, professional association, or other authoritative entity – or by published research results. In general, a method or program gains such status by being:

• Measurable. That means that its goals are clear and that progress toward them can be measured. A smoking cessation program, for instance, can find out exactly what percentage of the smokers it served quit, and remained smoke-free after a year. It can also compare that percentage to similar percentages for other smoking cessation programs and for the general population.
• Notably successful. The method or program not only gains good results, but makes more progress toward achieving its goals than most others with similar aims.
• Replicable. The method or program is structured and documented clearly enough so that it can be reproduced (“replicated” is the formal term that social scientists, health professionals, government agencies, and funders often use) elsewhere.

Best practices, in short, are those methods or programs that have been found to be successful in accomplishing their goals, and that can be used, or adapted for use, in your circumstances. The standards for choosing a best practice vary tremendously, depending upon who’s doing the choosing. In some cases, almost any program that can show some success is labeled a best practice. In others, the criteria are so strict that only a few are selected (more likely with professional associations that are trying to set or uphold research standards.)

Where the standards are relatively loose, programs designated as best practices may be only adequate, rather than truly the best the field has to offer. Where the standards are too strict, many superb programs may be passed over because they don’t collect enough data on themselves, or for other technical reasons. When looking at best practices with an eye toward using one for a local intervention, it’s important to keep in mind whose best practices they are, and how they were chosen.

Some other things to keep in mind when considering best practices:

• Fit with your community and population. Does the method or program make sense given the realities of your community? Can it be adapted to match those realities?

• Appropriateness to your goals. Does the best practice in question actually address your specific goals? The fact that it’s a best practice for the issue you’re concerned with doesn’t necessarily mean that it has the same aims you do. If it treats the symptoms of a problem, that may not be enough if you’re attempting to deal with the underlying causes, for instance.
• Fit with the structure and philosophy of the organization or initiative that will use it. A program all of whose authority is in the hands of organization staff would not be a good fit with an organization whose main thrust is to help participants take control of their lives, for example.
• Availability of resources. A sure way to make an effort fail is to approach it with inadequate resources, whether money, personnel, or skills. Make certain you understand exactly what a particular best practice will require in the way of resources – and that you can somehow provide them – before you commit to using it.
• Cost-effectiveness. If a program works well, but costs huge amounts of money or time to reproduce, it may be all but useless to most organizations or communities that want to use it. A program that works slightly less well, but costs a third as much might, in fact, be a much better candidate for the “best practice” label.

Why promote the adoption and use of best practices?

One answer to this question is obvious: employing a method or program that’s been tested and found successful increases the chances that you’ll accomplish your goals, and that life will therefore be better for the folks who participate. There are, however, further reasons why the use of a best practice can be advantageous.

• Using a recognized best practice makes it easier to justify the work. If an organization or initiative is starting from scratch, the community – and especially potential participants – may be justifiably skeptical about what it’s doing. Demonstrating that it’s using a practice that has been shown to be effective can relieve at least some of that skepticism and gain support.
• Using recognized best practices can bolster the credibility of an organization. It shows not only that the organization is using a tested process, but that it has been thinking ahead and conducting research to make sure it’s doing the best job possible.
• Using best practices can make it easier to get funding. Funders look more favorably on proposals that can demonstrate proven success.

• Using a best practice removes a lot of the guesswork from planning. Employing a program or method whose structure and process are carefully documented makes it easier to set up and implement, and increases the chances that it will go smoothly.
• The originators of the practice are known, and might be available to consult on how to best implement it. They can troubleshoot when there’s difficulty, or help to adjust it to fit the community or population. If the originators aren’t available, there may be others experienced with the practice who can help.
• Most important – and most obvious – we know that best practices work. They’ve been shown to provide the changes in behavior or conditions and the outcomes we’re interested in.

When should you promote the adoption and use of best practices?

Promoting the adoption of best practices should probably be an ongoing activity, but some times are especially appropriate for it.

• Before a new intervention or program begins. It’s easier to incorporate or adopt a practice for something new than to superimpose it on a program or intervention that’s already up and running. Those starting a new operation are usually more open to existing practices as well, especially if they hold out a reasonable promise of success. In addition, using a best practice starts a new operation out on the right foot politically.
• When there’s a serious community problem that has to be tackled. Nothing may have started yet, but the incidence of domestic violence, child abuse, tuberculosis cases, or homelessness has reached crisis proportions. The community and/or relevant organizations might be willing to entertain the idea of adopting a best practice to deal with the situation.
• When what’s being done isn’t working well. If a current intervention simply isn’t having the desired effect on an issue, it’s probably a good time to suggest a proven practice.
• When the community requests it. In some cases, publicity about a particularly effective program or process can mobilize community opinion, especially if citizens perceive, as in the paragraph above, that the community has a serious problem to address.
• When funders or officials request or demand it. As research results become more and more easily available through online sources, more funders insist that proven practices be followed by those they fund. A word of caution here: make sure that funders’ requirements don’t rule out adaptation to your specific circumstances. As mentioned above, strict use of best practices can sometimes get in the way of flexibility and new ideas.

Who should be involved in promoting the adoption and use of best practices?

In trying to persuade a community or organization to adopt best practices, it’s best to involve as many stakeholders – those affected by the proposed program or intervention – as possible. If they have a hand in seeking out and researching best practices, they’re more likely to be excited about and willing to adopt them, rather than feeling that their work is being challenged. Those who might be involved include:

• Practitioners – health and human service workers, community developers, etc.
• Members of the population that will participate in or benefit from the best practices in question.
• Those who’ll be indirectly affected by the program. These include people whose jobs might change – police, social workers, etc. who are not directly involved, but who might have to deal with the effects of the practice – as well as landlords, business people, town boards, and others who might experience changes as a result of an intervention.
• Interested community members. It’s always wise to include the community at large. Inclusion leads to more community support, which in turn can translate into resources.
• Local and, if appropriate, county or state officials. If you’re seeking public funding, or, again, if you simply want community support, it’s crucial that you invite these people to be part of the process.

Where do you find best practices?

To find best practices, try:

• The Internet. The Internet has over a billion sites, and grows by millions a year. Once you develop good search skills, you can find nearly anything.
• Networking. Talk to everyone you know, and find out what they know. They may even be able to provide introductions, or at least information, so that you can contact programs or initiatives and learn about what they're doing.
• Libraries. Public libraries, as well as those at colleges and universities, are a great source, and librarians can be extremely helpful in finding what you're looking for. Many journals or individual journal articles found in libraries can now be found on the Internet as well, but may also require subscription or a membership or user’s fee, whereas access to those items – whether in hard copy or online – is generally free in libraries.
• State and national advocacy and professional organizations. These organizations often give awards for best practices, or document them in journal articles and at conferences. The journals are usually available in libraries, either public or academic, and often on the Internet as well; conference proceedings are often posted on the Internet. You can contact the organization or go to its website to find out what's available.

• International, state, and federal agencies. UNESCO, the U.S. Council of Mayors, HUD, and others have listings of "best practices" in programs they fund. These may be on the Internet (see Resources for several listings), in government publications, or available in print from the agencies themselves.
• Foundations and other private funders. These funders also may list best practices, or may simply describe projects they fund. Many of these lists and descriptions are also on the Internet, in libraries, or are available from the funders themselves.
• Academia. Local colleges and universities may have researchers looking at just what you're concerned with, or know others who are. Furthermore, there may be graduate students who'd like to work with you on a project. Start by contacting the university department most closely connected to the work you do.
• Word of mouth from the community. Clergy, members of service clubs (Rotary, Kiwanis, etc.), business people, and other community members may know of successful programs or initiatives similar to the one you want to start.

Using the Internet to find best or promising practices

If you’re reading this now, you almost undoubtedly already have some Internet search skills. On the other hand, you may not know exactly what you’re looking for, or be aware of where it can be found. You may be looking for best practices in developing countries, or specifically in urban or rural areas of the developed world. How can you find exactly what you’re looking for?

There are a number of ways to search the Internet. The most common, of course, is to use a search engine, such as Google, or Bing. These are crawlers, or computerized searchers that scan the web and record information. (Although all search engines use computing power to scan the Internet, some others use people to organize their data bases.) Google is by far the most popular, and, in the minds of most people, the most effective of search engines for most purposes.

Most Community Tool Box users are familiar with Google and other search engines, and may well have originally found the Tool Box on one of them. A simple search is just that…but not all web searches, even those that may seem so, are necessarily simple. There are, however, some simple guidelines that can make a complicated search easier.

• Be as specific as possible. If you’re searching for best practices in child health, that’s what you should ask the search engine to find. If it’s best practices in child health in India – or Indiana – you should specifically search that. Tell the search engine exactly what you want, and you’re more likely to get it.
• Learn search engine language. There are really only four or five “words” that are necessary in order to speak reasonably fluent search engine.

• Try a number of different words or phrases if you don’t immediately get what you’re looking for. If “youth violence prevention” doesn’t work, try “preventing youth violence” or just “youth violence.” Think about how other people might phrase the same thought you have, or whether there are standard terms in addition to the one(s) you regularly use.

• Look for sites in the most appropriate language. If you’re searching for information about child health practices in Senegal or Mali, the sites with the most information might well be in French. You can ask many search engines, including Google, to search only for sites in a particular (non-English) language, and then ask it to translate the sites for you (both features are usually part of “Advanced search”).
• Use web sites’ internal search engines. Once you find a likely site – that of a foundation organization, for instance – you can use that site’s search function to find out if it has a “best practices” section.

You can find an up-to-date list of Databases of Best Practices on the Community Tool Box. It contains comprehensive web-based resources for exploring promising approcahes to promote community health and development, as well as resources by issue.

The Internet is undoubtedly the largest single source of best practice information available, but don’t ignore the others mentioned here. You can also find out about a program or method that will work for you by talking to others in the field and quizzing graduate students or other knowledgeable people. The Internet, for all its scope, doesn’t include everything, and is particularly unlikely to include small programs that may not have been thoroughly tested, but may be having tremendous success right in your own back yard.

How do you promote the adoption and use of best practices?

Once you’ve assembled a group of stakeholders to take part in helping to convince the community or organization to adopt best practices, you have to define what you’re doing, identify some possibilities that match your goals and circumstances, and do the job of persuasion. Even then, you’re not finished: you have to make sure that people have the proper training and resources to make the best practice a best practice for your situation, and you must continue examining what you’re doing to make it even better.

Define your issue, needs, and goals clearly, so that you can determine exactly what kind of best practice you’re seeking.

As mentioned above, not every best practice related to your issue is necessarily aimed at the same outcomes you’re working toward. In order to make sure that you’re choosing a practice that fits with your goals, your first steps should be to define what you want to do and how.

• Define your issue. What exactly is it you want to address? If it’s a broad issue, are you addressing the whole thing, or just a part of it? If the issue is violence in the community, for instance, are you planning to make that your focus, or are you going to concentrate on youth violence, or domestic violence, or certain kinds of violent crime? Remember, as we’ll discuss in more detail below, that you need resources that match what you want to do.
• Define the outcomes you intend to achieve. The best practice you choose should aim at the outcomes you’re interested in. If you’re trying to get at the causes of domestic violence, for instance, then you should be looking for a best practice that does specifically that, rather than one that simply reduces the incidence of domestic violence. The former is likely to include elements of community education, mentoring, peer support, counseling for abused children, etc., in addition to increased police training and enforcement and law or policy changes. A violence-reduction program might only include the training/enforcement and policy change pieces. It may be a highly effective program, but it won’t produce the outcomes you’re interested in.

• Identify the nature of your population. An exemplary model may nonetheless be aimed at a very different population, and may not work with yours (understanding such things is one reason for involving potential participants in searching for best practices). Does your population largely consist of a certain ethnic, racial, age, socio-economic, cultural, or other group? Does it have unusual or unique characteristics that would make a particular best practice suitable or unsuitable?
• Explore the context. Community history, geography (whether your community is urban, rural, isolated, etc.), attitudes, relationships, class structure – all can influence whether a method or program will be effective or not.

This kind of analysis should help you find a best practice that has been successful in producing the outcomes you want, in a way you approve of, with a population and in a community similar to yours

Search for appropriate best practices.

Now that you’ve defined what you’re looking for, it’s time to find out what’s available. Once you’ve found several best practice options that address your issue, the next step is to narrow down your search by weeding out the ones that aren’t appropriate for your community, aren’t sensitive to the culture of your population, or don’t aim at the outcomes you want. (This is a good time to involve stakeholders, if they weren’t already involved in searching out possible best practices.) That should leave you with a manageable number of choices, and allow you to pick one that seems to most nearly suit your community and its needs. Be prepared to adapt it to your context if necessary.

Promote the use of best practices.

Under “When should you promote the adoption and use of best practices?”, we discussed some times when it might be relatively easy to convince the community or an organization to adopt tested ideas and processes. When there’s a new initiative, when it’s obvious that what’s being done is ineffective, when there’s an immediate problem to be solved, when the community or funders demand proven practices – all these are times when best practices might be advanced and embraced without much resistance.

But what about the far more common situation in which there is already a service or initiative directed at the issue in question? It may be just successful enough that people can argue that it’s unnecessary to change it, even though it’s been documented that other approaches gain much better outcomes. In addition, the group administering or delivering it – or the community, for that matter – may have an emotional attachment to it. They may have developed it themselves, and/or invested a lot of time and effort to start and maintain it. How do you convince them to change direction?

If you’ve put together a multi-sector group of stakeholders to study best practices, that group’s recommendations, because of its broad membership, will already carry a great deal of weight. Some actions you can take during and after this participatory research process can increase your chances of success.

• Mobilize community opinion. Publicize the best practices you’ve found that seem to address the issues in your community. Emphasize the diverse nature of the group that found and recommended these practices for local use.
• Alert funders to best practice possibilities. Pressures – or offers – from current or potential funders can help speed the adoption of new methods or programs.
• Bring some of the people who originated or who use appropriate practices together with people in your community, especially some of those who oppose adopting those practices. In the discussion that takes place, questions can be raised and answered from practical experience, and much of the resistance might easily disappear.

• Suggest that, rather than substituting a best practice for what it is already doing, an organization or group simply add it, perhaps on a limited basis. Having the two approaches running side by side may show them that the new practice actually does work better than the old.

Ensure that anyone involved in trying to replicate a best practice is provided with the training to make it successful.

People should understand both the assumptions behind the program or method, and the theory that explains why it works. In addition, it’s absolutely crucial that they receive any specific training needed to do the work of the program. Without either of these, those attempting to do the work of the program are like sailors trying to cross the ocean with no maps or compasses and no idea of where they’re going, let alone any understanding of how to sail a boat. The chances of success under these circumstances are slim, to say the least.

A final requirement for anyone replicating a best practice is the belief in its effectiveness. It’s been proven again and again that, without this belief on the part of practitioners, a method or program won’t succeed, even if everything else is in place.

Provide those who’ll implement best practices with the necessary support.

It’s been explained both in the first section of this chapter and in this one that you can’t replicate a best practice without resources similar to the original. Those resources can embrace a number of different elements:

• Funding. This is probably the most obvious, but it’s often ignored. Trying to replicate a program with half the funding needed often means you get half a program…or less. Since the success of a program may be based on its operating as an integrated whole, trying to cut it in half can be a recipe for failure. Make sure adequate funding is available before you start.
• Volunteers. This may be an issue of fit for the community. In a community, for instance, where two-income and multi-job families are the rule, most people may simply have no time to volunteer, and volunteering may not be part of the community’s culture. A program that depends on volunteers may be difficult to run in such a community. Volunteers also need training and supervision, and those resources must be available as well if a volunteer-dependent program is to succeed.
• Space. This is sometimes a matter of funding, but just as often one of the availability of appropriate space in an area that’s easily reachable for potential participants. You have to consider access for people with disabilities, transportation, the size and character of the space needed, etc. If funding is an issue, the possibility of donated or shared space may have to be explored, and that raises its own problems.
• Time. Any new undertaking takes time to settle in and find itself. While there should certainly be accountability built into any program, there should also be a willingness to allow the time for experimentation and learning.
• The good will of local officials, other influential people, and the community at large. You should work to make sure that all those involved in a program, from line staff to participants, feel that the community is behind them and rooting for their success.

Keep making the best better, and maintain the community’s commitment to best practices.

Finally, remember that once you’ve convinced the community to adopt a specific best practice or a best practice philosophy, your work isn’t finished. Even though it’s labeled “best,” any practice can be improved. Part of your continuing responsibility is to see that programs keep improving.

Best practices are only as good as their implementation. If the problem seems to be solved, or if people grow tired of doing the work, you’ll soon find yourself back where you started.

The other important thing to keep in mind is that community memory can be short. Keep pushing best practices, and keep looking for appropriate ones that can be used in your community. Without that continuing attention, you may find yourself having to do your work all over again the next time a need for a new service or initiative arises.

In Summary

One way to attempt to ensure that you address community problems and issues as well as possible is to promote the adoption and ensure the implementation of “best practices” – methods or programs that have been proven successful elsewhere, and that have the capacity to be reproduced, or replicated. While this doesn’t guarantee success – not every intervention works in every community, and you may already have successful programs operating – it beats the “stab in the dark” approach that many health, human service, and community efforts take when planning new programs or initiatives.

Persuading the community to adopt best practices requires building credibility by assembling a multi-sector group – including local officials and influential citizens, potential participants or beneficiaries of a proposed intervention or initiative, and others affected by it – to research best practices and make recommendations; introducing the community and/or relevant organizations to the new practices (by, among other tactics, introducing them to people already using them) and suggesting ways to incorporate them; and by providing the resources and support necessary to make successful replication in your community possible.

Once you’ve convinced everyone that the adoption and use of best practices makes sense, you have to make sure that they’re implemented. You then must continue to remind and educate the community about best practices, and maintain community commitment to using them. In addition, remember that any practice, even a “best” practice, can be improved, and that the effort to make things better should never end.

What is a best practice?

A best practice is:

___Measurable

___Notably successful

___Replicable

___A good fit for your circumstances

Why promote the adoption and use of best practices?

___Using a recognized best practice makes it easier to justify the work.

___Using recognized best practices can bolster the credibility of an organization.

___Using best practices can make it easier to get funding.

___Using a best practice removes a lot of the guesswork from planning.

___The originators of the practice are known, and might be available to consult on how to best implement it.

___We know that best practices work.

When should you promote the adoption and use of best practices?

___When a new intervention or program is starting up.

___When what’s being done isn’t working.

___When there’s a serious community problem that has to be tackled.

___When the community demands it.

___When funders or officials demand it.

Who should be involved in promoting the adoption and use of best practices?

___Practitioners – health and human service workers, community developers, etc.

___Members of the population that will participate in or benefit from the best practices in question.

___Those who’ll be indirectly affected by the program.

___Interested community members.

___Local and, if appropriate, state officials.

Where do you find best practices?

___On the Internet.

___By networking.

___In libraries.

___Through national advocacy and professional organizations and their journals.

___Through international, state, and federal agencies.

___Through foundations and other funders.

___In academia.

___Through community word of mouth.

How do you promote the adoption and use of best practices?

___Define your issue, needs, and goals clearly, so that you can determine exactly what kind of best practice you’re seeking.

___Search for appropriate best practices.

You promote the use and implementation of best practices by:

___Mobilizing community opinion.

___Alerting funders to best practice possibilities.

___Bringing some of the people who originated or who use appropriate practices together with people in your community.

___Suggesting that, rather than substituting a best practice for what it is already doing, an organization or group simply add it, or try it out.

___Ensuring that anyone involved in trying to replicate a best practice is provided with the training to make it successful.

___Providing those who’ll implement best practices with the necessary support and resources.

___Continuing to make the best better, and maintaining the community’s commitment to best practices.

A PowerPoint presentation summarizing the major points in the section.