Section 7. Developing and Increasing Access to Health and Community Services

Learn how to increase access to health and community services.

 

• What are the barriers to access to health and community services?

• How do we remove barriers and increase access to health and community services?

• How do we find private funding sources?

• How do we break down the physical barriers to access?

• How do we make sure our program does the job?

• How do we remove barriers to individuals' participation?

We've all heard or experienced, at least at second hand, stories of handicapped people unable to take advantage of services because they literally couldn't get in the door. While that's often still a major issue, it's hardly the only instance in which people are denied access to services. What about the immigrant group whose only available English as a Second or Other Language (ESOL) class has a waiting list 1,000 people long, representing a three-year wait? Or the pregnant teen whose town has no prenatal services, no infant nutrition program, no support group for single parents? Or the job training program whose classes are held in an area that's difficult for most participants to reach? Or the program for delinquent youth whose recidivism rate is worse than that for youthful offenders who get no services at all?

All of these are examples of people being denied access to effective programs that would benefit them. This section looks at questions of access, and examines how we can make sure that health and community services are available when and where they're needed.

We'll begin by identifying the barriers to access, and then look at ways to deal with each of them.

What are the barriers to access to health and community services?

There are several kinds of barriers to access to health and community services. One concerns funding, without which necessary services either won't exist, or won't be adequate to meet the need. Another is physical, and relates to handicapped access and compliance with the Americans with Disabilities Act (ADA). A third involves programming, which, even with adequate funding, may be ineffective, or may not be reaching those who need it. And the fourth has to do with the personal barriers to access of individual participants, those things in their lives or circumstances which keep them from using services. We'll look at each of them in turn.

Funding-related barriers to access

Adequate funding can address two problems: the availability of services in the first place; and the adequacy of existing services to meet the need in the community.

Availability of services

Once a particular need in the community has been established, the question becomes whether there are programs (or potential funding for programs) available to address it.

If not, there may be a number of reasons:

• Lack of local resources. The state or county or community may simply not itself have the money to establish funding for services.
• Lack of recognition that there is a problem. The state or county or community may simply not be aware that a significant number of its citizens lack basic skills, or that the teen pregnancy rate is high, or that a large number of its children aren't immunized by the time they get to school. It may be more than willing to support the establishment of necessary services if it understands the need for them.
• Confusion or discouragement about approaching the problem. It may seem overwhelming to try to address the spread of youth violence in the community, or to respond to the widespread pollution of local drinking water. The community may be aware of the problem, and even be willing to do something about it, but have no idea where to start.
• Unwillingness to address the problem. Communities (or state or local governments) may be overwhelmed with other issues, and regard this one as a low priority. They may feel, cynically, that the target population doesn't deserve services, or that they don't have to pay attention to the needs of the target population because it doesn't have enough political or economic clout.

As you might suspect, these last attitudes are the hardest to deal with. They may stem from outright racism, from a perception of injustice ("I work hard for what I have. Why should I be paying for someone else who doesn't work?"), or simply from the feeling that things can be left as they are and no one (or at least no one who "matters") will care. Regardless of their origins, these attitudes are often deeply embedded and hard to change.

Whatever the reasons for the lack of program availability, they must be addressed and countered if you want to acquire funding for new programs or services.

Adequacy of available services to meet the need

Even if services are available, that doesn't necessarily solve the problem. Can those services admit and handle the number of people who need them? Again, the answer to this question is largely a matter of funding. In order to respond to everyone who needs their services, programs must have enough staff, enough space, and enough equipment and/or materials and supplies. They must be accessible to those with physical and other handicaps. Without these elements, the program essentially doesn't exist for those who can't use it.

The example above of an ESOL program with a 1,000-person, three-year waiting list was a real one. A few years ago, a program in Boston (the only program designed specifically for speakers of Cantonese and the only one located in the area where most Cantonese speakers lived) had just such a waiting list. Funding increases have since made it possible to find more space, hire more teachers, and decrease the list to a more manageable 150-200, with a waiting time of "only" a few months.

Physical barriers to access

People with physical or other handicaps often encounter the most visible barriers to access. The obvious ones - lack of wheelchair access and handicapped-accessible bathrooms, for instance -can be hard to address, especially for community-based and grass roots organizations, because of cost.

The Americans with Disabilities Act is a classic example of an unfunded mandate. It requires that publicly-funded, and many other, programs be handicapped-accessible in all ways, but provides no resources. This leaves community-based and grass roots organizations to beg landlords for accommodations or to try to raise the often considerable funds to make access possible. (A small-town library, for instance, was told by a state inspector that the only proper way to ramp its 100-year-old building would cost $350,000, a third of the town's annual budget.)

Removing physical barriers involves a great deal more than ramping. Bathrooms need to be fully accessible, doors must be usable by those who can't grip or pull, and there must be fire exits and a fire evacuation plan, among numerous other requirements. The U.S. Department of Justice ADA website, which includes all the regulations and other information, is helpful.

The Americans with Disabilities Act (ADA) also requires that organizations accommodate to other handicaps. This means providing services for those with learning disabilities, hearing or vision difficulties, or such problems as agoraphobia (the psychological inability to go out in public). Again, such action may be difficult for organizations with limited resources, thus providing further barriers to participants with these conditions.

While ADA is the law of the land, the government only enforces it when asked. Thus, if your organization is not physically accessible, no one will question you until a disabled person actually complains. Public funders, however, almost always require ADA compliance of anyone they fund, and will cut off funding if they don't get it. In addition, in most circumstances, ADA compliance is a matter of fairness: services should be available to anyone who needs them and is an appropriate participant.

Programmatic barriers to access

The availability of services for all who could use them still doesn't necessarily guarantee members of the target population access to what they need. Participants have to know that the programs exist, have to be willing to take part in them, and have to receive effective and useful service from them. There are a number of reasons why these conditions may not prevail.

Lack of outreach capacity

Programs may not have the staff time to reach out to the target population with information about what's available. This could be a funding issue, but it could also have to do with a program's understanding of its community and of the need for outreach.

Ineffective outreach

On the other hand, a program may be engaging in aggressive outreach, but in a way that doesn't reach the desired individuals or groups. It may be presenting its message in the wrong language, or in a form that doesn't reach its intended audience.

Negative perception of the program

The community as a whole or the target population might see the program - or the organization running it - in a negative light. This perception may be deserved or not, but either way it's a serious problem. Whatever the reason, negative feelings about the program can keep people away in droves.

Affordability, eligibility, and other issues raised by organizational resources or funders

Depending upon your level of funding, you may need to charge people something for your services. If they are unable to pay, and there is no alternative source of funding for them, then the service is unavailable to them.

By the same token, if a funder has certain requirements for service eligibility - income below a certain level, membership in a particular group (welfare recipients, for instance), an insurance plan, etc. - then your service is unavailable to anyone who doesn't meet those requirements.

Program quality

If a program is ineffective, if it treats participants in unproductive or disrespectful ways, if it simply doesn't care, it is denying access to services just as surely as if it didn't exist at all.

Program quality issues that might need to be examined include:

• Staff credentials and skills, which are often related both to staff training and development opportunities and to staff pay.
• The appropriateness and effectiveness of actual programming, involving exactly what, how, when, and where services are offered, what materials and equipment are used, how participants are treated, etc. Ineffective programming can be difficult to change, because it is often motivated by history ("We've always done things that way"); staff comfort level with the method ("That's how I was trained, and I can't imagine doing things differently"); and conventional wisdom, which is often based on what people would like to be true, rather than on an objective view of reality.
• Organizational and programming philosophy. If the organization treats adult participants as children, fails to approach the community with respect, doesn't really care about what happens to the people it serves, or otherwise fails to see its relationship with participants as positive and mutually beneficial, it's likely that its programs won't either keep participants coming or be successful. The "personality" of the organization has a great deal to do with the effectiveness of its programs.

Barriers to individuals' access

There are often factors in participants' lives that make access to services difficult for them, even when services are apparently readily available. Some of these are physical and logistical, some are circumstantial, some are psychological, and some are cultural, but all are real and important to those who experience them.

Transportation

Getting to the site of a program may mean traveling long distances, or may be nearly impossible, particularly in rural areas, if reliable transportation isn't available. In large cities, especially those with inadequate public transportation, access may involve hours of travel each way, with many changes and long waits between buses or trains. For some low-income families, even the relatively modest cost of public transportation may be too great to bear. Transportation for those with disabilities may not be available.

Program location

Programs may be located in areas that some participants see as dangerous or inhospitable. Neighborhoods with particular racial or ethnic characteristics, gang territories, colleges or high schools (which participants often find intimidating) - all may, in different circumstances, serve to keep participants away from programs. It's important to know the community and the target population before you decide on a site for service delivery.

Program schedule

If most participants work, then services must be available when they are - evenings and weekends, for example. If shift work is the issue, then programming needs to take place when participants can take advantage of it, whether that means mornings, afternoons, or at 11:00 p.m. Programs for mothers of school -age kids need to take place when those kids are in school.

Child care

Given the number of single-parent or two-income families, child care is often a major issue for people who need services. Many parents are unwilling to leave their children with people they don't know, or are unable to pay for child care. If one parent wants to participate in a program that takes place while the other is at work, there may be no one to take care of young children. The number of funded day care slots is far from large enough to meet the need, and many participants are not eligible for them in any case. This is an ongoing problem for many programs that offer services that require participants' attendance over an extended period.

The target population doesn't see the issue as a problem

If people can get along without your services, they may not see the need for them, or may not, in fact need them.

For example, when a free GED (high school equivalency diploma) course was offered at a paper mill, virtually no one signed up. While many of the workers had no high school diplomas, they felt that they were doing well - making good money, content with their jobs - and since they had no desire to become managers, they didn't need the GED. A year later, when the mill closed and the workers were laid off, they realized they couldn't get jobs elsewhere without a high school credential. Now, their lack of high school diplomas was an issue, but the service was no longer available, because they hadn't seen the need for it.

Personal issues

The idea of using the service may make many members of the target population embarrassed, hostile, or afraid. Many services come with a community stigma attached. Welfare, literacy instruction, WIC (mother-child nutrition), food banks - all may be seen in the community as evidence of failure of one sort or another. Staff members of these or other programs may not come from the community, and may be seen as interlopers, or as condescending. Program participants - in health-related and instructional programs particularly - may have to confront their fears of ill health or failure. All of these issues may work to keep people from gaining access to services.

Cultural issues

Cultural factors can present large barriers to access to services:

• Participants may not speak English, and thus assume - correctly or incorrectly - that they can't register for or use the service
• There may be cultural taboos against certain kinds of services - certain medical treatments, for instance
• A culture may frown on some services for women - e.g., education or job training, family planning, domestic violence prevention
• There may be cultural barriers against asking for help outside the family or the community

To approach members of the target population effectively, you have to understand and respect their cultural traditions. To deliver services effectively, you must ensure that potential participants will feel comfortable using them.

How do we remove barriers and increase access to health and community services?

As we've just seen, there are more than enough barriers to access to tear down. Let's look at those barriers again, but this time with an emphasis on the positive. How can you remove each of them, and make your program accessible to potential participants?

As we discussed earlier, actually getting a program started where there is none or increasing the capacity of an existing program almost always requires money. Regardless of the source of that money - public, private, or a combination - you aren't likely to get it without vigorous advocacy.

Advocacy for recognition and funding

What follows is an outline of the kinds of advocacy necessary to bring issues to the attention of those who might provide moral and funding support for them, and to actually engender funding for needed programs.

Legislative (federal or state) advocacy

There are a number of elements to legislative advocacy, but they all require organization, patience, and singleness of purpose.

• Organize. Form coalitions, an organization... whatever it takes to pull together as many of those concerned with the issue as possible and to coordinate activities.
• Make and develop personal contacts with legislators and/or their aides. Aides can sometimes be even more important than the legislators themselves, since they are often the real experts on the issue, and actually will draft any bills or budget items.
• Learn the real legislative process. Most important work is done in committees, and often the chairs of those committees - or their aides - may be the people with the real power to influence the legislation or funding you want.
• Use members of the target population who are their constituents to make legislators aware of the issue.
• Enlist a legislative champion. Try to find someone who really cares about the issue and will pull her colleagues along.
• Educate legislators and aides about the need. Meet with them, equipped with statistics, facts, anecdotes, members of the target population, etc. Invite them to existing programs, if there are any, or to meet with members of the target population.
• Educate the public, in order to create a groundswell that legislators will pay attention to. You may be able to enlist business and industry leaders, the media, or others with the resources and clout to spread the message widely.

If you can show widespread demand for the service in question, that's a powerful argument. In Massachusetts, adult literacy funding was increased eightfold over six years, partially on the strength of a documented waiting list of 13,000 people.

• Draft the legislative language or budget item yourself. This saves the sponsoring legislator from having to do it, and acknowledges your expert status. It also assures that the important points that your group agrees on are at least in the first draft.
• Put constituent pressure on legislators with calls, e-mails, letters, etc. The more people you can mobilize, the stronger your position.

Local government advocacy

This may also be legislative - your state representative or senator may be helpful here. Some of the elements of local government advocacy are similar to those of legislative advocacy, but some are markedly different. Even the question of what the real local government is can be sticky. In some areas of the US, for instance, counties hold the power; in others - particularly in the Northeast - they are practically nonexistent.

Some general guidelines for local advocacy:

• Organize. Just as for legislative advocacy, a far-reaching and well-organized group is essential for effective advocacy.
• Understand who the local policy makers really are. They may be the elected officials, or they may be appointed or hired individuals who do the actual day-to-day work of local government: administrative assistants, city planners, county administrators, etc.
• Establish and maintain relationships with elected and appointed officials, city or town and county staff and employees, etc. Nothing else is as effective as personal contact.
• Educate local policy makers about the need.
• Educate and garner support from the general public.
• Place the issue on city or county council agendas, town meeting warrants, selectmen's meeting agendas, local ballots, etc.
• Put pressure on local officials to support efforts and/or appropriate funds, using constituent letters, calls, e-mails, personal visits, etc.

Community advocacy

Whether you're enlisting the help of the community in advocating for public funds, or whether you're asking directly for local private money, you'll need to convince people that your cause is important. Local advocacy consists first of educating the public about your issue. Once you've effectively accomplished that goal, the other elements will more easily fall into place.

• Educate the public. In addition to such methods as fliers, posters, and personal contact, you can reach public consciousness through the media. There are Public Service Announcements and features on TV and radio, as well as press releases and press conferences, and news and feature stories you can prepare or suggest. Public meetings or information sessions and public speaking engagements at service clubs, churches, businesses, organizations, and institutions can also help to get the word out.
• Find key supporters and sponsors. Reaching respected and influential people in the community can be crucial to garnering community support. Community officials, religious or business leaders, or just well-respected citizens may be important spokespersons for your issue.
• Engage the public in the issue. Once people understand the need to create access to services, give them a way to take action. Involve them in the advocacy group or coalition that's spearheading the campaign, or enlist them as volunteers to address the issue directly. Giving people a means of acting on what they care about both strengthens their commitment and raises the profile of the issue in the community.

How do we find private funding sources?

Either in place of or in addition to public money, private funding is available in a variety of forms. Foundations and other organizations offer grants; community fundraising may turn into a major source of income; fees for service - either direct or from third party payers - can provide welcome funding; and other arrangements, such as shared grants, may also be feasible.

Foundations

Individuals, families, corporations, communities, and organizations may all establish foundations to support causes they believe in. But you have to find them and convince them that you're a worthy recipient of their money.

• Research private funding sources. This has recently grown a great deal easier for three reasons: the Internet, which provides remarkable search capacity; umbrella organizations which represent large numbers of small or medium-sized foundations or grantors (in this case, medium-sized can mean organizations that distribute several million dollars a year); and the proliferation of community foundations.

An example of an umbrella organization is Associated Grantmakers of Massachusetts, which is composed of a large number of small and medium-sized private and community foundations. Through publications, a library, and its website, Associated Grant Makers, AGM offers information about all its members' grant possibilities (many of them extending far beyond Massachusetts), including eligibility requirements, amounts available per grant, funding priorities, etc. AGM also conducts "Meet the Donors " conferences, at which representatives of organizations can talk with program officers and Board members from the various member foundations.

Community foundations are just that: foundations established by and for particular communities. They raise money from businesses and individuals in the community, and may also administer the money of smaller private and family foundations. The community foundation acts as the funder, inviting proposals from local organizations.

• Establish relationships with directors or program officers at likely foundations. They're generally happy to help you to conceptualize how you can meet foundation guidelines and create a program that will increase access to services in your community.
• Educate foundation staff about the need.
• Write a fundable proposal. Follow the guidelines the foundation gives you for a proposal. If they ask for no more than five pages, don't send them six. Ask for money for something that the foundation will fund.

Similar to, but not the same as, a community foundation is the local health and human service funding organization, usually either United Way or Community Chest. These organizations raise money directly from the community - often through workplace donations and pledges - and then distribute it as grants to local service providers. While there are disadvantages to membership - you can't fundraise during their campaign, you can't solicit member businesses or institutions, you have to clear all fundraising plans - it's often the only way to get business and institutional contributions.

Community fundraising

There are lots of ways to raise money in the community:

• Soliciting individuals. Many organizations or initiatives ask people for money directly, either in person, by mail, or over the phone. They may choose Board members specifically for their connections to wealth and skill at raising money.
• Membership. Another way to raise money from individuals is to ask them to be members of your organization for a set annual fee - usually a relatively modest $25 -50.
• Community events. A carnival, a concert, a music festival - often with proprietors ' or performers' services donated -- may be used as a fundraising tool by community organizations or coalitions. Another type of fundraiser has supporters gathering pledges for their participation in an activity (Boston's Project Bread "Walk for Hunger," for example), with all proceeds going to the community organization. Well-organized events like these can raise large sums.

"Well-organized" is the key phrase here. Pulling off a successful community event takes lead time, planning, and a huge amount of organization. Groups that do it well often have volunteers who devote lots of time and energy to one event.

• Sale of services or goods. Charging employers, institutions, or third parties (insurance companies, etc.) for your services can be a reliable source of income. Offering consulting or educational services for professionals and selling goods - books, tapes, equipment, etc. - both can be valuable sources of income, but you need to be sure you have, or can develop, the capacity for supporting your plans before you embark on them.

The community can also be a source of in-kind contributions - donations of goods or services. Good possibilities are office or building supplies, furniture (from businesses or institutions that are redecorating their offices), and volunteer time. (Remember that anyone who donates something he would normally sell can take a tax write-off on it if you're registered as a 501(c)(3) charitable corporation.

How do we break down the physical barriers to access?

Removing or adapting physical barriers is, in large part, a financial issue, but there may be some creative ways to address it without, or in addition to, money.

• Convince your landlord to make the necessary accommodations. Creating accessible space will increase the value of his property, allow him a tax write-off, and assure him of your continued occupancy.
• Do it yourself with volunteer labor and donated materials. Staff members, participants, or community volunteers may have and be willing to donate the skills to build ramps, move walls, replumb bathrooms, and move doorways. Local merchants can often be persuaded to donate building materials as a community service. Again, if you're tax -exempt, anyone making an in-kind donation can take a tax write-off on it.
• Find an alternative way of delivering services that's a reasonable accommodation. If you can provide services in a way that affords a disabled person the full benefit of your work, you're usually fulfilling the intention of the ADA. That may mean offering services or holding a group that includes a disabled person in a different place, for example, or having an American Sign Language (ASL) interpreter present to help a deaf person understand a lecture.

How do we make sure our program does the job?

Once you have the money to start or expand services, you still haven't necessarily solved the problem of access. You have to adjust your program capacity to meet the demand in the community; look at the amount and success of outreach; deal with the community's and target population's perceptions of the program; and, perhaps most important, evaluate and attend to program quality.

Increasing program capacity

In order to accommodate everyone who needs services, you need sufficient amounts of space, staff - administrative, support, and direct service - and materials and equipment appropriate to the task. While this is primarily a funding issue, there are some other paths you can explore.

Space

Some possibilities to find enough space in the right places:

• Donated space to increase or expand what's available. Other organizations, institutions, businesses, even a landlord - all may be sources of donated space that will allow you to expand services where you are, or to expand to another neighborhood or town.
• Reduced rent (partial donation). A landlord or other donor may be willing to rent you space at a greatly reduced rate as a tax write-off. A space which has hitherto gone unrented might be available for the cost of utilities, for instance.
• Sharing arrangements. You may be able to share space (either by using part of the space all of the time or using some or all of it part of the time) with another organization.

All of these arrangements can be facilitated by state legislators, local officials, or other respected individuals in the community.

Staff

If you don't have enough staff, or enough staff with the right credentials or skills, there are a number of things you can do to improve the situation, only one of which involves direct funding for new staff.

• Share staff with another organization. You may be able to work out an arrangement whereby another organization helps you to provide services to your target population.
• Start a volunteer program, or supplement your current staff with volunteers. In situations where it's possible, a volunteer program can make all the difference. Volunteers aren't totally free of charge; they still need training - both initial and ongoing - and regular supervision if they're to be effective.
• Write a joint proposal. You might be able to join with another organization or a coalition to find funding and support for your work, or for a number of services, including yours. You may not have to administer the money, but simply to do your job and get paid for it.
• Find another organization to deliver services, either in addition to what you 're already doing, or so that you can contract to do the actual work.
• Institute in-house professional training to upgrade staff skills. The more skilled staff can teach the less skilled, perhaps, or graduate students or others could be found to do training as part of a certification or degree program.

If, in fact, you do find money to hire new staff, you may be faced with a problem. What do you do if you've been a small, grass roots organization with untrained staff which has responded to an urgent community need, and the funding requires you to run a professional program with credentialed staff? Do you fire the original staff members, who built the program? Try to retrain them for other positions? Send them back to school? What are your obligations here? With luck, you've thought about all this before you applied for the funding, or you'll read this before you write the proposal. If not, you may find yourself in an ethical quandary.

• Materials and equipment. As with space, materials and equipment can be donated. A local paper mill (paper), a publisher (textbooks), or a computer hardware or software company might all be potential donors. In addition, the lease or purchase of equipment - a copier, for instance - can be shared by two or more organizations.

Developing effective outreach

If members of the target population don't know that services exist, they have no access to them. You have to let them know about services in a way they can understand and relate to. It also helps to use some creativity - humor or bright colors might do a lot to get your program on the neighborhood map.

Develop your outreach capacity

The ideal is that awareness of your services will become self-sustaining as time goes on, and that their existence will become common knowledge in the community. Until that point - usually at least two years from the start of the program - outreach needs to be energetic and constant. There are a number of ways you can develop outreach capacity.

• If possible, hire or find an outreach coordinator. This person - either a staff member or a volunteer, depending upon your circumstances - would be responsible for informing the community, and particularly the target population, about the availability of services, and for recruiting participants.
• Use the appropriate media to get your message out. Public Service Announcements, ads, feature stories, and other print and broadcast strategies can all help inform the community that you're there. Working with the media depends upon establishing relationships with reporters, station managers, and others.
• Use other organizations to help spread the word. Make sure that the health and human service network in your area - particularly organizations that serve your target population - knows about your services, and can refer people to them.
• Use satisfied customers. Ask those who've benefited from your program to let their friends and family know what you do, and to encourage those who need services to take advantage of them. You may be able to establish a network of current and former participants who'll inform people in their neighborhoods about your organization, and even hold meetings in their living rooms.
• Take advantage of community networks and connections. Find key people in the target community to help you spread the word.
• Be creative. Use as many different methods, media, and people as you can to get your message out. Humor, bright colors, a distinctive identifier, and other imaginative approaches will go a long way to making you known in the community.

Watch for ineffective outreach

If you're already conducting an outreach campaign, but it doesn't seem to be working, perhaps you're just not reaching the target population.

• If your target population includes language minorities, make sure that those doing outreach speak the language(s) in question, and that any written material is in both English and the language(s) of the target population.
• If English is the only language you need, keep your message simple and direct. Let people know exactly what your services are in as few simple words as possible.

An adult literacy program's posters went right to the heart of the matter. Their text read:

Need help with:

Reading?

Writing?

Math?

GED?

Call 123-456-7890

• Go where the target population is. Outreach needs to be done in the neighborhoods of potential participants. In rural areas, that may mean going door to door on back roads, getting to know the proprietors of small local stores, cafes, and gas stations, and putting posters at crossroads or at out-of-the-way post offices.
• Use a form of communication the target population will respond to. The Spanish-language radio station that many people listen to or a neighborhood newspaper that most people read may be better places to get your message out than the large-circulation newspaper.
• Try to find local residents who'll help. People are much more responsive to messages from someone they know and trust.
• As participants contact you, ask how they heard about the organization.Their answers will tell you what your most successful outreach strategies are.

Negative perceptions of the program

If your services are viewed negatively in the community - whether because of past history, misunderstandings, or real problems - people will be reluctant to use them.

There are some steps you can take to deal with this issue:

• Try to establish communication with those in the community who distrust you, so you can understand what their objections are. Listen to what they have to say, take it seriously, and make changes if they're needed.
• If their perceptions are based on misunderstanding or misinformation, make every effort to correct the negative impression. Invite people to visit and see what you actually do, get participants to vouch for you, explain your philosophy - whatever it takes to turn perceptions around. Personal contact is probably the most important factor. If people like and trust someone connected with the program, they'll accept the program as well.
• If your negative image is based in reality, admit it. Don't let defensiveness keep you from seeing and acknowledging the problem. Take action to correct the problem - perhaps including in your planning some of the people who have been negative - and let the community know you're doing it.
• Continue to try to establish and maintain communication with all sectors of the community, including those who feel negatively about you.

Affordability and eligibility

These are sticky issues, because they are, to a large extent, dependent on funding. You can, however, establish sliding fee scales for participants, and work out alternative arrangements for those who simply can't afford to pay anything. (A possibility is to barter services for labor, for instance.)

Eligibility can often be dealt with through creative juggling of funding sources. People who aren't eligible under one grant may be under another, or may be recorded as being funded through community contributions. As long as you keep your books straight, there's no problem with funding particular people out of particular sources.

Another possibility is to simply make the decision that you won't apply for or take money from certain sources because of their restrictions. This can be difficult - it's hard to turn down funding - but it may be important to the integrity of your organization and your reputation in the community in the long run.

Program quality

If the services you offer aren't having the desired results for participants - if job training consistently proves inadequate, if street workers don't establish contact or relationships with youth, if community health workers regularly misinform or mistreat people - then they really don't have access to services. How can you judge the quality of your program? And what can you do to improve it?

• If you're not already doing it, conduct an evaluation of your services. While evaluations can be as complicated as major research studies, they can also be as simple as polling participants about their treatment, goal achievement, and satisfaction. What's the community perception of your services? (See "Negative perceptions of the program" above.) Evaluate staff performance as well: Are people doing what is expected of them? Are they treating participants with respect? Are they successfully accomplishing their goals? Do they have the training and skills to do what they need to do?
• If your evaluation shows that your program quality is lacking, admit the fact and address the problem. Trying to ignore or avoid it will only make matters worse.

Conduct an evaluation of your services

While evaluations can be as complicated as major research studies, they can also be as simple as polling participants about their treatment, goal achievement, and satisfaction. What's the community perception of your services? Evaluate staff performance as well: Are people doing what is expected of them? Are they treating participants with respect? Are they successfully accomplishing their goals? Do they have the training and skills to do what they need to do?

If evaluation shows that there is a problem, admit it and address the problem

Trying to ignore or avoid it will only make matters worse.

• Look at the research. If there is research in the field, what does it say about what seems to lead to success? There may be many answers to that question, but research results should give you at least a start at thinking about other ways you could operate.

Remember that research won't tell you everything. Except in the unusual situation where a particular approach never works, almost everything works for some people, or in some organizations. The questions most research answers are "What is more likely than other approaches to work most of the time?" or "What is least likely to work?" Such variables as the culture of the target population, the personalities and competency of staff, and the nature of the community can change the equation considerably.

• Look at what other similar programs are doing that seems to be working. Are they using methods or approaches different from yours? Do they have different assumptions about the target population? Are their programs longer or more intensive? Do they have different qualifications for staff? Not everything that another program does will necessarily work for you, but if several successful programs are doing similar things, that's an important piece of information.

When looking at other programs, you have to examine not just what they do, but how and why they do it. You may find that in order to improve your program, you need to reexamine your philosophy and assumptions. Are you treating people in such a way that they can benefit from what the program offers? Should you involve participants more in planning, implementing, and evaluating services? If you currently see participants as clients who have something done to or for them by your program, questions like these may imply a whole different way of looking at what you do.

An example of how methods and philosophy are intertwined is a Certified Nurses Aide training program for welfare recipients, the most successful in its state in graduation rate, job placement, and the amount of time graduates stayed in jobs. The program treated participants not as clients, but as professionals. They were told they were expected to attend classes because they were learning things on which people's lives would depend, and it was assumed that they would act professionally. They were addressed as "Ms. _____," and treated by the instructor as colleagues. Respected as professionals, they responded the same way, never missing sessions, learning rapidly, achieving nearly a 100% graduation rate, and quickly getting jobs and staying off welfare.

• Discuss with staff and with current and former participants what they think might improve the effectiveness of your work. Using that feedback and the other information you've gathered, as well as what you know about your community and the target population, make a plan for redesigning your program.

If the redesign calls for differences in approach, assumptions, and/or philosophy, it's not going to work simply because you put it in place. All staff, including the administrators, will have to be retrained so that they understand not only what they're being asked to do, but how and why they need to do it. Otherwise, it simply won't make any difference. In some cases, staff may simply not have the skills to deliver services adequately. This presents a serious problem to any organization. Can you retrain the people you have, or is it necessary either to shift jobs around or to lay off some people and hire others with appropriate credentials and skills? As discussed above in reference to professionalizing a grass roots program, how do you reconcile what may be a real, demonstrated commitment to the work with the lack of background to do it effectively.

• Implement your new plan, evaluating it as you go. Be sure to give it enough time to work - change is always difficult, and staff and participants need time to adjust to new ways of doing things. By the same token, don't be afraid to change aspects of your new design that don't seem to be working after a reasonable amount of time. One hallmark of any effective program is dynamism - constant change, both to respond to changes in the needs and situation of the target population, and in response to the notion that no matter how well you're doing, it can always get better. If you aim for a dynamic program, you will probably be effective.

How do we remove barriers to individuals' participation?

Many services are most used by folks who are low income and/or otherwise disadvantaged. Their lives are often complicated by physical or financial hardships, or by the need to work long hours at low-paying jobs. Community services need to understand and try to alleviate the personal barriers that participants face.

Transportation

You can't solve transportation problems with money alone, unless you have unlimited amounts. Instead, you often need to be creative.

• Start your own transportation service. Some rural programs have one or more vans or buses with which they transport participants, usually bought with the help of grants. Some rural states may have money set aside for just such purposes.

Owning and operating a transport service doesn't come without complications. You need certain kinds of licenses and insurance in most states; you are responsible for the maintenance and repair of the vehicles; and you have more employees to cope with. In addition, you are always open to a suit if someone is injured (that's why you have insurance, but it can still be a huge amount of trouble), and you have to replace vehicles when they wear out, which usually means finding more grant money.

• Help participants organize car pools. If a few people have reliable cars, they may be able to bring others for either gas money from riders or a per-mile reimbursement.

Again, unless you have a grant specifically for this purpose, mileage reimbursement can be expensive. For example, at 30 cents a mile (the standard federal reimbursement rate), someone driving ten miles each way twice a week (a total of 40 miles) for 48 weeks would collect a total of $576.00 for the year. Multiply that by several people, and it adds up to a major chunk of a small budget.

• In urban areas, provide bus fare for participants, or try to obtain free bus or subway passes from the public transportation authority.
• In urban areas where safety may be as much a factor as availability of transportation, help participants organize public transport pools. Groups from the same or adjacent neighborhoods could meet to ride or walk to services together.
• Share transportation with other organizations that have their own, or make arrangements with public transportation or rural regional transport authorities.
• Consider starting a satellite site, or moving your program to an easier-to -reach area.

Program location

It's important to try both to locate programs in areas that are reachable for participants, and to pay attention to participants' attitudes toward particular locations. Establishing a program in one area may scare off participants from other areas, because of gang or racial or class issues. You might seek space that's seen by the target population as neutral.

Another location issue concerns the attitude of participants toward certain kinds of spaces. Institutional locations - high schools, colleges, government buildings, etc. - are intimidating to many people, and may affect access. Again, neutral space - facilities in a commercial building, e.g. - might help to address the problem.

Depending upon the nature of your services, you may be able to avoid the location issue altogether by delivering services directly to participants in their homes, either individually or in groups.

A story that illustrates this last point, as well as the possibility of providing services in ways that tie into the culture of the target population, is told by this section's editor:

"I was involved in a drug and alcohol prevention program that was doing outreach in the Latino community in a working-class city. Many of these community members were new to the city; some may have been in the U.S. illegally, though I didn't ask. But at any rate, for a wide variety of reasons, these were not the kind of folks who were likely to seek out help from existing social service agencies. To do so would be difficult and uncomfortable, if not also scary and threatening.

"So instead of them coming to us, we went to them. When our outreach worker made a receptive contact, we often asked about holding a meeting right in that person's home. Our target person would invite neighbors, friends, and family members. There would almost always be refreshments. And we would come and talk about drugs and alcohol - not in a heavy and didactic way, but much more informally, in dialogue style. These home visits (in Spanish, "charlas," or "house chats") seemed to work quite well. We got the information out. We reached people who would never have showed up downtown. We built some trust and rapport. And I think people enjoyed them -- I know we did."

Program schedule

The inability of participants to attend at the scheduled times because of work or other conflicts can be a major barrier to access. Although it's probably never possible to accommodate absolutely everyone, service schedules need to be devised for the convenience of participants, not of programs or staff members.

If the bulk of the target population is mothers with children in school, for instance, change times from afternoon or evening to morning to solve access problems. Programs may need to meet on weekends. In a particular ethnic community, virtually all the women - even those with full-time jobs - were expected to have dinner ready at 5:00, when most men returned from work. A program change from afternoon to 6:30 in the evening doubled attendance at ESOL classes.

A more difficult problem can arise in communities where many people work rotating shifts: two weeks on days, two weeks on evenings, two weeks on nights. It is possible to solve this problem by mirroring these changes in the scheduling of services. It may be difficult to find staff who will work under those conditions, however, since this schedule plays havoc with family, sleep patterns, and the general quality of one's life.

Child care

Again, money isn't the only solution here. Many parents are simply unwilling to leave their children with anyone they don't know, even certified child care providers. Some child care just costs too much for programs to subsidize. There are some ways to address this issue, however:

• Make arrangements with local organizations. You may be able to reserve some spaces in family day care for reduced rates, for instance, or persuade a day care center to reserve some of its low-income slots specifically for eligible participants in your program.
• Encourage participants to help one another. People may be able to take turns babysitting, or share a trustworthy child care provider.
• Hire someone - or recruit or pay participants - to provide on-site child care. There may be grant money available, or you may be able to negotiate a relatively low rate.

While on-site child care can be cost-effective and reassuring for parents, it comes with its own set of potential problems. In some states, you need a certified person to provide any child care, and the facility may need to have particular characteristics as well (a set number of bathrooms, small toilets, childproofing, etc.). In addition, if a parent hears her own child crying, she may feel the need to come running, even though the child care provider is capable of handling the situation. This can obviously be disruptive to whatever activity the parent and other participants are engaged in.

• Subsidize participants' child care. You may be able to allocate money to help participants pay for their own child care.

Target population doesn't see the issue as a problem

If the target population sees no reason for taking advantage of services, the services might as well not exist.

Some courses of action:

• Listen to the target population. What do they perceive as needs? In some cases, they may be right - the service offered may not be what they need, or they may have good reasons for not seeing it as such.
• Enlist members of the target population, trusted professionals and organizations, community leaders, etc. to help educate others. Community members who do understand why the service is useful or necessary may be more believable or may be able to explain the situation more convincingly than "outsiders" can.
• Where possible, provide facts, statistics, personal anecdotes, etc. to help people understand how this service affects them, not only now, but in the future.

Target population's personal issues with the service

All of the suggestions directly above apply here as well. Listening to and acting on the ideas and feelings of the target population, recruiting familiar figures to help introduce the service, and providing information are all important responses to the fears, hostility, or embarrassment of the target population.

Perhaps even more important is patience. It generally takes about two years to get a new service or program established in the community. During that time, you have to continue to be respectful, to maintain communication, to make allies one by one, and to build a store of trust. Ultimately, word of mouth will take over, and let the community know that you care, that you're there for the long haul, and that what you're offering is worthwhile. It takes time to get to that point, and there is simply no substitute for it.

Cultural issues

The barriers presented by culture can also be addressed by respect, listening, enlisting members of the target population, and patience. In addition, there are some other important steps to take.

• Hire members of the culture in question. Make sure that you have on your staff people who have first-hand experience of living in the culture of the target population.
• Train all staff - from the director to clerical and maintenance staff - in the culture of the community you're serving. Staff members from the culture and members of the target community can conduct or help with this training.
• Use interpretation, bilingual staff, community volunteers, translation of materials and information, etc. to deal with language barriers.
• Leave your preconceptions at the door, at least until you know the community well enough to argue with people as a friend, rather than as an "outsider."

In Summary

Access to health and community services involves three factors: funding; program barriers to access; and the personal barriers of the target population. The first of these can be addressed through legislative and community advocacy and public and private fundraising. The second demands a careful examination and evaluation of the what, why, where, and how of service delivery, and a reworking of those parts of your program or initiative that are not effective. And the last calls both for providing organizational support for participants and for exercising respect and patience over the long term. It takes all three to create a service delivery system that guarantees access to all those in the community who need it.