Example #1: Multnomah County Health Department
This is an example from the National Association of County and City Health Officials (NACCHO) website.
People with disabilities make up 16% of the total population of Multnomah County, Oregon. The Multnomah County Health Department (MCHD) and its community partners were interested in promoting health and well-being for these 115,000 county residents with disabilities. Working with the National Association of City and County Health Officials (NACCHO), the partners conducted the MAPP process to begin working toward this community goal.
Phase 1, Organize:
The Multnomah County Health Department (MCHD) partnered with several community organizations with funding from NACCHO.
Some of the community partners included:
- Oregon Health & Science University's Center of Excellence in Women's Health.
- Vocational Rehabilitation.
- Multnomah County Aging & Disability Services.
- City of Portland.
- State Independent Living Center.
- Center on Community Accessibility.
- Portland State University.
- AMHSA Advisory Council Member.
- Disability Arts and Cultural Program.
- Office of Emergency Management.
- Department of Human Services: Seniors & People with Disabilities, Arthritis Program, Oregon Asthma Program, & Tobacco Prevention Education
Phase 2, Vision:
The partnership worked together to brainstorm and decide upon a common vision: health and wellbeing for those with disabilities in Multnomah County.
They decided that their purpose was to "help the Health Department begin to address the health promotion needs of people with disabilities in their clinics and community.”
Phase 3, Assessments:
The Multnomah County Health Department (MCHD) Community Capacitation Center (CCC) created a Steering Committee that was divided into three subcommittees. With support from the MCHD Assessment and Evaluation Unit, the first subcommittee conducted a sample survey of health department clients with disabilities.
These surveys were based on stakeholder feedback and the existing literature on health promotion programming for people with disabilities. They were conducted in the waiting rooms of six primary care clinics operated by the Multnomah County Health Department. Survey staff (Health Department staff and public health/nursing students) approached all adult clients after they checked in and asked whether they would be interested in completing the survey. Surveys in Spanish were available at all locations, and Spanish-speaking staff were available at some locations to facilitate. The surveys were self-administered when possible and read to participants when wanted or needed.
Because survey takers were self-selected (not a random sample), findings cannot be generalized to the larger population of primary care clients seeking care at the Health Department and prevalence rates of disabilities cannot be determined from the survey results. The findings do speak for the group of clients responding, however, and can be used to inform future planning steps.
Of the total 144 surveys completed by individuals seeking health care in one of the Health Department's primary care clinics, 69 identified themselves as having a disability based on inclusion criteria.
The following findings are for these 69 respondents:
- 64% reported having a condition that greatly limits basic physical activities, such as walking, climbing, reaching, lifting, or carrying.
- 62% reported having a condition that results in difficulties with learning, remembering, or concentrating.
- 61% reported having a condition resulting in difficulties with working at a job or business.
- 58% reported a recurring condition that limits their ability to conduct basic daily activities.
- 41% reported difficulties with going outside the home alone to shop or visit a doctor’s office.
- 38% reported a mental health condition that limits basic daily activities.
- 33% reported a disability that limits functions such as learning, understanding or processing information.
- 32% reported difficulties with dressing, bathing, or getting around the houses.
- 25% reported deafness or a severe hearing loss.
- 92% wanted to know about health promotion activities, information, and support when these become available.
- 65% were interested in sharing their opinions and thoughts and/or becoming involved with future planning of health promotion activities for people with disabilities.
These summaries were made from the findings:
- Respondents wanted more information from their health care providers about treatments for specific conditions and about prevention and general health.
- Respondents were interested in a wide array of health promotion activities and supports, including help with stress reduction, cooking classes, help finding employment, and resource information.
- Lack of money was the most commonly cited barrier to taking care of one’s health.
- The majority of respondents were satisfied with the information and treatment they are currently receiving, but would like to get even more from their doctors, social services, and case managers.
- Respondents reported being eager to participate in future planning activities and to get together with other people to participate in health promotion activities.
Phase 4, Strategic Issues:
The results of the survey were incorporated into the health promotion summit, the product of the second subcommittee. The summit focused on the notion that people with disabilities constitute a community, and that public health professionals should relate to them as a community.
Possible strategic issues:
- How can people with disabilities become more involved in the health promotion of their own community?
- How can those people working in public health, health providers, and people with disabilities work together to develop health promotion efforts?
- How can people with disabilities receive more information from their health care providers about prevention and general health?
- How can the lack of money be overcome as a barrier to taking care of health issues?
Phase 5, Goals/Strategies:
The committees decided on these strategies:
- Identify and survey health department clients with disabilities to support the planning and implementation of health promotion programming for this community.
- Develop a voluntary registry of people with disabilities in order to be able to provide appropriate services in the event of an emergency.
- Convene a summit for people with disabilities and providers of services for people with disabilities to establish a long-term agenda for health promotion programming.
Phase 6, Action Cycle:
The third subcommittee is working to develop a voluntary registry to alert emergency response workers to community members with disabilities. The success of this project is dependent on approaching health promotion in the disability community in the same way it approaches health promotion in other communities, by working in partnership with leaders and members of the disability community and focusing on the underlying social determinants of health.
The Multnomah County Health Department used the MAPP tool to find out what issues were being faced by those with disabilities within the community and what the community could do about the issues. They developed a vision and mission, assessed the community, identified problems and potential strategies, and created an action plan. The partnership members are currently still working on the action cycle phase of the process but have made progress in providing health services and health promotion programming for community members with disabilities.
Please see the Multnomah County Health Department for further information.
Example #2: Richland County Public Health Department
In 2007, the Richland County Public Health Department decided to engage the Richland County community in the Mobilizing Action through Partnership and Planning (MAPP) process.
Organize for Success/Partnership Development
A partnership was formed between the Richland County Public Health Department, the Communities in Action Steering Committee and staff, and many other interested and active organizations, agencies, coalitions, and individuals in Richland County. One especially important partner was the AmeriCorps*VISTA program. Much of the information collection was done by AmeriCorps*VISTA members along with volunteers from the Richland County community.
Richland County wishes to “cultivate individual and community involvement in all aspects of our health, safety, and wellness by empowering people to capitalize on available resources to achieve our highest quality of life.” Their goal is to begin a community building process to make Richland County into the healthiest community possible, where the definition of healthy community includes social circumstances, environmental conditions, economic development, and country/cities growth policies.
Assessment (links to assessments and results following each explanation)
First, demographic and other statistical information was collected about the physical health of the Richland County residents: Community Health Assessment.
- A County Windshield Survey was also conducted. AmeriCore*VISTA members were taken on car tours of each town in Richland County guided by two residents from each town. Discussion topics included health, environment, youth, seniors, local business, housing, protection, transportation/road conditions, and safety. City of Sidney Windshield Survey.
- Several methods were used approaches were taken to learn about the broad array of issues that matter to people in the community.
- A County Telephone Survey was conducted by the University of Montana’s Bureau of Business and Economic Research, which contacted a random sampling of residents. The topics chosen by area groups for this survey included local housing, business, volunteerism, and the importance of a local school system to their community. Richland County Telephone Survey.
- To assess the views of youth, the young people of the community were given a chance to voice their opinions on what they liked and what they would change about their communities. They used a methodology called PhotoVoice. Youth were given disposable cameras and asked to take photos of the positive areas of their community and the areas that needed improvement: Richland County PhotoVoice slideshow. For more information on Photovoice.
- The views of the elderly were also assessed. Focus groups were formed to address senior citizens’ accessibility to physical activity. Seniors were asked to comment on what forms of exercise were currently available to them, what barriers existed that prevented physical activity, and what changes and programs they would like implemented in the future. Richland County Senior Focus Group.
- Written surveys were given out to Richland County residents inquiring about their views on various environmental health topics. The top concerns that surfaced from this survey were: illegal drugs and alcohol use, road safety and unsafe drivers, crime and domestic violence, oil/gas development, water and air quality, and the quality of medical facilities. Environmental Health in Richland County.
- Finally, a Local Public Health System Assessment was conducted using the Local Public Health System Performance Assessment Instrument. This instrument evaluated the performance and implementation of ten essential services that the community should do: monitor health status; diagnose and investigate health problems; inform, educate and empower people; develop policies and plans; link people to needed personal health services; assure a competent workforce; evaluate effectiveness, accessibility, and quality of services; and research for new insights and innovative solutions. These ten essential services are guidelines for the optimal performance of the public health system. Richland County Local Public Health System Assessment. For more information on the Ten Essential Services.
- In an effort to look to the future, a Forces of Change assessment was performed by members of the organization in charge of this effort, the Communities In Action Steering Committee. This was a brainstorming activity that looked at potential forces of change in the community and the potential threats and opportunities created from each change. Some examples of these factors include political or legislative changes, demographic shifts, or changes in availability of natural resources. Richland County Forces of Change Assessment.
Strategic Issues, Goals/Strategies, Action Cycle
The Richland County Health Department and its partners have not yet completed these steps. The Health Department reports, “With the list of concerns now compiled, community members must next identify strategic issues to determine which issues are the most critical for Richland County to address. Once these critical issues have been identified, community members will help to formulate goals and strategies to address these identified issues. After this is completed, the necessary steps to reach our goals can be put into motion.
Example #3: Chicago Partnership
This is an example from the National Association of County and City Health Officials (NACCHO) website.
The Chicago Partnership was created in orderto improve the Chicago Department of Public Health. The Partnership engaged many different stakeholders in its efforts, from health department workers and medical providers to religious leaders and philanthropists.
- Phase 1, Organize: First, an advisory committee with representation from the health department, the business community, the board of health, and a health policy/advocacy organization was formed. This committee was in charge of identifying stakeholders and deciding who should be included as members of the partnership. They appointed members from the public hospital, community health centers, governmental agencies with ties to public health, the religious and business communities, health advocacy organizations, philanthropy, and academia.
- Link to Chicago Partnership MAPP Phase 1 on NACCHO website
- Phase 2, Vision: To develop a vision, members were asked to describe what they thought would be important components of the ideal public health system for Chicago. They were asked to consider:
- Past public health successes in Chicago.
- Their organization's capability to contribute to public health.
- Health conditions facing Chicago residents.
- Guiding principles and assumptions adopted for the planning process.
The members' input was categorized into three areas:
- Who would the system serve.
- What would the system do?
- How would the system function?
At the next meeting, the partnership members discussed these questions and decided on their vision for local public health:
"A responsive, sustainable public health system that, through cooperative efforts, planning and policy development, a broad focus on health promotion and disease prevention, and shared leadership and accountability, is positioned to respond to current and future public health challenges, and protects and promotes the health and well-being of all Chicago communities, residents, and visitors, particularly the most disadvantaged."
During this visioning process, input by the department of public health was limited, which helped expand the role of nongovernmental partners. In the end, the process resulted in a vision that could be embraced by all partners. The group agreed to periodically review and potentially revise this vision to align it with the progress and development of the overall assessment and intervention process.
Link to Chicago Partnership MAPP Phase 2 on NACCHO website
Phase 3, Assessments:
- Community Health Status Assessment: The Chicago Partnership compiled the Chicago Health Profile, which included data pertaining to:
- Demographic and socioeconomic indicators.
- Health status indicators.
- Health perceptions and health-related behaviors.
- Social and environmental factors.
- Healthcare delivery and access to care.
- This information was collected from the U.S. Census, vital records and reportable diseases records (maintained by the Public Health Department), hospital discharge data, adult and youth behavior risk factor surveys, violent crimes records from the police department, and a recently completed broad-scale survey of Chicagoans.
- Based on these data, the staff wrote up a narrative report that was reviewed and discussed at the next Partnership meeting. Members were encouraged to voice their opinions and recommend changes. The staff then condensed the findings of the Chicago Health Profile into a seven-page summary and presented it at the September 1999 meeting.
Some important findings:
- Significant health status disparities exist by race/ethnicity and by gender.
- The city experienced a 12 percent decrease in available jobs from 1992 to 1997, with a slow growth in new jobs from 1997 to 1999.
- Mortality rates overall were declining, but hospitalizations for related conditions were up.
- Infant mortality rates continued to decline, despite no decreases in low weight births.
- Despite significant progress in recent years, incidence of most types of sexually transmitted infections had increased in the past year.
- Most Chicagoans had some source of regular medical care; most of the insured, however, were not covered for wellness services.
- At the meeting, the partnership discussed the data found in the assessment and what it meant. It was decided that the decreasing mortality rates (including infant deaths) and rise in hospitalizations, along with the lack of improvement in low birth weight, suggested that while advances were being made in medical intervention, more work was needed in the area of primary prevention.
Link to Chicago Partnership MAPP Phase 3a on NACCHO website
Community Themes and Strengths Assessment: Since much of the Chicago Partnership's focus was on the systems and policy level, it was deemed important to engage partners at the community level to develop a strengthened public health system. The partnership contracted with four existing community-based partnerships that each focused on a specific region of Chicago. These organizations already had the experience and expertise for engaging the resources and assets of their respective communities. The local partnerships each conducted a series of three community forums. The first forum set focused on providing information, and the second and third forums gathered input on strategic issues and Partnership strategies.
During the first set of forums, community members discussed their perceptions about:
- Priority health and public health issues.
- Barriers to the delivery of local public health services.
- Elements for successful community-based health improvement efforts
- .Systems-level changes needed to support local public health improvement efforts
The local community-based partnerships reported the results back to the Chicago Partnership. Forum participants identified pressing health problems, including substance abuse, violence, cancer, hypertension, diabetes, and asthma. Some of the identified barriers to health were poor transportation access, language or other cultural barriers, and poor healthcare coverage. Resources identified included parks, community diversity, and relationships with neighbors. The community members made suggestions for system improvements, including greater community involvement in local planning, more free or affordable housing and health care services, better communication, greater collaboration, increased police presence, increased trust within the community, greater numbers of community resource centers for information sharing, and stronger public health leadership.
These findings, consistent with the partnership's vision, were presented and discussed at the next Chicago Partnership meeting.
Link to Chicago Partnership MAPP Phase 3b on NACCHO website
- Forces of Change assessment: Members of the Partnership each completed a worksheet identifying forces and trends in public health as well as possible threats and opportunities resulting from those forces and trends. When the worksheets were analyzed, over 75 forces and trends had been identified. Partnership staff consolidated the submissions into one worksheet, without changing the writers' wordings. The input was grouped into 11 broad categories, allowing the partnership to identify which forces were concerning to the most members.
- The Chicago Partnership debated the forces and trends identified in the document, offering additions and challenging assumptions. After much deliberation, including an extra three-hour meeting scheduled just for that purpose, the forces and trends identified were consolidated into eight main categories:
- Lack of public health constituency Shifting funding streams and focus.
- Governmental role in public health.
- Health status disparities.
- Healthcare system changes.
- Emerging public health issues.The aging population.Economic development
Once the group had reached consensus on the content and organization of the worksheet document, a narrative was drafted to reflect the details of the discussion process. When the narrative had been reviewed and revised, it was included in the final public health systems improvement plan.
Link to Chicago Partnership MAPP Phase 3c on NACCHO website
- Local Public Health System Assessment: A committee was formed to assess the extent to which Chicago organizations contributed to public health, specifically by providing the Ten Essential Public Health Services. and see Ten Essential Public Health Services. The Systems Assessment Committee considered public health and related government agencies, community health centers, hospitals, policy and advocacy organizations, coalitions, educational institutions, social service providers, philanthropy organizations, businesses, and religious communities, and made a list of specific providers from each of these areas.
- The next step was to formulate a survey to determine which of the 10 essential services the agencies were providing and to collect examples of the ways they delivered those services. This survey was distributed to more than 150 agencies. Forty-eight responses were received. Partnership staff organized the responses by arena and service provided. Then it was noted how many and which of the 10 essential services were provided in which areas of the city.
- It was found that almost all of the essential services were provided in almost all areas of the city. This led to the conclusion that while Chicago has many resources, the issue may be how those resources are being used. Furthermore, some public health services were being provided deliberately and others were being provided incidentally. These incidentally provided services would be improved by being better incorporated into the systemas this would strengthen the direction of their efforts and make them more accessible to the community.
- The committee members agreed that a more refined analytic framework would be needed to better understand the contributions being made to the development of the public health system, but for the time being, the information from the surveys would be useful in characterizing the existing system.
In addition to this survey, an extensive review was conducted of public health mandates in the City Municipal Code.
The review showed that the municipal code played three roles:
- Laid out the administrative structure for governmental public health.
- Empowered the Department of Public Health and its board to establish standards for public health protection.
- Authorized the department to actively enforce the rules and regulations designed to assure those standards
These mandates were then compared with and incorporated into the essential public health services. Most fell under diagnosis and investigation of health problems, enforcement of laws and regulations, and policy and plan development.
The third and final component of the public health system assessment involved mapping the geographic locations of existing community-based health improvement partnerships onto a map of Chicago. This revealed that 16 of Chicago's 77 formally designated community areas are served by seven existing partnerships. The other 61 community areas are not served.
Link to Chicago Partnership MAPP Phase 3d on NACCHO website
Phase 4, Identifying Strategic Issues: The Chicago Partnership needed to come up with a list of possible strategic issues to achieve the vision for public health in Chicago. First, the partnership reminded members of five key points that had surfaced from the work completed so far that should be kept in mind for the strategizing portion:
- Vision for Chicago's Public Health System.
- Health Profile.
- Community Forums.
- Analysis of Trends and Forces.
- Public Health System Assessment
Members were asked to consider the findings individually and discuss them in groups in an effort to identify the big and reoccurring issues. Six possible strategic issues were considered and critiqued. Each of the six issues were debated and questioned as to how well it fit with the partnership's vision and captured the findings of the assessments that had been conducted.
Some major changes and new wordings were adopted to better link the strategies to the vision and assessment findings, and these final strategic issues were adopted:
- How can governmental public health agencies demonstrate more effective leadership in areas of policy development, assessment, and assurance?
- How can the Partnership strengthen coordination among public health partners?
- How can Chicago's public health community and its partners eliminate racial/ethnic, gender, and social class disparities in health status?
- How can the public health community ensure that the general public has access to personal healthcare services?
- How can the partnership foster the development of sustainable community-based partnerships to increase the community's voice in systems planning, program development, policy, and advocacy
- How can the public health community most effectively:
- Foster the sharing of data and other information between agencies,
- Group information and resources in the most useful manner, and
- Disseminate information to the public and other users?
Link to Chicago Partnership MAPP Phase 4 on NACCHO website
Phase 5, Goals/Strategies: This involved developing broad areas of action to address the identified strategic issues. The partnership brainstormed and identified strategies with the PEARL criteria that would address the identified strategic issues. (See below for more information about the PEARL criteria.)
Each member was given six blank index cards and asked to write down what they viewed as the most important strategies. Then, using a round-robin approach, members took turns reading their priority strategies and staff then taped the cards to the wall. During this process, members were allowed only to raise issues of clarification.
Once all of the suggested strategies had been placed on the wall, members discussed, consolidated, and then organized the strategies into logical clusters. When the two groups had each completed this exercise, the larger partnership reconvened and considered all of the strategies together. At this point, further consolidation occurred.
Throughout the strategy development process, members were asked to consider their proposed strategies against the following set of PEARL criteria:
- Propriety: Does the strategy address the issues identified? Is it technically workable?
- Economical: Is the strategy cost-effective? Does it make financial sense?
- Acceptability: Is the strategy acceptable to the community and other stakeholders?
- Resources: Are there resources to implement the strategy?
- Legality/Legitimacy: Does the group have the legal authority to implement the strategy? Is it a legitimate function of the proposed implementers and consistent with their mission?
At the meeting's conclusion, the partnership had identified a set of 20 strategies and organized them into the following seven action areas:
- Creating the public health system through partnership development.
- Setting Chicago's public health policy agenda.
- Building community capacity and constituency.
- Strengthening the public health workforce.
- Strengthening the system through information.
- Advancing the public health agenda through research.
- Getting the word out: marketing public health messages
The strategies in these areas served as the basis for the partnership's priority-setting and more specific action-planning activities.
Link to Chicago Partnership Phase 5 on NACCHO website
Phase 6, Action Cycle: Out of the 20 total strategies developed, two fundamental strategies were chosen to focus on first:
1) the development of a network of community-based coalitions, and 2) the creation of a coordinated citywide policy agenda for public health in Chicago.
The strategy of developing a network of community-based coalitions was chosen because of Chicago’s large and diverse nature. The Chicago Partnership could not possibly represent all of the city's communities, but the partnership believed that additional community participation was essential. To ensure that the need for community participation was met, an organized structure was needed. The partnership submitted a funding request to the Kellogg Foundation to initiate work on this strategy.
The second strategy – to develop a coordinated citywide public policy agenda -- was chosen because policy was an area in which most of the partners had a stake and the partnership already had resources needed to take action.
The Committee on Community Partnerships and the Policy Committee were created to address these strategies. At each committee's first meeting, members talked about additional organizations and/or individuals who would be important to involve in the effort.
For example, citywide and other large agencies with resources in multiple communities (such as the city's workforce development office and the community health ministry) were invited to serve on the Committee on Community Partnerships. Policy representatives from a range of agencies, including labor and adolescent health, were invited to serve on the Policy Committee. With membership expanded, the efforts of each committee focused on the development of more specific action plans, including committee member assignments and timelines.
A third committee, the Implementation Committee, comprised solely of formal partnership members, was convened to consider the feasibility of the 18 remaining strategies to be addressed. At the initial meetings, members rated the strategies on levels of need and feasibility and are in the process of making recommendations to the partnership as to where effort should be placed next.
Two additional committees would be formed by the end of the year. A Coordinating Committee would consider the operations of the partnership, including membership issues and the work of the various committees. A working group would also be formed to promote the partnership and its strategic plan.
The project planner at the Department of Public Health staffs the committees. Additional in-kind staff support is provided to the Policy Committee by the department's director of policy and legislative affairs.
Evaluation activities consisted of monitoring implementation of strategies. It was anticipated that evaluation plans would need to be developed separately as each strategy was addressed. However, the Chicago Partnership has not yet reported on the methods of evaluation they have used so far.
Link to Chicago Partnership MAPP Phase 6 on NACCHO website
Through a comprehensive MAPP Process, the Chicago Partnership was able to engage diverse community stakeholders in identifying community needs, creating a partnership, prioritizing issues to address, creating action plans, taking action, and evaluating their efforts.
For a thorough report of the work done by the Chicago Partnership, please see the pdf file: Chicago Plan for Public Health System Improvement 2006-2011 (Aug. 2006)