|Learn how to use the MAPP model to improve the local public health system and mobilize local partnerships.|
How do you conduct a MAPP process?
This section, like the others in this chapter, describes a process you might use to improve the quality of life in your community. This one, MAPP, focuses on health from the community perspective, so it’s easy to see how the process could be adapted to address other community issues as well. It includes many of the same features as the other models described in this chapter – a participatory process guided by a community-generated vision; strategies and goals based on an assessment of the community’s priorities and needs; an action plan that grows from the vision and the goals; and evaluations of the process itself and of the implementation and results of the action plan, with an eye toward improving MAPP’s effectiveness in the community as it’s maintained over time.
The major (although not the only) difference between this and other models is the nature of the community assessment, which actually involves conducting and combining the results of assessments of four separate, but connected, areas. The purpose here is to create as complete a picture of the community’s health, assets, and needs as possible in order to understand fully what changes need to take place, and how they might be set in motion.
This section will walk you through the MAPP process, and discuss how it might be adjusted to address other issues besides health. Along the way, we’ll also look at how the process might be adapted for smaller organizations or communities with limited resources.
What is MAPP?
The development of the Mobilizing for Action through Planning and Partnerships (MAPP) process was a joint project of the non-profit National Association of County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC), the U.S. government agency that “serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States” (from the CDC mission statement).
Not surprisingly, since it is the creation of two organizations made up of public health officials, MAPP’s efforts are meant to be focused, though not exclusively, on local public health structures and institutions. Its vision is “Communities achieving improved health and quality of life by mobilizing partnerships and taking strategic action.” The MAPP section of the NACCHO website makes clear that the achievement of this vision relies not just on improving specific health organizations or processes, but on building a healthy community.
The concept of health that MAPP embraces is that of most of the other models in this chapter, and indeed, that of the Community Tool Box as a whole: that health is not simply a matter of medical treatment or the absence of disease, but must be viewed from a community perspective. The World Health Organization (WHO) has long recognized that health “is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity (WHO Executive Committee, 1998).”
A community-based view of health implies that real health for all individuals can only be achieved when the community as a whole is healthy. That requires a community that encourages and supports not only physical health, but economic, environmental, social, psychological, and political health as well.
In 1986, WHO, in a document generally called the Ottawa Charter, set out nine requirements for a healthy community: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. In WHO’s view, only when all of these requirements are available to everyone can a community be truly healthy.
MAPP has seven underlying principles and six phases. The underlying principles are important to the success of implementing MAPP in the community, and the six phases provide the structure for the MAPP process. We’ll briefly set out and describe these principles and phases here, and then address them more fully in the “How-to” part of the section.
The underlying principles:
- Systems thinking involves examining the underlying structure of community health issues and systems in order to create lasting positive change on a community level.
- Dialogue ensures the inclusion of diverse perspectives, and that the voices of all stakeholders are heard in the MAPP process.
- Shared vision guarantees approval and ownership of the process by all concerned, thereby increasing its chances of success.
- Data, rather than preconceptions, anecdotes, or intuition, provides a firm basis for planning and action.
- Partnership and collaboration makes not only for a fairer process, but increases access to resources and places the responsibility for success on more shoulders.
- Strategic thinking makes for a proactive, rather than a reactive, approach to issues and systems.
- Celebration of successes keeps enthusiasm high and marks progress and individual and group achievements.
The six phases of the MAPP process are:
- Organize for Success/Partnership Development. In this phase, a core group and an inclusive steering committee are recruited, and the process is organized and planned out.
- Visioning. The community and the committee work together to develop an overall, shared vision of health in the community that will guide the planning and action to follow.
- The Assessments. As mentioned, perhaps the main feature that sets MAPP apart from other similar models is the depth of its community assessment. There are really four assessments, although they are clearly connected:
- The Community Themes and Strengths Assessment asks residents to name the issues that are important to them, to talk about how they feel about the community, and to identify community assets – the resources that already exist in the community that can be used to address health and other issues.
- The Local Public Health System Assessment (LPHSA) examines all elements of the public health system, from hospitals to home health aides, as well as how those elements work, how they’re structured, how they interact with other sectors and elements of the community, and the nature of their resources. This assessment is completed using the National Public Health Performance Standards Program local instrument.
The National Public Health Performance Standards Program local instrument provides performance standards and measures for assessing how well a public health system provides the Essential Public Health Services. We’ll examine the Ten Essential Services in the “How-to” part of the section.
- The Community Health Status Assessment looks at the health of community members and of the community. Quality of life issues – employment, housing, the environment, etc. – are also considered here as part of the community perspective on health.
- The Forces of Change Assessment examines what is happening or might happen in the future that will have an impact on community health.
The National Public Health Performance Standards Program local instrument provides performance standards and measures for assessing how well a public health system provides the Essential Public Health Services. We’ll examine the Ten Essential Services in the “How-to” part of the section.
4.Strategic Issues. Using a participatory approach, the community and the committee examine the data collected in the previous phase to identify the key issues that must be addressed in order to realize the shared vision.
5. Goals / Strategies. Once the strategic issues are identified, the group sets goals for each, based on the vision and assessment data, and formulates strategies for reaching those goals. These goals and strategies map the route from the current circumstances of the community to the future laid out in the vision.
6. Action Cycle. This phase comprises the planning, implementation, and evaluation of the action that the group takes to achieve its goals. It’s seen as a cycle because the assumption is that the process is ongoing. Action is continually evaluated and adjusted to achieve greater effectiveness. The planning/implementation/evaluation cycle continues until the community achieves its vision...and generates a new vision to work toward.
As explained earlier, MAPP is concerned with community health and health systems. While it assumes that public health officials and agencies will be among the effort’s leaders and committee members, it nonetheless views health as an issue that transcends medical care and prevention and health systems. A similar process, therefore, can be used for any other community system as well – education, elder or children’s services, human services – or even for a focus on overall community quality of life. (A case can be made that any effort directed at a particular area necessitates a focus on the community as a whole, as the health field has recognized.) Although the description of MAPP emphasizes the health system, any other system, or the community as a whole could just as well be the target of an effort using MAPP’s principles and process.
Another important feature of the MAPP process is that it isn’t a one-time endeavor. It’s meant to be an ongoing cycle, maintaining and expanding the original partnership and continuing to address community health in whatever ways are necessary. Community assessments – as well as monitoring and evaluation of the process, its methods, and its outcomes – should be conducted regularly, so that the effort continues to speak to the current realities of the community, and so that it remains as effective as possible.
Why use MAPP?
(The following material is adapted from the MAPP website).
- MAPP uses a participatory process. By including all stakeholders in assessment, planning, and implementation, such a process ensures that everyone’s concerns and ideas are heard, and that the community drives and assumes ownership of whatever plan results. Both of these make success much more likely, as well as encouraging new leadership and laying the foundation for other community initiatives.
- The MAPP model is based on partnership and collaboration among all relevant public health bodies, and between the public health system and the community. This means that everyone is moving in the same direction with the same goals and the same strategy, so there are no duplicated or contradictory efforts. Like participation, it also sets the stage for collaboration in other areas and other efforts.
- The MAPP process has been developed using information gleaned from previous planning efforts.This eliminates the repetition of old mistakes, and builds on elements that have proven effective.
- MAPP brings to bear four different assessments to get the clearest picture possible of community health issues and systems. By looking at the community and the public health system from multiple perspectives – the community’s concerns and assets, the state of the local public health system, the health status and issues in the community, and possible changes on the horizon – the process provides as much information as possible upon which to base a strategic plan.
- The MAPP model includes strategic planning. As regular users know, the Community Tool Box is an advocate of strategic planning for nearly any organizational or community effort. By including a full strategic plan in its model, MAPP can utilize the information from assessments to greatly increase the chances that its actions will lead to the desired results.
- MAPP helps the community to anticipate and manage change. The Forces of Change Assessment provides advance knowledge of possible changes – both positive and negative – that might affect community health or the community as a whole. The strategic planning process then provides a vehicle for preparing for those changes before they occur, allowing the community to plot its own future, rather than to have that future shaped by events.
- MAPP focuses on strengthening the local public health system through analysis and adjustment of the system, support for partnership among the various elements of it, and input from all sectors of the community. This creates a stronger public health infrastructure, leading to better coordination of services and resources, a higher degree of coordination and collaboration – as well as awareness of one another’s work – among partners, and less duplication of services.
Another advantage here is the use of the Ten Essential Public Health Services to assess the local system. Research has shown these services to be the keys to a well-functioning system that meets the needs of all members of the community.
- MAPP increases the visibility of public health in the community. By recruiting members of all community sectors to serve on the MAPP Committee, and by publicizing its efforts, the process raises the profile of health issues and systems among groups that may not have considered them in the past, thus creating more community support for public health.
- The MAPP process creates government leadership on public health issues. As a result of their involvement in MAPP, elected and appointed officials and public health and environmental agencies may be more likely to take leadership roles when – or before – health issues arise, and to be more proactive in enacting health policy.
- MAPP takes a community perspective, with the overall goal of creating a healthy community. This means not only improvement in public health systems, but a healthy community and an overall improvement in the quality of life for everyone.
Who should take part and use the MAPP process?
The assumption is that the effort will be convened, but not driven, by a public health agency (probably local-level), which will also provide much of the necessary staffing and technical assistance. The real planning and implementation, however, is the responsibility of a MAPP Committee meant to represent the community. Given that structure, who should be represented on that committee? Who needs to be at the table in order to assure the fullest possible community participation in the process?
At a minimum, it would seem that the following individuals and groups should be involved:
- Local and state public health officials and agencies. These would include Boards of Health, the state or local Health Department, human service agencies, environmental inspectors and agencies, workplace health and safety inspectors and agencies, Department of Public Works (usually responsible for waste disposal, sewage, and water systems, all of which can have major health impacts), etc.
- Health practitioners, administrators, and others who are part of the local public health system. Those responsible for delivering essential public health services and/or have knowledge of and involvement in the system. These might include physicians, nurses, alternative medicine practitioners that work or interact with local medical practices, hospital and clinic directors and administrators, mental health professionals, physical and massage therapists, and athletic trainers. Public health system partners include public, private, voluntary entities that contribute to ensuring the public’s health.
- First responders – EMT’s and paramedics, ambulance crews, police, firefighters. First responders play a prominent role in public health preparedness.
- Local and state elected and appointed officials. In order to ensure government support for any development or change of policy, you should include mayors, city or town councils, planners, county officials, and state or provincial (or federal, depending on the governmental structure) legislators.
- Human service organizations.These often serve and represent the people most troubled by health issues, and may have a very good understanding of the health situation in the community. In addition, they may have relationships with groups the health system finds hard to reach.
- Community organizations. Service clubs (Lions, Rotary), the Chamber of Commerce, youth organizations, athletic clubs, the YMCA, etc. These organizations have valuable knowledge about their members and the capacities and concerns of community members.
- Public schools, local colleges and universities, and other educational institutions. Schools deliver essential public health services such as monitoring the health status of their students, engaging in health promotion and education, providing research and evaluation, and developing the public health workforce.
- Faith communities. Through their work with the community, faith-based institutions have valuable information about quality of life and issues that are important to community residents.
- Businesses. These may be represented by the Chamber of Commerce, but some individual business people may be interested in the issue. Health is an issue for businesses in many ways – insurance costs, loss of productivity because of worker illness, the availability of a healthy workforce able to take on particular jobs, etc. In addition, many local businesses are committed to community development and improvement.
- Community members representing the diversity of ages, incomes, and the racial/ethnic mix in the community. It’s especially important that people who are un- or underinsured are included, as well as language minorities (who may have difficulty gaining access to health care because of language barriers) and other underserved populations.
When might you employ a MAPP process?
Implementing MAPP could make sense for your community at any time. However, if there is an increased focus on improving health in the community, conditions might be especially ripe. Here are some circumstances that bring health into the minds of the public and/or officials:
- When a current or potential health issue surfaces, either in the media or among health practitioners. This might range from the worldwide concern caused by the SARS epidemic in 2002-2003 to the staff of a local hospital emergency room noticing a larger-than-usual number of cases of pneumonia among members of a particular population.
- When there’s been an issue or crisis that everyone agrees wasn’t handled well. The start of the AIDS epidemic in the early 1980s, the 2004 Indian Ocean tsunami, the Szechuan earthquake in China in 2008 – all sorely tested local public health systems and found them wanting, despite the best efforts of all involved. An epidemic, a spike in the incidence of a particular kind of cancer, or a natural disaster are certainly not things to wish for, but when they do occur, they can lead a community to want to restructure its public health system and strive toward a healthy community.
- When there’s money available for public health improvement. State, federal, and international agencies, as well as private foundations, may sometimes offer grants to conduct just such a process as MAPP.
- When there’s no money available for public health systems. With full community participation, a MAPP process could be conducted without outside funding. It might bring far better and more cost-effective results than spending millions to build a facility, because it would address a range of community needs and would mobilize the community’s strengths to develop and support an effective health system that was fully integrated into a healthy community.
- When the community is about to build a new health facility. If your community is going to spend millions to build a new facility, it makes no sense to do it without conducting a comprehensive analysis of the current system and a planning effort in order to understand both how the new facility can best be used and how the system can be reimagined to take advantage of it.
- When there’s a government push to reexamine the public’s health or the local public health system. The local, state, or federal government may support or mandate that municipalities engage in healthy community initiatives.
- When the community is growing rapidly, or is about to because of planned development. When a community grows rapidly, all systems – health, education, welfare, fire, police, human services, employment, etc., all of which are in fact, to some degree, part of the local health system – are strained. Whether you’re anticipating growth or experiencing it, MAPP can help your community manage it effectively.
How do you conduct a Mapp process?
The six phases of the MAPP model provide a framework for constructing the process. If we examine each phase in turn, by the time we finish, you should have a pretty clear sense of how to proceed. Before we do that, however, we should look at the seven underlying principles we described earlier in the section.
The seven principles complement the structure of the process and make it effective. Some of those principles are simple. Celebration of success, for example, is just what it sounds like: when you accomplish something, mark it with some kind of celebration, both to acknowledge everyone’s work and to build enthusiasm for the next step. Others, however, particularly systems thinking, might bear some further explanation. Since all the principles are important elements in the MAPP model, we’ll restate them here and go into a bit more detail about them before we walk through the steps of the process.
- Shared vision. One of the first steps in any community effort is to develop a vision of the future that everyone can support and work toward. MAPP is no exception here: the real work starts with the development of a vision worked out among all the stakeholders that reflects their hopes for how health and other systems can work together to create a truly healthy community.
Developing a vision may sound like a simple step, but it seldom is. It is often where disagreements and differences in philosophy and outlook surface, and these have to be confronted and resolved so that the end result is a vision that everyone concerned can enthusiastically adopt. It’s worth whatever time and effort it takes. Very little can do more to doom an effort than the lack of a shared vision among the partners involved in carrying it out.
- Partnerships and collaboration. A real and permanent change in any community system requires the collaboration of everyone involved in that system, from those that administer and direct it to those that receive its services or are otherwise affected by it. Organizations and agencies that are officially part of or interact with the local public health system, for example, have to work together to avoid duplication of effort, make sure that everyone who needs services receives them, provide coverage to all geographic areas, pass on procedures and practices that work well, share resources when necessary, and plan together. They also have to coordinate efforts, especially in emergencies, both among themselves and with other sectors of the community and the state. This is one reason for assembling a diverse MAPP Committee – to get as many individuals and organizations in the community as possible moving in the same direction and communicating well with one another.
All too often, organizations with similar purposes see one another as rivals, rather than partners. They may feel they’re competing for a limited amount of funding or other resources, and want to defend “their” territory. These turf battles serve no one well, and deprive the community of services and ideas. By bringing together all the players, MAPP tries to replace competition and mutual distrust with partnership, shared purpose, and collaborative effort.
- Dialogue. Dialogue isn’t one party speaking in a vacuum: it’s everyone speaking in turn, and everyone listening and reacting respectfully to everyone else. When individuals and organizations can voice their hopes and concerns, discuss their disagreements, and come to compromise or common ground, it leads to the resolution of differences and real problem-solving. It’s fundamental to the establishment of trust and collaboration.
- Systems thinking. Systems thinking looks at the larger structures within which most events and processes operate. One way to explain it is to describe three ways of looking at the world – three ways of thinking.
- The first we can call Type E, for Events. Here, we take each event as it happens and act on it. We don’t necessarily link events together. Think of a hospital emergency room, where a lot of people come in with similar complaints. A Type E reaction would be to treat each person for her symptoms, but not to notice that the complaints are similar.
- The second type of thinking is Level P, for Patterns. Here, we see the connections that link events together. The doctors and nurses in that hospital emergency room, if they’re thinking at Level P, would notice the similarity of a large number of cases, and react by ordering large amounts of the appropriate medication, brushing up on the necessary procedures, alerting the hospital staff and/or the public health system, etc.
- The third level we’ll call Level S, for Structure. At this level, we examine the structure of the systems that an event or pattern is part of. We try to understand the causes of the patterns we see, and to understand the structure into which they fit. If we can see the structure clearly, we can understand how to intervene to eliminate problems or to bring about positive change. If the emergency room symptoms we’ve been talking about were those of a specific disease, for example, an epidemiologist, operating at Level S, might try to put the patterns together to find out what was causing it, and whether an intervention in a particular geographic area or among a particular group of people might stop the outbreak and keep it from happening again.
(Thanks to Deb Reidy of Reidy Associates of Holyoke, MA, for this picture of systems thinking.)
Only if you intervene at the structural level are you likely to solve a community problem permanently. The key is usually to find one or more “leverage points,” places where you can apply pressure to the system to change it – and thus the situation or policy you’re concerned with – in the desired way. What you choose to do and how you choose to do it require strategic thinking, another of the underlying principles of MAPP.
- Strategic thinking. A strategy is a plan for action. When you’re engaged in strategic thinking, you’re not simply reacting to a situation, but planning how to control it to gain the outcome you want. That means setting goals, analyzing the situation, and setting a course of action that’s likely not only to allow you to reach your goals, but to put you in a position to continue moving forward when you do.
- Strategic thinking gives you the freedom to be proactive – to choose the future you want and work toward it – rather than simply reacting to what happens and hoping that things will go in the right direction. Systems thinking informs strategic thinking, providing the understanding of the systems that bear on the situation so that you can determine the strategy most likely to change things in the direction of a healthier community.
- Data. The MAPP process specifically relies on accurate information rather than speculation or rumor. Only if you start with real data and a clear understanding of the needs and wishes of community members will you be able to draw conclusions and devise strategies that speak to the reality of conditions in the community.
Gathering reliable data is an extremely important part of the MAPP process. That’s the reason for including four separate assessments of the community and its systems. The better and more nearly complete the information you have, the more likely you are to develop strategies and action plans that work.
- Celebration of successes. In order to maintain enthusiasm for the effort and to draw attention – for those involved and for the community as a whole – to its achievements, it’s important to mark those achievements. Celebration of successes – whether in the form of publicity or of gatherings of participants to share food and satisfaction, or both – is an important element in sustaining momentum for change.
Keep these principles in mind and think about how to apply them in each phase as we walk through the MAPP model. We’ll go phase by phase, explaining how to proceed in each, and discussing how each phase can be adapted for initiatives that focus on areas other than health.
Phase 1: Organize for Success/Partnership Development
This phase, while it doesn’t directly address issues, lays the foundation for the whole effort. It’s the phase in which the MAPP Committee and other participants are recruited and the planning process designed. Phase 1 establishes the participatory nature of the effort, and builds community participation and support. Both a well-thought-out planning process and broad-based participation are vital factors in creating and implementing an effective action plan.
The assumption of NACCHO is that the initial push for MAPP will come from a local or state public health agency. The process is driven, however, by the MAPP Committee, which is representative of multiple sectors of the community and of community members from a wide variety of backgrounds. The convening agency won’t control the process, but will rather serve as (or provide) the Core Support Team, which will lend support and technical assistance to the committee and other involved community members and organizations throughout the process. It is the Core Support Team that will conduct the initial recruitment of the MAPP Committee and community participants.
The steps to complete Phase 1 include:
- Determine the necessity of undertaking the MAPP process. Does the community really need this process? Is there already a similar initiative under way? What can MAPP accomplish, and what are the potential barriers to the process and its goals? Are there other less comprehensive or differently-focused initiatives that could link to MAPP? Make sure that MAPP can bring real benefits to the community: don’t embark on it simply because it seems like a good process and a good idea.
- Identify and organize participants. This step requires familiarity with the community – its history, relationships among its groups and key individuals, its economics, its politics, its diversity. Members of the Core Support Team, who may or may not have that familiarity, should be sure to consult with a variety of community informants about who the key participants are, about the groups and individuals who need to be included on the committee, and about the individuals and organizations whose support is crucial to the success of the effort.
The more recruitment that can be done by community members themselves, the better, but all elements of the community should be represented, not just “community leaders” or the friends and associates of specific informants. Community leaders and influential people should be part of the process – they bring legitimacy, and they often carry their own base of support as well. It’s equally important, however, to include also those whose voices often aren’t heard: people with low-income; racial, ethnic, or cultural minorities; people with disabilities; youth; people who don’t speak the majority language. A process whose aim is change needs broad-based participation to ensure success.
- Design the planning process. This, after organizing itself – choosing a facilitator or chair, establishing ground rules, etc. – will be the first task of the MAPP Committee. They’ll design the process through which the planning for action will take place. How to design a planning process can be explained by detailing the questions that the process needs to answer:
- Who, if anyone, else needs to be involved? Are all sectors of the community and a broad range of backgrounds and points of view represented?
- What will the planning process entail? What needs to be planned out, and in how much detail?
- How long will it take? How much time do you expect to allot for each stage of the planning before you get to implementation? How long do you have? Should you set formal deadlines or simply aim informally to be done by a specific date?
Some hints: Look at the upcoming phases. You’ll have to plan how you’ll conduct the visioning process and the four assessments – data gathering and analysis, how you’ll use the data to identify strategic issues, and how you’ll set goals and strategies to address those issues (your action plan.)
Time can be a major concern here. There’s never enough time to plan properly, but if planning goes on too long, the community (and many participants as well) can lose interest and abandon the effort. You’ll have to strike a balance that allows enough time to do reasonable planning, but doesn’t bog the planning group down in endless circular arguments or nitpicking. At some point, you have to declare, “We have a serviceable plan – it’s time to move to the next phase.”
It’s important to remember that the MAPP process is designed to be ongoing. Mistakes you make the first time around can be corrected in the next. The important thing is to get the community involved and the process functioning. Your plan should be as good as you can make it, but it doesn’t have to be perfect.
- What will the results be? What will a finished plan look like, and how will you know when it’s done? This relates back to what the plan entails. If you know at the beginning what you want to cover, it should be obvious when you’ve completed all the planning. Set clear goals at the beginning, and you’ve arrived when those goals have been met.
- Who will perform each task? This is always a crucial question. It’s important to make sure that everyone carries out the responsibilities he takes on, and that those responsibilities fall within his abilities and interests. You don’t want to ask someone who hates reading to do library or Internet research, for example, or to assign someone with no social skills to do personal interviews. Assembling teams to work on various aspects of the planning can both speed up the process and help to keep everyone accountable and interested.
An important note about evaluation.
Planning for evaluation should come here, at the beginning of the process. The process itself needs to be evaluated, and that can only be done well if information gathering starts at the very beginning, and if the MAPP planners have a reasonably clear idea of what information is needed and why. Therefore, now is when the thinking about the form, goals, and methods of the evaluation should take place.
Evaluation should be conducted throughout the MAPP process, from the beginning of planning to the end of the action phase, so that appropriate adjustments can be made to aid the success of the effort. Then, as the effort goes on, evaluation should be ongoing, so that both new interventions and activities and repetitions of those already established can be as effective as possible.
- Determine the resources you’ll need for the planning process. Money (for travel, materials and supplies, printing, etc.), space, people with and without specific skills (volunteers or hired), transportation, child care – any or all of these might be necessary. Most or all may be available from members of the MAPP partnership, or may not. In either case, it’s important to know where you’ll get what you need before you start.
In some communities, you’ll need virtually nothing that isn’t readily available. Meeting space, reliable volunteers with a wide array of skills, clerical support, printing, Internet access, and supplies may all come from member organizations without any discussion, or may simply be available in the community. In other communities, you may have to approach public and private funders for money, negotiate with businesses organizations, or institutions for donations of space and/or materials and supplies, and hire some people with expertise in specific areas. Whatever your circumstances, you should try to secure commitments at least for the most important elements of the planning process before you embark on it.
- Make sure the community is ready to conduct a successful planning process. The MAPP process requires partnership and collaboration, a view of health (or any other issue) that takes a community perspective, and community participation and support. Support from community leadership and a champion of the process – a mayor, a well-known and trusted citizen, the leader of a well-regarded institution or organization – is crucial for the effort’s success. Different communities are at different stages of readiness for these elements, depending on how much their members know and care about the issue at hand, how well individuals and organizations already know, trust, and collaborate with one another, and a number of other factors.
- Develop a management structure for the process. There are three important things to do here:
- Agree on any guiding assumptions for the process. Some possibilities might be ground rules for discussion, inclusion of the viewpoints of all groups in the community, the necessity of changing the current system, etc.
- Put together a workplan that lays out what has to be done to complete the planning process, the order in which elements of the process should follow on one another, who’s responsible for each piece, and a timeline specifying when each should be completed.
- Designate one person or small group to act as coordinator, so that someone’s keeping track of overall progress and can intervene if there seems to be a snag anywhere. The coordinator may be the only party that sees the process as a whole, and her or their ability to catch and troubleshoot problems is crucial to keeping everything flowing smoothly.
Phase 2: Visioning
There are two main reasons for creating a vision for the community’s future. Most obviously, it puts forth an ideal to strive toward, endowing the MAPP effort with purpose. Equally important, the vision results from an inclusive and collaborative process in which the voices of all sectors and groups are heard. This process can unite the community and make clear the hopes and goals that all community members have in common.
By taking into account everyone’s ideas, such a process is more likely to result in a vision that accurately reflects the hopes and aspirations of the whole community.
Steps to completing the visioning phase:
- Identify other visioning efforts and make connections as needed. If other groups in the community have been or are engaged in a visioning process, it would be of benefit to both if you could link to them. If the other group’s visioning process relates to the community as a whole, you might be able to reconcile it with yours, so that there’s a consistent vision across sectors. If it relates to a specific area, it could perhaps incorporate yours and vice-versa. In the ideal, you could develop a joint vision that looked at all concerns from a community or healthy community perspective.
- Design the visioning process and decide how it will be managed. The MAPP website suggests that a small group work with whoever is chosen as facilitator to design the process.
A visioning process almost always needs an expert facilitator in order to help the visioning group work through conflict and identify the common aspirations and values that should be included in the final statement. Especially for a large group, you may have to hire a trained facilitator from outside the community, one that will be perceived as neutral and objective. That will short-circuit any old rivalries or mistrust that would lead individuals or groups to feel that there was prejudice at work.
In order to reap all its benefits, the visioning process has to be truly participatory. The MAPP website suggests two possibilities:
- Community visioning involves a large number of people – perhaps 40 to 100 – representing all elements of the community. Its advantages are that it includes all voices and can mobilize the community as a whole in support of the MAPP process and of the vision produced. Its disadvantages are that it can be difficult to manage, may take a long time, and could be costly, since it may require paying for a skilled facilitator, mailing and printing expenses, and a variety of large and small spaces for necessary meetings.
- Advisory committee/key leadership visioning involves only members of the MAPP Committee and other community leaders. This type of process, involving only perhaps 10-20 people, is much easier to manage and may be possible without an expert facilitator, but lacks the broad community involvement that is so important to the visioning process.
While the first of these is ideal, the process you choose will depend on the circumstances of your community and the resources you have available.
- Conduct the visioning process. There are various ways to do this, but starting by brainstorming is probably the most common approach. What do you want the community to look like (either in general or in terms of a particular issue, such as health)? Getting a number of answers to that question from a broad range of community members will start to reveal patterns of agreement, and ultimately lead to a vision statement that encapsulates the hopes of the community.
After a vision has been agreed upon, the group should agree as well on shared values that act as the guiding principles for the vision. As with the vision, these can vary greatly from community to community.
The visioning process can be more complex and take longer: in fact, it’s likely to if you’re engaged in community visioning. Although a large group will probably split into several smaller ones to do the actual work, the need for everyone to be heard and the task of combining a number of different versions of a vision into a single statement may require several meetings and a good bit of time.
Some hints from the MAPP website:
Sample questions for brainstorming a shared vision:
- What does a healthy [Name] County mean to you?
- What are the important characteristics of a healthy community for all who live, work, and play here?
- How do you envision the local public health system in the next five or 10 years?
Sample questions for brainstorming common values:
- Taking into consideration the vision that has been developed, what key behaviors will be required from the local public health system partners, the community, and others in the next five to 10 years to realize the vision?
- What type of working environment or climate will be necessary to support these behaviors and achieve the vision?
- Formulate vision and values statements. This can be the hardest part of the visioning process.
A vision statement should be short – one sentence is best, but certainly no more than a paragraph – powerful, couched in language that everyone in the community can understand, and describe where you want the community to go. An example might be “A community where all residents have the opportunity and the means to live a physically, economically, and socially healthy and satisfying life in a healthy environment.”
A values statement lays out the shared values that underlie the vision statement and the MAPP process. It can be longer than the vision statement, but should also be in language that’s understandable, and should emphasize positive values that contribute to the realization of the vision. Examples might include collaboration and respect for others regardless of differences.
- Keep the vision and values alive throughout the MAPP process. Because the vision should drive the process, it’s important to keep it at the forefront as you go through planning and implementing your action plan. The vision and values statements could be on your stationery or other printed materials, posted at the front of the room for any planning meeting, read aloud at meetings, etc.
While they should be familiar to everyone involved, it’s also important that they’re not seen as set in stone. They can be added to or changed as circumstances dictate, or refined as some aspects of them are accomplished and the vision broadens.
Phase 3: The Assessments
The MAPP process, because of its emphasis on data, includes an unusually detailed assessment phase. It looks at the community from four different angles:
- The Community Themes and Strengths Assessment identifies thoughts, opinions, and concerns that interest and engage the community, including insights about quality of life and community assets that can be used to improve health. Using whatever techniques are appropriate to the community – surveys, individual and/or group interviews, observation, focus groups, community forums, etc. – and made possible by available resources, the MAPP Committee finds out from community members what they care about and how they see the community, as well as what they perceive as the resources the community already possesses. (For health, those resources might include bike and walking trails, a good water supply, a hospital, clinics, accessibility for people with disabilities, many people trained as EMT’s, alternative medicine practitioners, affordable sports and workout facilities, etc.)
- The Local Public Health System Assessment (LPHSA) is completed using the National Public Health Performance Standards Program (NPHPSP) local instrument and looks at the state of the public health system as a system. It considers all the elements of that system and how they fit and function together, from home health aides to huge public hospitals to pharmacists to child psychologists. The LPHSA looks at the system through the lens of the Ten Essential Public Health Services mentioned earlier, and explores whether and how those services are being delivered. This not only provides an objective standard for examining the effectiveness of the system, but links the local system to the National Public Health Performance Standards Program.
The Ten Essential Public Health Services:
- Monitor health status to identify and solve community health problems. Regularly assess the community to identify and address health issues.
- Diagnose and investigate health problems and health hazards in the community. These actions also imply further action to solve problems and eliminate hazards.
- Inform, educate, and empower people about health issues. This may encompass anything from elementary school curricula to media campaigns to ensuring that all medical personnel have up-to-date and accurate information to communicate to the public.
- Mobilize community partnerships and action to identify and solve health problems. The health system should be proactive in forming partnerships, both internally and with other sectors, and in starting or joining community coalitions and initiatives such as MAPP.
- Develop policies and plans that support individual and community health efforts. Such policies and plans might include willingness to collaborate and share resources and ongoing advocacy for funding, support, and health-friendly policies.
- Enforce laws and regulations that protect health and ensure safety.
- Link people to needed personal health services and assure the provision of health care when otherwise unavailable. In addition to providing free or affordable health care to those without insurance or the means to obtain it, this service might also involve advocacy for (and participation in formulating) a universal health policy.
- Assure competent public and personal health care workforce. The competence of health care workers depends not only on their credentials and previous experience, but also on their ongoing training, self-education (e.g., reading medical journals and other research publications), and competent oversight and supervision aimed at the encouragement of questions and improvement of performance.
- Evaluate the effectiveness, accessibility, and quality of personal and population-based health services. Is it relatively easy, for instance, for everyone in the community to receive necessary medical services, regardless of their circumstances or ability to pay? How long are emergency room waiting times? What percentage of the population doesn’t have a primary health care provider? What percentage of children has received all necessary vaccinations by the beginning of kindergarten?
- Research for new insights and innovative solutions to health problems.
Assessing the state of the local public health system demands that we define that system, which requires systems thinking. We may think of a local public health system as being composed of certain obvious pieces:
- Government health departments and agencies at various levels.
- Hospitals, public and private.
- Private medical practices.
- Mental health services and providers, both public and private.
- Physical and occupational therapists.
- Alternative medical practices such as acupuncturists, massage therapists, and chiropractors.
- EMT’s and ambulance services.
- Pharmacies (and the pharmaceutical industry).
- Insurance companies.
- Organizations that represent the interests of service recipients
But there are many more elements to the system that we must consider also:
- Police and firefighters, who answer 911 medical and mental health emergency calls.
- Community and peer health educators and education programs.
- School nurses, counselors, coaches, and athletic trainers.
- School health teachers.
- Those who work with elders, children, people with disabilities, and other vulnerable populations: human service agencies, child care facilities, teachers, home care workers and home health aides.
- People trained in emergency first aid who may take immediate lifesaving action: lifeguards, YMCA and private gym employees, ski patrollers, camp counselors.
- People and organizations working to teach or promote healthy practices for individuals or groups: personal trainers, nutritionists, athletic clubs of various kinds, the YMCA, private gyms, bicycling associations, Weight Watchers and similar organizations, etc.
- Substance use education and treatment programs and facilities.
- Violence prevention programs, gang outreach, and similar efforts.
- Environmental programs designed to protect community health, focusing on clean air and water, on the establishment of healthy outdoor recreation opportunities, and on the use of clean and sustainable resources and methods. (See of this chapter Health Impact Assessment.)
The same kind of thinking is necessary to define and describe any community system. You have to consider all the factors that affect it, including some that may not be part of the community itself.
- The Community Health Status Assessment looks at community health and quality of life. What are the major health issues in the community? Are there diseases or conditions that are concerns, or occur at high rates? What is the general health status of the population? Are there ways in which the community or the population is particularly healthy, and how can you maintain and build on them? How does the community quality of life affect health?
The methods used here, again, would be whatever is appropriate to the community – interviews, observation, surveys, study of records, etc.
- The Forces of Change Assessment attempts to identify any current or anticipated factors – legislation, population shifts, technology, economic ups or downs – that directly or indirectly affect health and the health of the community. These may carry positive or negative possibilities (or both), but will bring changes in any case. By understanding and preparing for those changes, the community can act to ward off or reduce threats and take advantage of opportunities to protect and improve community health and the public health system.
Plan out how you’ll conduct the assessments, and in what order. All four assessments don’t need to take place at the same time, although there may be some overlap among them. (Parts of the Community Themes and Strengths and Community Health Status Assessments, for example, might be conducted at the same time, thus saving time and effort.) Think about which assessments, or which parts of which assessments, can inform others. (Community Themes and Strengths might give you some clues as to what to look for in Community Health Status or Forces of Change, for example.)
While the Forces of Change Assessment may be conducted in one brainstorming session and involve only the Committee and a few others chosen for their knowledge of the community and their expertise at anticipating change, others may take weeks or months. NACCHO suggests that the first three assessments each be run by a subcommittee whose members are chosen for the skills they can bring to that particular assessment. In some cases, members may belong to more than one subcommittee, which will encourage coordination among the assessments.
It is important that the assessments be linked to one another. Each can use the findings of the others to inform its own, and proper coordination will avoid duplicating efforts and overloading particularly good informants. It can also help to ensure cross-referrals of information and informants among the assessments.
It is also important to celebrate successes – both the completion of each assessment and the successes it reveals. This can create and maintain enthusiasm among participants in the effort, as well as keep the community informed of the work being conducted.
Phase 4: Strategic Issues
A community can be proactive by identifying the issues that will help it realize its vision. MAPP defines strategic issues as “those fundamental policy choices or critical challenges that must be addressed for a community to achieve its vision.” These are not specific public health issues, such as diabetes or heart disease, but issues that underlie a broad range of public health concerns. An example might be improving access to health information and health care by improving the relationship between the health care system and those who don’t trust it.
The MAPP process to this point has focused on developing a vision and gathering information. In this phase, you use the guiding vision and the information to determine which community issues are most important to helping make your vision a reality. While building on what’s gone before, this phase is really the choice point in deciding what your action plan will look like.
Strategic issues are informed by analyzing and integrating the results of all four assessments. Only by considering all the available information can you be sure to find issues that go beyond immediate problems or conditions and address the overall health of the community.
In order to identify the real strategic issues, you have to employ systems thinking. If you recall the discussion of systems thinking earlier in this part of the section, you’ll remember that it’s crucial to make changes at the structural level in order to address the real causes of community issues and resolve them permanently. When you’re searching for strategic issues – those issues that represent the leverage points we talked about earlier, points where you can apply pressure to change the system – you have to understand the structures within the community that affect the areas you want to change.
The MAPP website offers a five-step procedure for identifying strategic issues:
NACCHO recommends that Phase 4 involve the Core Support Team and the MAPP Committee. If the Committee is truly representative of the community, this may be fine, but it is also possible to recruit other community members to participate in this part of the process, in order both to generate as many ideas as possible, and to make sure that you include the voices of all stakeholders.
- Brainstorm potential strategic issues. This step should start with the MAPP vision. You have to know where you want to go before you figure out how to get there. Then attention should go to all four assessments, where patterns can emerge. What issues seem to surface in more than one (or, more tellingly, all) of the assessments? How do these patterns relate to your vision?
- Develop an understanding of why an issue is strategic. Will it directly affect an element of your vision? Does it represent a leverage point, a place in the system that can change how the system operates? Is it important in more than one way? Does it contain a number of other, smaller issues within it? Can you actually do something about it in a reasonable and cost-effective way? These are the kinds of questions that can help you understand why an issue is or is not strategic.
- Determine the consequences of not addressing the issue. Addressing a particular issue may be difficult, tying up scarce resources and requiring a lot of time and effort. The consequences of not addressing it might be much worse, however. If it’s a key to realizing your vision, or if not addressing it will maintain or make worse an already unacceptable situation, then you can’t afford not to address it.
- Consolidate overlapping or related issues. Once you’ve identified all the issues you feel are strategic, consider which ones are in fact similar, or address the same concerns. It’s likely you’ll find, if you’re using systems thinking, that the actual number of issues is much smaller than the number you’ve come up with. Finding connections and paring down the number of issues have two purposes:
- They leave you with a manageable number of issues to deal with. MAPP suggests choosing three to five strategic issues to address, and most communities, in practice, choose no more than five. It’s important to experience some success at the beginning, and that’s less apt to happen if expectations include solving a large number of problems. If this is the first collaborative effort for your community, even five may be too many.
- They identify the really important structures that need attention. If you want to resolve issues once and for all, you have to change the systems they’re part of. You can only do that if you correctly identify those systems, which consolidating will help you do.
- Arrange issues into an ordered list. Before you make your list, decide on a maximum number of issues to put on it. Then sort out from the list of all the issues you’ve identified those most likely to help you achieve your vision. (Remember that you don’t have to, and in fact shouldn’t, try to tackle all of them at once. One or two at a time usually makes more sense.)
Next, list the chosen issues in a logical order. You might want to construct this list in priority order, either by urgency, or by what needs to be done first so that the next issue on the list can be successfully addressed. Some issues may be controversial, for instance, and difficult to address until you’ve won trust and buy-in from the community by resolving something else first.
The list then becomes the beginnings of your action plan. It tells you what you need to address and when you need to do it in order to bring about community change.
Phase 5: Goals/Strategies
Once you’ve constructed your list of strategic issues, and know what you want to do, you have to decide how to do it. For each issue you’ve chosen, you should set one or more reasonable goals that reflect why you’ve chosen that issue in the first place. The question, then, is: What action can you take that will allow you or your group to reach your goal? In other words, what’s your strategy?
Let’s go through setting goals and developing strategies for achieving them step by step. In the last phase, we suggested that community members be recruited to work with the MAPP Committee. In this phase, it probably makes more sense for the committee to work alone. It’s generally both more efficient and more effective to develop strategy in a smaller group. You might make exceptions for a small number of people who have specific knowledge of the community or of at-risk populations that could inform the Committee’s choices of both goals and strategy.
The MAPP website suggests that the Committee break up into small groups for all but the last two steps of this phase. You might consider using that structure, but coming together at the end of each step so that the whole committee has a chance to react to the goals and strategies chosen. Step 5, selecting and adopting strategies, probably ought to be the work of the full committee. Then drafting the planning report might be delegated to a smaller group, again coming back to the full committee for tweaking.
- Develop goals related to the vision and strategic issues. Revisit your vision and strategic issues to remind yourself of what you want to accomplish. Then, taking the issues one by one, decide on the actual goal(s) that will help you resolve each one. It makes sense to generate goals for all of the issues, even if some won’t be tackled for quite a while, because that way you can develop an overall strategy that fits together. Achieving one goal may pave the way for another. That’s much easier to see if you plan out the whole strategy at once.
Let’s suppose that your vision encompasses excellent health and care for all children in the community. One of your strategic issues might be that many families with children don’t have access to the health information, health care, and healthy products and practices afforded by the local public health system. An overall goal, then, might be to increase that access.
Access, however, is much more than physical access to clinics or doctors’ offices. It includes community attitudes – both how those without access view the local public health system and how the system and the rest of the community view them. It extends to locations of businesses (Are there stores in every part of the community where healthy foods and products are available?), to public transportation routes, to government health care policies, to education, to law enforcement...the list could go on and on.
A goal, like this one, that encompasses many elements must be broken down into objectives – steps that lead to the achievement of the whole package. These objectives might be pursued at the same time, or one after another, depending on the capacity and resources of the community. Each objective needs a strategy that will lead to its realization.
- Generate strategy alternatives. When you have a list of goals, the next step is to design strategies for reaching them. Each goal may require more than one strategy, and strategies should, where possible, build on the assets you’ve identified, use the opportunities you’ve found, and respond to the threats that have presented themselves in the assessments. Small group brainstorming sessions, with each group taking on different goals may be a good way to split up tasks here.
Let’s look at access to the local public health system again as an illustration.
There are a number of reasons why a large number of families might be unwilling or unable to gain access to health information, health care, and healthy products and practices. Your assessments have probably given you the information to understand what at least some of them are. Here are four possibilities:
- Cost. Many families are uninsured, and even some of those with insurance may have difficulty with co-payments. If there are free or low-cost services, these families may be – or think they are – ineligible for them, or may simply not know they exist.
- Availability. There may not be enough services available to families with children in the community, or services may be inadequate or inappropriate (no pediatric services, for example). This could extend not only to medical care – clinics, medical practices, mental health centers – but to safe places to play and exercise, stores and restaurants offering healthy foods, and sources of information about nutrition, parenting, prenatal care, etc.
- Distrust of the health care system. Families may see the health care system as condescending or dictatorial, may have had bad experiences with it, or – if they lack legal status – worry that they’ll get in trouble with the law if they use it.
- Personal issues. Substance use, mental illness, domestic violence, or simple lack of experience and knowledge may keep some families away from some or all aspects of the local public health system.
Each of these reasons constitutes a threat to access to health information, care, and practices, and each needs a different strategy to counter it.
There may be an overriding strategy that spans all of these, and that may be used in carrying them out. One that comes to mind is recruiting and training community members as peer health educators that could work with both individual families and groups to spread information about the possibilities available in the rest of the local public health system, and about nutrition, parenting, healthy lifestyle, and similar topics.
- Cost might be addressed by legislative advocacy for funding for health care for uninsured families with children. In addition, or instead, it might entail obtaining grants in order to fund that care. It might also require negotiation with hospitals, clinics, and pediatricians about providing free and/or sliding-scale services.
- Lack of availability might also be addressed by legislative advocacy or fundraising, in this case for establishing local clinics or other treatment centers. If treatment centers are already available, there may be a need for more providers qualified to treat families with children – pediatricians, pediatric nurses, child psychologists, etc. The availability of other health-related facilities and products – e.g., safe play areas, stores offering healthy foods – may involve local advocacy, negotiation with local or larger store chains, agreements with police about neighborhood patrols, etc.
- Distrust of the health care system might be addressed by personal outreach and home visits by health workers or peer health educators fluent in whatever languages the families speak. If people are in fact being condescended or dictated to, that might be remedied by working with health care providers to help them change their approach to those they serve. Many families might be referred by people they trust – clergy, friends, leaders in their language communities, etc. Part of the strategy would involve spreading the word about services to these and other trusted key informants through community networking. The strongest strategy here might be to recruit parents that don’t have, or don’t feel they have – access to the local health system to help with MAPP planning, or with planning specific activities or projects, thus affording them with a sense of investment in the system.
- Personal problems. Here, connections with substance use treatment programs and counselors, mental health workers, the court system, homeless and women’s shelters, might bring (or force, in the cases of the courts and treatment centers) families into the health care system. An outreach program similar to that described just above might also be necessary here, especially for those who are homeless. Once again, peer health educators could prove valuable here.
- Consider barriers to implementation. Here, the small groups examine each potential strategy to identify factors that would make it difficult to implement. A short list of potential barriers would include lack of resources (funds, people, and time); official policies that work against the thrust of the strategy; logistical or technological difficulties; poor communication, particularly where there are many language groups involved; lack of trust; internal conflict within health or other systems; and lack of community support. None of these should necessarily eliminate a strategy, but it’s important to understand what barriers must be overcome to carry it out, and to determine whether you have the capacity to do so.
- Consider implementation details. Next, the small groups flesh out how each strategy will be implemented. This includes establishing timelines, assigning responsibility, identifying sources of funding and other resources, specifying participants and deciding how to recruit them, etc. Refining implementation details, along with examining barriers, should help to clarify which strategies are both feasible and likely to succeed.
Don’t undertake this step without bringing in whoever is likely to actually do the work, if they’re not involved already. Not only should they have a voice in decisions about what they might do, but they are also apt to know what’s feasible.
- Select and adopt strategies. By this point, both the feasibility and the probable effectiveness of various strategies should have become clear. These are obvious criteria for selecting strategies to implement. Another is how well the strategies fit into an overall strategy. Do the strategies work together to help realize your vision? Do they form a coherent overall strategy that you can employ over the long term to create real and lasting change?
- Draft the planning report. An individual or small group should put together the results of the planning in a form that serves as both a road map for the work ahead and a document that can inform the community about the process. It should communicate the vision, goals, and strategies of the MAPP process to partners and the community. Once the Committee has reviewed and adjusted it, if necessary, it should be formally adopted as the MAPP plan for action, and circulated as much as possible to all sectors of the community.
Once the planning phase is completed, there should be a celebration that serves, as before, both to energize participants and create interest and support in the community. It will let everyone know that the action phase of the initiative is beginning, while at the same time celebrating the collaboration that made it possible and the work that went into the plan that’s about to be implemented.
Phase 6: Action Cycle
This final phase is where you apply all the planning and organization you’ve done. It comprises nine steps, divided into three stages: planning, implementation, and evaluation.
A. First stage: Planning for action
- Organize for action. A subcommittee, which includes those who will be involved in the implementation of the action plan, should oversee the action cycle. It will be responsible for coordinating the process and trying to ensure that it goes smoothly – that things happen when they’re supposed to, that all participants fulfill their responsibilities, and that everything is carried out according to plan.
- Develop objectives and establish accountability. Objectives are the very specific accomplishments that lead to the overall achievement of goals. Every goal should have one or more objectives that, if met, are indicators of a process that operated as it should have.
If we look at the goal and strategies we discussed earlier, the idea of objectives becomes clear. The overall goal was to increase access to the local public health system for families with children. One strategy was to train members of the community as peer health educators. Some objectives for this strategy might be:
- To contact, within the first three months, at least 150 families, and to recruit 25 parents from the community of concern to be trained as peer health educators
- To conduct a 30-hour, five-week peer health educator training followed by a two-week practicum, to be completed by the sixth month of the effort. Child care will be offered to participants in the training, and those who complete it will receive a stipend.
- To graduate 18 peer health educators, who will then go on to work in the community.
- To provide one hour of weekly group supervision to peer health educators.
- Each peer health educator will make at least three visits a week to families with children, starting within two weeks after they complete their training. The purpose of these visits will be to check health status, make appropriate referrals and suggestions, answer questions (or refer the family to someone who can), etc. Each visit will also include a report on the family’s health status, changes since the last visit, etc.
- Peer health educators will conduct, with technical assistance and other help from the MAPP Committee, one workshop a month on a topic of interest and concern to families with children. Examples might include nutrition, substance use, safe sex, discipline, etc.
(There are many other objectives that might be relevant here – the number of referrals made to which elements of the local public health system, the number of hours spent by peer health educators, the number of hours of child care to be provided, the frequency with which families are to be visited, and more. For purposes of space, we’ll limit objectives to what we’ve listed above.)
One way to develop objectives is to use the SMART-C set of criteria. Good objectives have these qualities.
- They are Specific. That is, they tell how much (e.g., 40%) of what is to be achieved (e.g., what behavior of whom or what outcome) by when (e.g., by 2010). In our example, we set out the number of trained peer health educators and the number of visits and workshops we aim to reach.
- They are Measurable. Information concerning the objective can be collected, detected, or obtained from records (at least potentially). The numbers we’re expecting can be compared to the actual number of trained people and the number of visits and workshops the health workers engage in.
- They are Achievable. Not only are the objectives themselves possible, it is likely that your organization will be able to pull them off. These numbers shouldn’t be unreasonable, given the size of the population in question, the time involved, the number of workers we expect to have on the job, and our knowledge of and contacts in the community.
- They are Relevant to the mission. Your organization has a clear understanding of how these objectives fit in with the overall vision and mission of the group. The objectives are clearly related to the achievement of our goal and strategy, which are in turn related to the overall strategy for realizing our vision.
- They are Timed. Your organization has developed a timeline (a portion of which is made clear in the objectives) by which they will be achieved. We specify the timeline for each of the objectives given, and that timeline should fit with an overall timeline for the implementation of the whole process. (Other goals may not be addressed until much later – even years later – but we should know that now.)
- They are Challenging. They stretch the group to set its aims on significant improvements that are important to members of the community.
Establishing accountability means determining who will be responsible for each objective, and creating clear lines between those responsible and the carrying out of the actions they’re responsible for. (That’s not always the same as whether those actions are successful. You can do everything exactly as you planned it and still get little or no result, either because your plans were flawed, or because of unforeseen or unusual circumstances.)
If there are clear lines of accountability, you can trace and correct whatever goes wrong, and make sure it doesn’t happen again. You can also determine who did a terrific job, and give her more responsibility, or ask her to take on a leadership role.
- Develop action plans. Your objectives now have to be turned into specific plans for accomplishing them. That means not only how you’ll do what you’ve planned, but also how you’ll conduct whatever hiring, training, fundraising, or other preparation is needed to put those plans into action.
Depending on the goals and strategies involved, some of these plans may be carried out by one organization, others by another, and still others by a collaboration among several.
To look again at our example, let’s consider exactly how you could accomplish the objectives we set out.
We’ll need resources: People, space, perhaps money (for stipends and/or pay for peer health educators, trainers, supervisors). Many of these resources may be available through shared resources among organizations represented on or connected to the MAPP Committee. Others may involve applying for grants or obtaining contracts to provide services.
In order to contact 150 families, we first have to find them – they are, after all, those that aren’t expected to have contact with the health system. We’ll have to use community networks – families who are taking advantage of the health system, clergy, human service organizations, social workers, street workers, community activists, homeless and women’s shelters, etc. The Committee may want to reach out to more partners – organizations or individuals that have contact with these families – in order to reach as many of them as possible.
To deliver training, you’ll need trainers – people who have both the outreach skills and know ledge to help trainees gain the competence they need. Those people may be available through the organizations and institutions represented on the Committee, or you may have to bring in more partners in order to find them. Child care slots with providers represented on or through the Committee might also be available.
In addition to skills and knowledge, peer health educators will need a structure within which to operate. They have to know when and how to refer people to other elements of the local public health system, whether and how to follow up, etc. There should be policies and procedures that cover what these workers are expected to do. If they have transportation, should they drive people to appointments, for instance? Anticipating this sort of issue and having clear guidelines beforehand will make the workers’ jobs much easier.
Finally, peer health educators should know what records and documentation they need to keep, how they get paid (if they get paid – they may be volunteers, depending on how the program is set up), what they can and can’t do without conferring with a supervisor, etc. The clearer the guidelines are, the better the job peer health educators are likely to do, and the more likely the effort is to meet its objectives.
Second Stage: Implementation
- Review action plans for opportunities for coordination. As you make and look at your action plans, try to identify actions or situations where organizations might combine operations, or where more than one objective can be addressed by a single action. Look for places where duplication of service can be avoided, so that you can maximize the impact of scarce resources. Use the existing community assets you’ve identified in the assessments to the fullest extent possible.
- Implement and monitor action plans. This stage is where everything finally comes together, and strategies and action plans are put into practice in the real world. Monitoring implementation means keeping careful documentation of what goes on – the process of implementation as well as its results – so that you’ll have a clear record of what happened to use in constructing your evaluation.
Your action plan should give you a step-by-step outline of what to do and when to do it for each strategy. Following that outline should bring success if your plan was realistic, and if you were right about what you needed to do. If you don’t follow your action plan, then it’s much harder to determine where the problem might be if you don’t achieve what you intended.
There’s no guarantee that you didn’t miss something, even with a high level of participation in the planning and careful thought. That’s another reason for monitoring: if you know, from monitoring, that you did everything according to plan, but didn’t get the results you hoped for, then the fault was not with the implementation. It must be either with the plan itself or with your basic assumptions about what would work. That information gives you a basis for understanding what actually happened and for making appropriate adjustments.
The MAPP website suggests that each MAPP participant – members of the Committee and others involved in the planning process – should be involved in implementing at least one strategy. “Involved” here can mean one of several things. To name a few:
- A participant might be directly involved as a staff member or director of an organization implementing one or more strategies.
- He might monitor a strategy being implemented by an organization or collaboration to which he has no ties.
- He might be part of an organization that provides support for or coordinates with another that is implementing a strategy.
- He might be an evaluator for one or more organizations implementing strategies.
- He might be engaged in advocacy, either as the direct implementation of a strategy or to make a particular strategy possible.
How easy it would be to get everyone directly involved depends to a large extent on the number of strategies being implemented, the timeline, and the actual nature of the strategies.
It would be helpful at this stage to include in the process any other individuals or organizations who can be helpful, either in moving the implementation phase forward, or in garnering community awareness and support. The more sectors – and people – in the community are involved, the more likely it will be that plans will be implemented effectively.
Third Stage: Evaluation
While each strategy should be evaluated individually, there needs also to be an evaluation of both the overall implementation and the outcomes of the MAPP process as a whole. Evaluation may be the third stage discussed, but that doesn’t mean that it’s necessarily the last stage of this phase to be attended to.
As we explain throughout the Tool Box chapters on the subject, evaluation has to be planned and conducted at the same time as the initiative itself. If you intend to evaluate the MAPP process, then that process must be monitored from the very beginning, and evaluation should start when the process does. The questions you’ll want to answer about both the individual strategies and the entire process require a record of what actually happened:
- What did we actually do?
- Were we able to conduct the process or strategy implementation as we planned, and within our intended time frame? If not, why not? What happened instead, and why?
- Should we have included sectors, organizations, or individuals we missed, or excluded some we included?
- Was there enough participation? Did participants assume and carry out responsibilities?
- Was the implementation carried out as we intended (methods, personnel, timeline)? If not, why not?
- What were the results of each strategy? Was it successful? If not, why not? How did results compare to those of other strategies tried in similar circumstances or communities?
- What were the results of the overall MAPP process, both short-term (improved and/or extended service to a particular population, for instance) and long-term (restructuring of partnerships among organizations and sectors, restructuring of health or other community systems, changes in the way public health – or another area – is viewed by both its practitioners and the community)?
- What went well? What needs to be maintained and strengthened?
- What were the challenges and barriers (how good were our predictions)? What needs to be added, changed, or eliminated?
Given these and other questions that should be addressed in the evaluation, the evaluation process must start at the same time as the MAPP process itself, and continue throughout.
- Prepare for evaluation. Monitoring with an eye toward evaluation should begin at the beginning of the MAPP process. Notes of all meetings, documentation of the progress of the process itself, the names and connections of participants and of the Committee, those who take leadership roles, the results of the assessments – all of these will eventually become raw material for the evaluation. The evaluation plan – what you’re going to evaluate and how – should begin as soon as planning begins for the MAPP process, because the process itself is part of what will be evaluated.
Part of evaluation planning is deciding who should be involved. This decision often may revolve around whether the evaluation will be conducted by an objective individual or group from outside the community – possibly a firm or someone from academia, who may or may not be paid – or by a participatory group from among the Committee and other stakeholders. MAPP clearly favors a participatory process, in keeping with the participatory aspect of the MAPP process as a whole.
- Focus the evaluation design. The design for the evaluation of the overall MAPP process should be developed, as we’ve explained, at the beginning of that process. What needs to be done here is to design evaluations for each strategy/action plan. This involves (as it does for the overall evaluation) choosing the questions to be answered by the evaluation, deciding what information is needed to answer those questions, how and from whom it should be gathered, how these activities will be carried out, and how the information will be reported and used.
- Gather credible evidence and justify conclusions. Here, the evaluation team collects and analyzes the data to answer evaluation questions. Again, this step is ongoing from the beginning of the process or activity that is being evaluated. This may mean that evaluation continues over a period of years – as long as the MAPP process or any single strategy continues.
Since the MAPP process is meant to continue as an ongoing cycle, evaluation should be an integral part of any of its activities, because – even when the activity is extremely successful – conditions can change in the community or in an organization, and there may be need for rethinking. Evaluation can show this, and make it possible to adjust before you find yourself failing at something you thought you were good at.
The same is true for the partnerships and participation generated by the MAPP process. Partnerships, community participation, coalitions, collaboration – all of these need nurturing if they’re to last. You can’t build a house and assume that all its systems will continue to operate perfectly without maintenance. The same is true of any systems you’ve changed or created in your community – they need maintenance for as long as they exist, and ongoing evaluation is an important part of that maintenance.
- Share lessons learned and celebrate successes. As the MAPP process continues, and you get feedback from your evaluation, be sure to share the results with all partners and participants and with the community at large. Let people know what you’ve found out, so that the effective strategies can be repeated, and the unsuccessful ones won’t be. Celebrate your successes with media stories, parties, press conferences – whatever makes sense in your community. Nurture participants’ enthusiasm for the next stage of the process, and let the community know that things are better because the MAPP process took place.
- Keep at it indefinitely. MAPP is designed as an ongoing process that is meant to continue indefinitely. The ongoing refrain of the Community Tool Box, therefore, applies here as it does elsewhere. You have to keep at it to sustain your partnership, maintain positive changes, face the new challenges that will certainly arise, deal with shifts in community circumstances and needs, and develop more community assets. No community is ever perfectly healthy, nor is any community system ever perfect. And as long as that’s the case, you should be on the job.
MAPP (Mobilizing for Action through Planning and Participation) is a model for developing a healthy community. While it focuses on improving the local public health system, its community perspective both addresses the community as a whole, and makes it flexible enough to be used with any community system. Its basic philosophy – broad community participation in planning and implementation of the initiative – and structure – visioning, community assessment, issue identification, strategic planning and goal setting, implementation and evaluation – are similar to those of other models in this chapter. It is distinguished, however, by the thoroughness of its Assessment Phase, which includes four different assessments (community themes and strengths as identified by community members, the state of the local public health system, the state of the community’s health status, and real or potential forces of change) and by its use of systems thinking to analyze these assessments, identify key issues, and develop strategies for addressing them.
The MAPP process is aimed at real and lasting change in the local public health system and the community. Its emphasis on partnership and broad-based participation, if properly realized, can permanently alter for the better the ways in which individuals and organizations relate to one another and the extent to which the community can control and improve its own health and quality of life.
Achieving Healthier Communities through MAPP: A User’s Handbook by the National Association of County & City Health Officials.
Atlantic County Community Health Improvement Plan. This information may also be useful outside of Atlantic County, New Jersey.
The MAPP section of the website of NACCHO, the National Association of County and City Health Officials, co-developer with the U.S. Centers for Disease Control and Prevention, of the MAPP model. The website includes numerous tools for communities engaged in MAPP, many of them specific to individual MAPP phases and activities. Among these tools are illustrated guides that can be used to provide information to the community and participants in the process.
A Strategic Approach to Community Health Improvement is an especially good field guide.