Chapter 2. Other Models for Promoting Community Health and Development | Community Tool Box

What is a logic model?

A logic model presents a picture of how your effort or initiative is supposed to work. It explains why your strategy is a good solution to the problem at hand. Effective logic models make an explicit, often visual, statement of the activities that will bring about change and the results you expect to see for the community and its people. A logic model keeps participants in the effort moving in the same direction by providing a common language and point of reference.

More than an observer's tool, logic models become part of the work itself. They energize and rally support for an initiative by declaring precisely what you're trying to accomplish and how.

In this section, the term logic model is used as a generic label for the many ways of displaying how change unfolds.

Some other names include:

• road map, conceptual map, or pathways map
• mental model
• blueprint for change
• framework for action or program framework
• program theory or program hypothesis
• theoretical underpinning or rationale
• causal chain or chain of causation
• theory of change or model of change

Each mapping or modeling technique uses a slightly different approach, but they all rest on a foundation of logic - specifically, the logic of how change happens. By whatever name you call it, a logic model supports the work of health promotion and community development by charting the course of community transformation as it evolves.

A word about logic

The word "logic" has many definitions. As a branch of philosophy, scholars devote entire careers to its practice. As a structured method of reasoning, mathematicians depend on it for proofs. In the world of machines, the only language a computer understands is the logic of its programmer.

There is, however, another meaning that lies closer to heart of community change: the logic of how things work. Consider, for example, the logic to the motion of rush-hour traffic. No one plans it. No one controls it. Yet, through experience and awareness of recurrent patterns, we comprehend it, and, in many cases, can successfully avoid its problems (by carpooling, taking alternative routes, etc.).

Logic in this sense refers to "the relationship between elements and between an element and the whole." All of us have a great capacity to see patterns in complex phenomena. We see systems at work and find within them an inner logic, a set of rules or relationships that govern behavior. Working alone, we can usually discern the logic of a simple system. And by working in teams, persistently over time if necessary, there is hardly any system past or present whose logic we can't decipher.

On the flip side, we can also project logic into the future. With an understanding of context and knowledge about cause and effect, we can construct logical theories of change, hypotheses about how things will unfold either on their own or under the influence of planned interventions. Like all predictions, these hypotheses are only as good as their underlying logic. Magical assumptions, poor reasoning, and fuzzy thinking increase the chances that despite our efforts, the future will turn out differently than we expect or hope. On the other hand, some events that seem unexpected to the uninitiated will not be a surprise to long-time residents and careful observers.

The challenge for a logic modeler is to find and accurately represent the wisdom of those who know best how community change happens.

The logic in logic modeling

Like a road map, a logic model shows the route traveled (or steps taken) to reach a certain destination. A detailed model indicates precisely how each activity will lead to desired changes. Alternatively, a broader plan sketches out the chosen routes and how far you will go. This road map aspect of a logic model reveals what causes what, and in what order. At various points on the map, you may need to stop and review your progress and make any necessary adjustments.

A logic model also expresses the thinking behind an initiative's plan. It explains why the program ought to work, why it can succeed where other attempts have failed. This is the "program theory" or "rationale" aspect of a logic model. By defining the problem or opportunity and showing how intervention activities will respond to it, a logic model makes the program planners' assumptions explicit.

The form that a logic model takes is flexible and does not have to be linear (unless your program's logic is itself linear). Flow charts, maps, or tables are the most common formats. It is also possible to use a network, concept map, or web to describe the relationships among more complex program components. Models can even be built around cultural symbols that describe transformation, such as the Indigenous medicine wheel, if the stakeholders feel it is appropriate.

See the "Generic Model for Disease/Injury Control and Prevention" in the Examples section for an illustration of how the same information can be presented in a linear or nonlinear format.

Whatever form you choose, a logic model ought to provide direction and clarity by presenting the big picture of change along with certain important details. Let's illustrate the typical components of a logic model, using as an example a mentoring program in a community where the high-school dropout rate is very high. We'll call this program "On Track."

• Purpose, or mission. What motivates the need for change? This can also be expressed as the problems or opportunities that the program is addressing. (For On Track, the community focused advocates on the mission of enhancing healthy youth development to improve the high-school dropout rate.)
• Context, or conditions. What is the climate in which change will take place? (How will new policies and programs for On Track be aligned with existing ones? What trends compete with the effort to engage youth in positive activities? What is the political and economic climate for investing in youth development?)
• Inputs, or resources or infrastructure. What raw materials will be used to conduct the effort or initiative? (In On Track, these materials are coordinator and volunteers in the mentoring program, agreements with participating school districts, and the endorsement of parent groups and community agencies.) Inputs can also include constraints on the program, such as regulations or funding gaps, which are barriers to your objectives.
• Activities, or interventions. What will the initiative do with its resources to direct the course of change? (In our example, the program will train volunteer mentors and refer young people who might benefit from a mentor.) Your intervention, and thus your logic model, should be guided by a clear analysis of risk and protective factors.
• Outputs. What evidence is there that the activities were performed as planned? (Indicators might include the number of mentors trained and youth referred, and the frequency, type, duration, and intensity of mentoring contacts.)
• Effects, or results, consequences, outcomes, or impacts. What kinds of changes came about as a direct or indirect effect of the activities? (Two examples are bonding between adult mentors and youth and increased self-esteem among youth.)

Putting these elements together graphically gives the following basic structure for a logic model. The arrows between the boxes indicate that review and adjustment are an ongoing process - both in enacting the initiative and developing the model.

Using this generic model as a template, let's fill in the details with another example of a logic model, one that describes a community health effort to prevent tuberculosis.

Remember, although this example uses boxes and arrows, you and your partners in change can use any format or imagery that communicates more effectively with your stakeholders.

As mentioned earlier, the generic model for Disease/Injury Control and Prevention in Examples depicts the same relationship of activities and effects in a linear and a nonlinear format. The two formats helped communicate with different groups of stakeholders and made different points.

The linear model better guided discussions of cause and effect and how far down the chain of effects a particular program was successful. The circular model more effectively depicted the interdependence of the components to produce the intended effects.

When exploring the results of an intervention, remember that there can be long delays between actions and their effects. Also, certain system changes can trigger feedback loops, which further complicate and delay our ability to see all the effects. (A definition from the System Dynamics Society, might help here: "Feedback refers to the situation of X affecting Y and Y in turn affecting X perhaps through a chain of causes and effects. One cannot study the link between X and Y and, independently, the link between Y and X and predict how the system will behave. Only the study of the whole system as a feedback system will lead to correct results.")

For these reasons, logic models indicate when to expect certain changes. Many planners like to use the following three categories of effects (illustrated in the models above), although you may choose to have more or fewer depending on your situation.

• Short-term or immediate effects. (In the On Track example, this would be that young people who participate in mentoring improve their self-confidence and understand the importance of staying in school.)
• Mid-term or intermediate effects. (Mentored students improve their grades and remain in school.)
• Longer-term or ultimate effects. (High school graduation rates rise, thus giving graduates more employment opportunities, greater financial stability, and improved health status.)

Here are two important notes about constructing and refining logic models.

Outcome or Impact?

Clarify your language. In a collaborative project, it is wise to anticipate confusion over language. If you understand the basic elements of a logic model, any labels can be meaningful provided stakeholders agree to them. In the generic and TB models above, we called the effects short-, mid-, and long-term. It is also common to hear people talk about effects that are "upstream" or "proximal" (near to the activities) versus "downstream" or "distal" (distant from the activities). Because disciplines have their own jargon, stakeholders from two different fields might define the same word in different ways.

Some people are trained to call the earliest effects "outcomes" and the later ones "impacts." Other people are taught the reverse: "impacts" come first, followed by "outcomes." The idea of sequence is the same regardless of which terms you and your partners use. The main point is to clearly show connections between activities and effects over time, thus making explicit your initiative's assumptions about what kinds of change to expect and when. Try to define essential concepts at the design stage and then be consistent in your use of terms. The process of developing a logic model supports this important dialogue and will bring potential misunderstandings into the open.

For good or for ill?

Understand effects. While the starting point for logic modeling is to identify the effects that correspond to stated goals, your intended effect are not the only effects to watch for. Any intervention capable of changing problem behaviors or altering conditions in communities can also generate unintended effects. These are changes that no one plans and that might somehow make the problem worse.

Many times our efforts to solve a problem lead to surprising, counterintuitive results. There is always a risk that our "cure" could be worse than the "disease" if we're not careful. Part of the added value of logic modeling is that the process creates a forum for scrutinizing big leaps of faith, a way to searching for unintended effects. (See the discussion of simulation in "What makes a logic model effective" for some thoughts on how to do this in a disciplined manner.)

One of the greatest rewards for the extra effort is the ability to spot potential problems and redesign an initiative (and its logic model) before the unintended effects get out of hand, so that the model truly depicts activities that will plausibly produce the intended effects.

Choosing the right level of detail: the importance of utility and simplicity

It may help at this point to consider what a logic model is not. Although it captures the big picture, it is not an exact representation of everything that's going on. All models simplify reality; if they didn't, they wouldn't be of much use.

Even though it leaves out information, a good model represents those aspects of an initiative that, in the view of your stakeholders, are most important for understanding how the effort works. In most cases, the developers will go through several drafts before producing at a version that the stakeholders agree accurately reflects their story.

Should the information become overly complex, it is possible to create a family of related models, or nested models, each capturing a different level of detail. One model could sketch out the broad pathways of change, whereas others could elaborate on separate components, revealing detailed information about how the program operates on a deeper level. Individually, each model conveys only essential information, and together they provide a more complete overview of how the program or initiative functions. (See "How do you create a logic model?" for further details.)

Imagine "zooming-in" on the inner workings of a specific component and creating another, more detailed model just for that part. For a complex initiative, you may choose to develop an entire family of such related models that display how each part of the effort works, as well as how all the parts fit together. In the end, you may have some or all of the following family of models, each one differing in scope:

• View from Outer Space. This overall road map shows the major pathways of change and the full spectrum of effects. This view answers questions such s: Do the activities follow a single pathway, or are there separate pathways that converge down the line? How far does the chain of effects go? How do our program activities align with those of other organizations? What other forces might influence the effects that we hope to see? Where can we anticipate feedback loops and in what direction will they travel? Are there significant time delays between any of the connections?
• View from the Mountaintop. This closer view focuses on a specific component or set of components, yet it is still broad enough to describe the infrastructure, activities, and full sequence of effects. This view answers the same questions as the view from outer space, but with respect to just the selected component(s).
• You Are Here. This view expands on a particular part of the sequence, such as the roles of different stakeholders, staff, or agencies in a coalition, and functions like a flow chart for someone's work plan. It is a specific model that outlines routine processes and anticipated effects. This is the view that you might need to understand quality control within the initiative.

Families, Nesting, and Zooming-In
In the Examples section, the idea of nested models is illustrated in the Tobacco Control family of models. It includes a global model that encompasses three intermediate outcomes in tobacco control - environments without tobacco smoke, reduced smoking initiation among youth, and increased cessation among youth and adults. Then a zoom-in model is elaborated for each one of these intermediate outcomes.

The Comprehensive Cancer model illustrates a generic logic model accompanied by a zoom-in on the activities to give program staff the specific details they need. Notably, the intended effects on the zoom-in are identical to those on the global model and all major categories of activities are also apparent. But the zoom in unpacks these activities into their detailed components and, more important, indicates that the activities achieve their effects by influencing intermediaries who then move gatekeepers to take action. This level of detail is necessary for program staff, but it may be too much for discussions with funders and stakeholders.

The Diabetes Control model is another good example of a family of models. In this case, the zoom in models are very similar to the global model in level of detail. They add value by translating the global model into a plan for specific actors (in this case a state diabetes control program) or for specific objectives (e..g., increasing timely foot exams).

When can a logic model be used?

Logic models are useful for both new and existing programs and initiatives. If your effort is being planned, a logic model can help get it off to a good start. Alternatively, if your program is already under way, a model can help you describe, modify or enhance it.

Planners, program managers, trainers, evaluators, advocates and other stakeholders can use a logic model in several ways throughout an initiative. One model may serve more than one purpose, or it may be necessary to create different versions tailored for different aims. Here are examples of the various times that a logic model could be used.

During planning to:

• clarify program strategy
• identify appropriate outcome targets (and avoid over-promising)
• align your efforts with those of other organizations
• write a grant proposal or a request for proposals
• assess the potential effectiveness of an approach
• set priorities for allocating resources
• estimate timelines
• identify necessary partnerships
• negotiate roles and responsibilities
• focus discussions and make planning time more efficient

During implementation to:

• provide an inventory of what you have and what you need to operate the program or initiative
• develop a management plan
• incorporate findings from research and demonstration projects
• make mid-course adjustments
• reduce or avoid unintended effects

During staff and stakeholder orientation to:

• explain how the overall program works
• show how different people can work together
• define what each person is expected to do
• indicate how one would know if the program is working

During evaluation to:

• document accomplishments
• organize evidence about the program
• identify differences between the ideal program and its real operation
• determine which concepts will (and will not) be measured
• frame questions about attribution (of cause and effect) and contribution (of initiative components to the outcomes)
• specify the nature of questions being asked
• prepare reports and other media
• tell the story of the program or initiative

During advocacy to:

• justify why the program will work
• explain how resource investments will be used

How do you create a logic model?

There is no single way to create a logic model. Think of it as something to be used, its form and content governed by the users' needs.

Who creates the model? This depends on your situation. The same people who will use the model - planners, program managers, trainers, evaluators, advocates and other stakeholders - can help create it. For practical reasons, though, you will probably start with a core group, and then take the working draft to others for continued refinement.

Remember that your logic model is a living document, one that tells the story of your efforts in the community. As your strategy changes, so should the model. On the other hand, while developing the model you might see new pathways that are worth exploring in real life.

Two main development strategies are usually combined when constructing a logic model.

• Moving forward from the activities (also known as forward logic). This approach explores the rationale for activities that are proposed or currently under way. It is driven by But why? questions or If-then thinking: But why should we focus on briefing Senate staffers? But why do we need them to better understand the issues affecting young people? But why would they create policies and programs to support mentoring? But why would new policies make a difference?... and so on. That same line of reasoning could also be uncovered using if-then statements: If we focus on briefing legislators, then they will better understand the issues affecting young people. If legislators understand, then they will enact new policies...
• Moving backward from the effects (also known as reverse logic). This approach begins with the end in mind. It starts with a clearly identified value, a change that you and your colleagues would definitely like to see occur, and asks a series of "But how?" questions: But how do we overcome fear and stigma? But how can we ensure our services are culturally responsive? But how can we admit that we don't already know what we're doing?

At first, you may not agree with the answers that certain stakeholders give for these questions. Their logic may not seem convincing or even logical. But therein lies the power of logic modeling. By making each stakeholder's thinking visible on paper, you can decide as a group whether the logic driving your initiative seems reasonable. You can talk about it, clarify misinterpretations, ask for other opinions, check the assumptions, compare them with research findings, and in the end develop a solid system of program logic. This product then becomes a powerful tool for planning, implementation, orientation, evaluation, and advocacy, as described above.

By now you have probably guessed that there is not a rigid step-by-step process for developing a logic model. Like the rest of community work, logic modeling is an ongoing process. Nevertheless, there are a few tasks you should be sure to accomplish.

To illustrate these in action, we'll use another example for an initiative called "HOME: Home Ownership Mobilization Effort." HOME aims to increase home ownership in order to give neighborhood control to the people who live there, rather than to outside landlords with no stake in the community. It does this through a combination of educating community residents, organizing the neighborhood, and building relationships with partners such as businesses.

Steps for drafting a logic model

• Find the logic in existing written materials to produce your first draft.
  • Available written materials often contain more than enough information to get started. Collect narrative descriptions, justifications, grant applications, or overview documents that explain the basic idea behind the intervention effort. If your venture involves a coalition of several organizations, be sure to get descriptions from each agency's point of view. For the HOME campaign, we collected documents from planners who proposed the idea, as well as mortgage companies, homeowner associations, and other neighborhood organizations.
  • Your job as a logic modeler is to decode these documents. Keep a piece of paper by your side and sketch out the logical links as you find them. (This work can be done in a group to save time and engage more people if you prefer.)
  • Read each document with an eye for the logical structure of the program. Sometimes that logic will be clearly spelled out (e.g., The information, counseling, and support services we provide to community residents will help them improve their credit rating, qualify for home loans, purchase homes in the community; over time, this program will change the proportion of owner-occupied housing in the neighborhood).
  • Other times the logic will be buried in vague language, with big leaps from actions to downstream effects (e.g., Ours is a comprehensive community-based program that will transform neighborhoods, making them controlled by people who live there and not outsiders with no stake in the community).
  • As you read each document, ask yourself the But why? and But how? questions. See if the writing provides an answer. Pay close attention to parts of speech. Verbs such as teach, inform, support, or refer are often connected to descriptions of program activities. Adjectives like reduced, improved, higher, or better are often used when describing expected effects.
• Determine the appropriate scope of the model for its intended users and uses. Consider creating a family of models for multiple users.
  • The HOME initiative, for instance, created different models to address the unique needs of their financial partners, program managers, and community educators. Mortgage companies, grant makers, and other decision makers who decided whether to allocate resources for the effort found the global view from space most helpful for setting context. Program managers wanted the closer, yet still broad view from the mountaintop. And community educators benefited most from the you are here version. The important thing to remember is that these are not three different programs, but different ways of understanding how the same program works.
• Check whether the model makes sense and is complete.
  • Logic models convey the story of community change. Working with the stakeholders, it's your responsibility to ensure that the story you've told in your draft makes sense (i.e., is logical) and is complete (has no loose ends). As you iteratively refine the model, ask yourself and others if it captures the full story.
  • Here are the plot points common in most community change initiatives, presented with their "storytelling" names.
    • The Promised Land (desired effects). Does the model show specific measurable results that you hope to achieve? Does it contain big leaps of faith or does it show change through a logical sequence of effects? Are crucial behavioral changes identified (e.g., more applications for home ownership, increased home buying, greater engagement in community and civic affairs, etc.)? And if those behavior changes are supposed to be sustained, does the model explain how community conditions will change to reinforce new behaviors (e.g., home owner support groups, tax cuts on owner-occupied housing, discounts at the local hardware store for customers who own property in the neighborhood, etc.)? In the HOME model, we specified the following sequence of effects:
      • Short-term - Potential home owners attain greater understanding of how credit ratings are calculated and more accurate information about the steps to improve a credit rating; mortgage companies create new policies and procedures allowing renters to buy their own homes; local businesses start incentive programs; and anti-discrimination lawsuits are filed against illegal lending practices.
      • Mid-term - The community's average credit rating improves; applications rise for home loans along with the approval rate; support services are established for first-time home buyers; neighborhood organizing gets stronger, and alliances expand to include businesses, health agencies, and elected officials.
      • Longer-term - The proportion of owner-occupied housing rises; economic revitalization takes off as businesses invest in the community; residents work together to create walking trails, crime patrols, and fire safety screenings; rates of obesity, crime, and injury fall dramatically.
    • An advantage of the graphic model is that it can display both the sequence and the interactions of effects. For example, in the HOME model, credit counseling leads to better understanding of credit ratings, while loan assistance leads to more loan submissions, but the two together (plus other activities such as more new buyer programs) are needed for increased home ownership.
• Drama (activities, interventions). How will obstacles be overcome? Who is doing what? What kinds of conflict and cooperation are evident? What's being done to re-arrange the forces of change? What new services or conditions are being introduced? Your activities, based on a clear analysis of risk and protective factors, are the answers to these kinds of questions, Your interventions reveal the drama in your story of directed social change.

Dramatic actions in the HOME initiative include offering educational sessions and forming business alliances, homeowner support groups, and a neighborhood organizing council. At evaluation time, each of these actions is closely connected to output indicators that document whether the program is on track and how fast it is moving. These outputs could be the number of educational sessions held, their average attendance, the size of the business alliance, etc. (These outputs are not depicted in the global model, but that could be done if valuable for users.)

• Raw Materials (inputs, resources, or infrastructure). The energy to create change can't come from nothing. Real resources must come into the system. Those resources may be financial, but they may also include people, space, information, technology, equipment, and other assets. The HOME campaign runs because of the input from volunteer educators, support from schools and faith institutions in the neighborhood, discounts provided by lenders and local businesses, revenue from neighborhood revitalization, and increasing social capital among community residents.
• Setting (background, context and conditions). Really good stories convey facts, but they also have texture. There is a backdrop against which the main action takes place. Community change always takes place in the context of history, geography, politics, etc. Although it is impossible to represent all of those factors in a model, you can strive to include features that remind users those conditions exist and will affect how change unfolds.
  • Stakeholders working on the HOME campaign understood that they were challenging a history of racial discrimination and economic injustice. They saw gentrification occurring in nearby neighborhoods. They were aware of backlash from outside property owners who benefit from the status quo. None of these facts are included in the model per se, but a shaded box labeled History and Context was added to serve as a visual reminder that these things are in the background.
• Attend to the nuts and bolts of drawing the model.
  • Draft the logic model using both sides of your brain and all the talents of your stakeholders. Use your artistic and your analytic abilities.
  • Arrange activities and intended effects in the expected time sequence. And don't forget to include important feedback loops - after all, most actions provoke a reaction.
  • Link components by drawing arrows or using other visual methods that communicate the order of activities and effects. (Remember - the model does not have to be linear or read from left to right, top to bottom. A circle may better express a repeating cycle.)
  • Allow yourself plenty of space to develop the model. Freely revise the picture to show the relationships better or to add components.
  • Neatness counts, so avoid overlapping lines and unnecessary clutter.
  • Color code regions of the model to help convey the main storyline.
  • Try to keep everything on one page. When the model get too crowded, either adjust its scope or build nested models.
  • Make sure it passes the "laugh test." That is, be sure that the image you create isn't so complex that it provokes an immediate laugh from stakeholders. Of course, different stakeholders will have different laugh thresholds.
  • Use PowerPoint or other computer software to animate the model, building it step-by-step so that when you present it to people in an audience, they can follow the logic behind every connection.
• Revisit and be ready to revise the model as necessary.
  • Don't let your model become a tedious exercise that you did just to satisfy someone else. Don't let it sit in a drawer. Once you've gone through the effort of creating a model, the rewards are in its use. Revisit it often and be prepared to make changes. All programs evolve and change through time, if only to keep up with changing conditions in the community. Like a roadmap, a good model will help you to recognize new or reinterpret old territory.
  • Also, when things are changing rapidly, it's easy for collaborators to lose sight of their common goals. Having a well-developed logic model can keep stakeholders focused on achieving outcomes while remaining open to finding the best means for accomplishing the work. If you need to take a detour or make a longer stop, the model serves as a framework for incorporating the change.
  • As you improve, modify or realign your model, take stock of emerging activities and effects. You might need to do one or more of the following:
    • Clarify the path of activities to effects and outcomes
    • Elaborate links
    • Expand activities to reach your goals
    • Establish or revise mile markers
    • Redefine the boundary of your initiative or program
    • Reframe goals or desired outcomes

What makes a logic model effective?

You will know a model's effectiveness mainly by its usefulness to intended users. A good logic model usually:

• Logically links activities and effects
• Is visually engaging (simple, parsimonious) yet contains the appropriate degree of detail for the purpose (not too simple or too confusing)
• Provokes thought, triggers questions
• Includes forces known to influence the desired outcomes

The more complete your model, the better your chances of reaching "the promised land" of the story. In order to tell a complete story or present a complete picture in your model, make sure to consider all forces of change (root causes, trends, and system dynamics). Does your model reveal assumptions and hypotheses about the root causes and feedback loops that contribute to problems and their solutions?

In the HOME model, for instance, low home ownership persists when there is a vicious cycle of discrimination, bad credit, and hopelessness preventing neighborhood-wide organizing and social change. Three pathways of change were proposed to break that cycle: education; business reform; and neighborhood organizing. Building a model on one pathway to address only one force would limit the program's effectiveness.

You can discover forces of change in your situation using multiple assessment strategies, including forward logic and reverse logic as described above. When exploring forces of change, be sure to search for personal factors (knowledge, belief, skills) as well as environmental factors (barriers, opportunities, support, incentives) that keep the situation the same as well as ones that push for it to change.

Take time to simulate

After you've mapped out the structure of a program strategy, there is still another crucial step to take before taking action: some kind of simulation. As logical as the story you are telling seems to you, as a plan for intervention it runs the risk of failure if you haven't explored how things might turn out in the real world of feedback and resistance.

Simulation is one of the most practical ways to find out if a seemingly sensible plan will actually play out as you hope. Simulation is not the same as testing a model with stakeholders to see if it makes logical sense. The point of a simulation is to see how things will change - how the system will behave - through time and under different conditions.

Though simulation is a powerful tool, it can be conducted in ways ranging from the simple to the sophisticated.

• Simulation can be as straightforward as an unstructured role-playing game, in which you talk the model through to its logical conclusions.
• In a more structured simulation, you could develop a tabletop exercise in which you proceed step by step through a given scenario with pre-defined roles and responsibilities for the participants.
• Ultimately, you could create a computer-based mathematical simulation by using any number of available software tools.

The key point to remember is that creating logical models and simulating how those models will behave involve two different sets of skills, both of which are essential for discovering which change strategies will be effective in your community.

What are the benefits and limitations of logic modeling?

You can probably envision a variety of ways in which you might use the logic model you've developed or that logic modeling would benefit your work.

Here are a few advantages that experienced modelers have discovered.

• Logic models integrate planning, implementation, and evaluation. As a detailed description of your initiative, from resources to results, the logic model is equally important for planning, implementing, and evaluating the project. If you are a planner, the modeling process challenges you to think more like an evaluator. If your purpose is evaluation, the modeling prompts discussion of planning. And for those who implement, the modeling answers practical questions about how the work will be organized and managed.
• Logic models prevent mismatches between activities and effects. Planners often summarize an effort by listing its vision, mission, objectives, strategies and action plans. Even with this information, it can be hard to tell how all the pieces fit together. By connecting activities and effects, a logic model helps avoid proposing activities with no intended effect, or anticipating effects with no supporting activities. The ability to spot such mismatches easily is perhaps the main reason why so many logic models use a flow chart format.
• Logic models leverage the power of partnerships. As the W.K. Kellogg Foundation notes (see Internet Resources below), refining a logic model is an iterative or repeating process that allows participants to "make changes based on consensus-building and a logical process rather than on personalities, politics, or ideology. The clarity of thinking that occurs from the process of building the model becomes an important part of the overall success of the program." With a well-specified logic model, it is possible to note where the baton should be passed from one person or agency to another. This enhances collaboration and guards against things falling through the cracks.
• Logic models enhance accountability by keeping stakeholders focused on outcomes. As Connie Schmitz and Beverly Parsons point out (see Internet Resources), a list of action steps usually function as a manager's guide for running a project, showing what staff or others need to do to--for example, "Hire an outreach worker for a TB clinic." With a logic model, however, it is also possible to illustrate the effects of those tasks--for example, "Hiring an outreach worker will result in a greater proportion of clients coming into the clinic for treatment." This short-term effect then connects to mid- and longer-term effects, such as "Satisfied clients refer others to the clinic" and "Improved screening and treatment coverage results in fewer deaths due to TB."

In a coalition or collaborative partnership, the logic model makes it clear which effects each partner creates and how all those effects converge to a common goal. The family or nesting approach works well in a collaborative partnership because a model can be developed for each objective along a sequence of effects, thereby showing layers of contributions and points of intersection.

• Logic models help planners to set priorities for allocating resources. A comprehensive model will reveal where physical, financial, human, and other resources are needed. When planners are discussing options and setting priorities, a logic model can help them make resource-related decisions in light of how the program's activities and outcomes will be affected.
• Logic models reveal data needs and provide a framework for interpreting results. It is possible to design a documentation system that includes only beginning and end measurements. This is a risky strategy with a good chance of yielding disappointing results. An alternative approach calls for tracking changes at each step along the planned sequence of effects. With a logic model, program planners can identify intermediate effects and define measurable indicators for them.
• Logic models enhance learning by integrating research findings and practice wisdom. Most initiatives are founded on assumptions about the behaviors and conditions that need to change, and how they are subject to intervention. Frequently, there are different degrees of certainty about those assumptions. For example, some of the links in a logic model may have been tested and proved to be sound through previous research. Other linkages, by contrast, may never have been researched, indeed may never have been tried or thought of before. The explicit form of a logic model means that you can combine evidence-based practices from prior research with innovative ideas that veteran practitioners believe will make a difference. If you are armed with a logic model, it won't be easy for critics to claim that your work is not evidence-based.
• Logic models define a shared language and shared vision for community change. The terms used in a model help to standardize the way people think and how they speak about community change. It gets everyone rowing in the same direction, and enhances communication with external audiences, such as the media or potential funders. Even stakeholders who are skeptical or antagonistic toward your work can be drawn into the discussion and development of a logic model. Once you've got them talking about the logical connections between activities and effects, they're no longer criticizing from the sidelines. They'll be engaged in problem-solving and they'll be doing so in an open forum, where everyone can see their resistance to change or lack of logic if that's the case.

Limitations

Any tool this powerful must not be approached lightly. When you undertake the task of developing a logic model, be aware of the following challenges and limitations.

First, no matter how logical your model seems, there is always a danger that it will not be correct. The world sometimes works in surprising, counter-intuitive ways, which means we may not comprehend the logic of change until after the fact. With this in mind, modelers will appreciate the fact that the real effects of intervention actions could differ from the intended effects. Certain actions might even make problems worse, so it's important to keep one eye on the plan and another focused on the real-life experiences of community members.

If nothing else, a logic model ought to be logical. Therein lies its strength and its weakness. Those who are trying to follow your logic will magnify any inconsistency or inaccuracy. This places a high burden on modelers to pay attention to detail and refine their own thinking to great degree. Of course, no model can be perfect. You'll have to decide on the basis of stakeholders' uses what level of precision is required.

Establishing the appropriate boundaries of a logic model can be a difficult challenge. In most cases, there is a tension between focusing on a specific program and situating that effort within its broader context. Many models seem to suggest that the only forces of change come from within the program in question, as if there is only one child in the sandbox.

At the other extreme, it would be ridiculous and unproductive to map all the simultaneous forces of change that affect health and community development. A modeler's challenge is to include enough depth so the organizational context is clear, without losing sight of the reasons for developing a logic model in the first place.

On a purely practical level, logic modeling can also be time consuming, requiring much energy in the beginning and continued attention throughout the life of an initiative. The process can demand a high degree of specificity; it risks oversimplifying complex relationships and relies on the skills of graphic artists to convey complex thought processes.

Indeed, logic models can be very difficult to create, but the process of creating them, as well as the product, will yield many benefits over the course of an initiative.

In Summary

A logic model is a story or picture of how an effort or initiative is supposed to work. The process of developing the model brings together stakeholders to articulate the goals of the program and the values that support it, and to identify strategies and desired outcomes of the initiative.

As a means to communicate a program visually, within your coalition or work group and to external audiences, a logic model provides a common language and reference point for everyone involved in the initiative.

A logic model is useful for planning, implementing and evaluating an initiative. It helps stakeholders agree on short-term as well as long-term objectives during the planning process, outline activities and actors, and establish clear criteria for evaluation during the effort. When the initiative ends, it provides a framework for assessing overall effectiveness of the initiative, as well as the activities, resources, and external factors that played a role in the outcome.

To develop a model, you will probably use both forward and reverse logic. Working backwards, you begin with the desired outcomes and then identify the strategies and resources that will accomplish them. Combining this with forward logic, you will choose certain steps to produce the desired effects.

You will probably revise the model periodically, and that is precisely one advantage to using a logic model. Because it relates program activities to their effect, it helps keep stakeholders focused on achieving outcomes, while it remains flexible and open to finding the best means to enact a unique story of change.

What is a logic model?

___You understand the purpose and elements of a logic model as a picture of why and how your effort is supposed to work

___You understand the utility of family, nested, or zoom in models for a complex initiative

___You have an initial plan for how and when to use your logic model

How do you create a logic model?

___Apply forward and/or reverse logic to your effort or initiative

___Create the first draft by finding the logic in existing written materials

___Adjust the model's scope to make it appropriate for intended users and uses

___Create multiple (family, nested, or zoom in) models if needed by users

___Check whether the model makes sense and is complete, including the common plot points

___Attend to the nuts and bolts of drawing the model

___Revisit and revise the model as necessary

These are examples of logic models that other people have found effective. Please note, however, that no other person's or group's logic model can serve as template for your own; even if your initiative is similar, the forces of change and other important details for each effort will differ.

Example 1: Community Health Assessment and Action Planning (CHAAP) Process Improvement Plan in St. Louis County

This logic model lays out St. Louis County’s Department of Public Health and Human Services’ proposed improvement plan to overcome the challenges of protecting vulnerable populations in the event of a disaster.

Example 2: Integration of Mental Health into Chronic Disease Prevention Strategies and Health Promotion Efforts

As mental health greatly affects an individual's capacity to participate in health promoting-behaviors, this logic model details possible steps to address mental health and its relationship with chronic disease prevention and health promotion.

Example 3: Georgia Society for Public Health Education Logic Model

Example 4: Alcohol and Other Drugs (AOD) Education Program Logic Model

 

Example 5: National Endowment for the Arts - "Our Town" Logic Model

This logic model was developed by the National Endowment for the Arts for their Creative Placemaking Grants Program deemed "Our Town". The model promotes strengthening communities by advancing local physical, economic, and social outcomes.

Example 6: CDC Cardiovascular Disease and Stroke Prevention Program Logic Model

Example 7: LHFA Logic Model / Framework

Example 8: Tenderloin Health Improvement Partnership Logic Model

This logic model helps visualize how TLHIP, an initiative led by the Saint Francis Foundation, works collectively with community partners and other stakeholders to improve the health of Tenderloin residents in downtown San Francisco.

Tool 1: Tearless Logic Model

 

The Tearless Logic Model breaks down the logic model process into a series of manageable, jargon-free questions. Access the tool.

Tool 2: Logic Model to create a Framework or Model of Change

This logic model template (docx) provides a framework to help begin the process.

A PowerPoint presentation summarizing the major points in the section.

If you were a contractor setting out to build a wood-frame house, you wouldn’t just pick up whatever wood you found lying around and begin. You’d consult first with the owner, and start with an idea of the house she wanted – its size, its shape, its features. You’d want a picture of the finished house, and a floor plan as well, with some notes on measurements and materials. You’d plan the construction with her, and set out a process for getting it done. And you’d do all this before you ever picked up a tool, because otherwise the process would be hit-or-miss: she wouldn’t get the house she wanted, and your time would be wasted.

The same is true if you’re developing an intervention to address a health or community issue. It makes no sense to pick an issue at random, and to use whatever service happens to be available to try to address it. You have to consult with the community, understand and analyze community information, your own and others’ observation, and the context of the issue to create an intervention that will actually bring about the changes the community wants and needs.

In the first section of this chapter, we introduced the need for a process for doing health and community work. In this section, we’ll look at PRECEDE-PROCEED, the first of several specific models that may prove helpful to you in carrying out your own work. We’ll examine other models in subsequent sections of this chapter. Then in the last section, we’ll examine some ways in which elements of various models can be combined to respond to your particular situation.

What is PRECEDE-PROCEED?

Like most of the other models we’ll examine in this chapter, PRECEDE-PROCEED was developed for use in public health. Its basic principles, however, transfer to other community issues as well. As a result, we’ll treat it as a model not just for health intervention, but for community intervention in general. And in fact, PRECEDE/ PROCEED focuses on the community as the wellspring of health promotion.

In the latter half of the 20th Century, as medical advances eliminated many infectious diseases, the leading causes of disability and death in the developed world changed to chronic conditions – heart disease, stroke, cancer, diabetes. The focus of health maintenance, therefore, shifted from the treatment of disease to the prevention of these conditions, and, more recently, to the active promotion of behaviors and attitudes – proper diet, exercise, and reduction of stress, for instance – that in themselves do much to maintain health and improve the length and quality of life.

Behind PRECEDE-PROCEED lie some assumptions about the prevention of illness and promotion of health, and, by extension, about other community issues as well. These include:

• Since the health-promoting behaviors and activities that individuals engage in are almost always voluntary, carrying out health promotion has to involve those whose behavior or actions you want to change. PRECEDE-PROCEED should be a participatory process, involving all stakeholders – those affected by the issue or condition in question – from the beginning.
• Health is, by its very nature, a community issue. It is influenced by community attitudes, shaped by the community environment (physical, social, political, and economic), and colored by community history.
• Health is an integral part of a larger context, probably most clearly defined as quality of life, and it’s within that context that it must be considered. It is only one of many factors that make life better or worse for individuals and the community as a whole. It therefore influences, and is influenced by, much more than seems directly connected to it.

AIDS has changed the way many people in the US view and practice sex, for instance. In some other countries, it has affected the whole social structure because of the number of orphans it has created, and its impact on the workforce. By the same token, youth violence changes the views and actions of many people who are at no risk of being its victims, and may put a community at an economic disadvantage by making it less attractive to new business or industry. Almost any other issue could serve equally well as an example of the broad reach of community problems (or assets, for that matter).

• Finally, health is more than physical well-being, or than the absence of disease, illness, or injury. It is a constellation of factors – economic, social, political, ecological, and physical – that add up to healthy, high-quality lives for individuals and communities.

This broad perspective on health extends to other community issues. We can define the health of a community as its fitness in many areas, of which citizens’ physical health is only one. Indications of a community’s overall health include how well it:

• Contributes to the stability of families
• Nurtures and supports children
• Fosters lifelong learning
• Provides meaningful work for its citizens
• Invites involvement in the democratic process
• Cares for those who need help
• Protects and sustains the natural environment
• Encourages the arts
• Values and encourages racial and cultural diversity
• Works to promote and maintain safety and physical well-being for its members

PRECEDE and PROCEED are acronyms (words in which each letter is the first letter of a word). PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation. As its name implies, it represents the process that precedes, or leads up to, an intervention.

PROCEED spells out Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development, and, true to its name as well, describes how to proceed with the intervention itself.

PRECEDE has four phases, which we’ll explore in greater detail later in the section:

• Phase 1: Identifying the ultimate desired result.
• Phase 2: Identifying and setting priorities among health or community issues and their behavioral and environmental determinants that stand in the way of achieving that result, or conditions that have to be attained to achieve that result; and identifying the behaviors, lifestyles, and/or environmental factors that affect those issues or conditions.
• Phase 3: Identifying the predisposing, enabling, and reinforcing factors that can affect the behaviors, attitudes, and environmental factors given priority in Phase 2.
• Phase 4: Identifying the administrative and policy factors that influence what can be implemented.

Another premise behind PRECEDE-PROCEED is that a change process should focus initially on the outcome, not on the activity. (Many organizations set out to create community change without stopping to consider either what effect their actions are likely to have, or whether the change they’re aiming at is one the community wants and needs.) PRECEDE’s four phases, therefore, move logically backward from the desired result, to where and how you might intervene to bring about that result, to the administrative and policy issues that need to be addressed in order to mount that intervention successfully. All of these phases can be thought of as formative.

PROCEED has four phases (also to be discussed in more detail later) that cover the actual implementation of the intervention and the careful evaluation of it, working back to the original starting point – the ultimate desired outcome of the process.

• Phase 5: Implementation – the design and actual conducting of the intervention.
• Phase 6: Process evaluation. Are you actually doing the things you planned to do?
• Phase 7: Impact evaluation. Is the intervention having the desired impact on the priority population?
• Phase 8: Outcome evaluation. Is the intervention leading to the outcome (the desired result) that was envisioned in Phase 1?

A word about logic models: Although most formal models, like PRECEDE-PROCEED present themselves as the way to structure an intervention or other activity, the word “logic” implies that you should carefully consider your own situation as well as the model. If there are reasons why a particular part of a model might not work for you, it’s reasonable (logical) to change it. While PRECEDE-PROCEED presents a structure that could conceivably work well (and has worked well) in a variety of situations, it’s still important to think about whether all parts of it will work for you.

A flow chart of the model (see Fig. 1), developed by its originators, shows a circular process. It starts (on the upper right) with a community demographic and quality-of-life survey, and goes counterclockwise through PRECEDE’s four phases that explain how to conceive and plan an effective intervention. PROCEED then picks up with the intervention itself (described here as a health program), and works back through the first five phases, evaluating the success of the intervention at addressing each one (The process evaluation in Phase 6 looks at whether the intervention addressed the concerns of Phase 3 as planned. The impact evaluation of Phase 7 examines the impact of the intervention on the behaviors or environmental factors identified in Phase 2. And the Outcome evaluation of Phase 9 explores whether the intervention has had the desired quality of life outcome identified in Phases 1 and 2). Eventually, the process arrives back at the beginning, either having achieved the desired quality of life outcome, or to start over again, incorporating the lessons of the first try. The arrows in the flow chart demonstrate the effects of each phase’s issues on the next one to the right. Since you’re working backwards from the ultimate outcome, effects move to the right. If the chart was demonstrating the direction of analysis, the arrows would point in the opposite direction.

Figure 1. Generic representation of the Precede-Proceed Model. From L. Green and M. Kreuter. (2005). Health Promotion Planning: An Educational and Ecological Approach (4 th Ed.). Mountain View , CA : Mayfield Publishers.

 

• The PRECEDE-PROCEED model applies a medical perspective to public health, even though its focus is health promotion, rather than treatment of disease. Just as a medical diagnosis precedes treatment, the model assumes that a far-reaching diagnosis should precede a public health intervention. A diagnosis suggests a treatment (an intervention), which is closely monitored for process (Is the patient getting the treatment prescribed?), impact (Is the treatment having the hoped-for impact on the symptoms?), and outcome (Does the treatment cure the patient, or have the desired effect on her overall health?). A premise of the model is that a diagnosis should start with the desired end result and work backwards to determine what needs to be done to bring about that result.
• Another basic premise of the model is that the purpose of a health program – and by extension, the purpose of any proactive type of community intervention – is to improve the quality of life for individuals and their community, and that the two are largely inseparable. Thus, any intervention should be community-based, and should look at the needs of the community, even if the intervention is aimed at a more specific priority group.
• A final premise of any community-based model for intervention is that planning and implementing a community intervention calls for a joint effort among (health and other) professionals and organizations, policy makers, community officials, community leaders, and community members at large, including members of the priority population. In order to ensure accurate information and community support, all elements of the community should be involved in the process from the beginning.

Why use PRECEDE-PROCEED?

First, there are good reasons for using some kind of logic model or theoretical framework for any intervention:

• It provides a structure within which to plan your work, so that you’re not simply grasping at straws. As a result, you’re more likely to develop a coherent plan that addresses the necessary issues.
• Most models give you either a guide or a foundation for critical analysis of the issues at hand. That doesn’t guarantee that your analysis will be complete or accurate, but it significantly increases the chances. (See Analyzing Community Problems and Solutions, for more on logical analysis.)

This is not to say that you have to use a logic model. There are other ways to approach developing an intervention, many of them outlined in the Community Tool Box. The advantage of PRECEDE-PROCEED and similar models is that they tell you exactly what to do: you follow directions, and you have a procedure for developing an intervention. The disadvantage of these models is that they tell you exactly what to do: if some part of the model isn’t appropriate for your setting or your circumstances, you’ll have to realize that, and change it to fit, or risk a problem. PRECEDE-PROCEED now offers a flow chart or algorithm to facilitate decisions for skipping some steps or phases, thereby tailoring the model to different local situations.

Usually, the originators of the model will tell you that you have to follow it exactly. In fact, that’s rarely the case. If you like the model, you can be sure to include all its elements, but you can still change some of them, change the timing, even change the order to better match the needs of your community. You might also find yourself taking some pieces of one model and grafting them on to another, or reinterpreting a model in light of a particular theoretical framework.

Over and above the use of logic models in general, there are some good reasons for using PRECEDE-PROCEED specifically:

• PRECEDE-PROCEED provides a template for the process of conceiving, planning, implementing, and evaluating a community intervention.
• PRECEDE-PROCEED is structured as a participatory model, to incorporate the ideas and help of the community. That means that its use will provide you with more, and more accurate, information about the issues in question, and with a better understanding of their history and context in the community.
• Community involvement is also a means of building community ownership of the intervention, leading to more community support and a greater chance of success.
• PRECEDE-PROCEED considers the ways in which administrative and policy guidelines can limit or shape an intervention, an area of planning too often ignored.
• PRECEDE-PROCEED incorporates evaluation of the process, the intervention itself, and the final outcome. That allows the intervention to be monitored and adjusted to respond to community needs and changes in the situation, and checks that its accomplishments actually lead to the projected goal.
• Although PRECEDE-PROCEED sets out a strict process, it says much less about content. It leaves plenty of leeway for adapting your intervention’s design and methods to the situation, the needs of the community, etc.

Although these are good reasons to use PRECEDE-PROCEED, they are also good reasons to use some of the other models in this chapter. This is the reason we are presenting several – so that you can decide which among them, if any, makes the most sense to you, and would be best for your circumstances and community. PRECEDE-PROCEED’s greatest strength may be its comprehensive and rigorous structure – it covers all the bases.

How do you use PRECEDE-PROCEED?

Logic models don’t really mean much unless you actually use them in the community. Once you’ve decided that PRECEDE-PROCEED provides a good model for your intervention, how do you translate it into action? We’ll look at each of the nine phases of the model with that question in mind.

PRECEDE: Doing the groundwork. PRECEDE starts by determining the desired outcome for the community, and then works back to what has to be done to obtain that outcome. Each phase moves one step closer to the actual intervention.

Our presentation of the model assumes that, although it was developed for use in public health, it can be used by activists or organizations concerned with any issues that affect the quality of life in a community, as seen in some of the 950 published applications.

Phase 1: Defining the ultimate outcome. The focus here is on what the community wants and needs, which may seem unrelated to the issue you plan to focus on. What outcome does the community find most important? Eliminating or reducing a particular problem (homelessness)? Addressing an issue (race)? >Improving or maintaining certain aspects of the quality of life (environmental protection?) Improving the quality of life in general (increasing or creating recreational and cultural opportunities)?

This phase starts with the collection of demographic data, which is then presented to the community to help citizens decide on priorities. The way to determine what citizens want for their community is to ask them. There are a number of options here, which can be used individually or in combination, including:

• Community surveys
• Focus groups
• Phone interviews
• Face-to-face interviews
• Questionnaires in public places

Rather than just asking them for their opinions about what would improve the community, it’s far more powerful to involve community members in the whole process from the beginning, including them in all phases of the PRECEDE-PROCEED model. While actual applications of the model often tend to be top-down, it is likely to work better if the community has significant input and decision-making power from the beginning.

Phase 2: Identifying the issue. In Phase 2 of PRECEDE, you look for the issues and factors that might cause or influence the outcome you’ve identified in Phase 1 (including supports for and barriers to achieving it), and select those that are most important, and that can be influenced by an intervention. (One of the causes of community poverty, for instance, may be the global economy, a factor you probably can’t have much effect on. As important as the global economy might be, you’d have to change conditions locally to have any real impact.)

It’s important to analyze these issues carefully, and to make sure that you’ve chosen the right ones. What would the elimination of a particular factor make possible, for instance, that isn’t possible already? How does a particular issue create a barrier to the desired outcome? What else do these issues affect, besides the desired outcome?

Which are the issues with the most drastic effects? And how do you define “the most drastic effects?” Are they economic? Social? Physical?

An industry responsible for pollution that actually or potentially causes health problems may also be the local economic mainstay. Even if the industry has the best of intentions, it may be unable to afford to clean up its operation. The town may be faced with the choice of either losing the jobs and tax base that the industry provides, or continuing to live with a health hazard. What’s more important here, and how do you decide what to focus on? (And is there an answer that isn’t either-or ?)

This kind of situation is by no means universal...but it isn’t particularly unusual, either.

In some cases, the issues you choose to focus on may be directly related to the outcome you’re seeking – building more affordable housing as a way to address homelessness, for instance. In others, you may be trying to affect factors that have just as great an impact on the outcome, but seem further removed from it – e.g., addressing safe streets by providing parenting courses and other services for families experiencing increased risk.

Once again, involving stakeholders and other community members here is likely to get you the best information possible about which issues to emphasize, and to keep you from making mistakes based on ignorance of the community’s history or of the relationships among community members.

Phases 1 and 2 are where you develop the long-term goals for your intervention. They tell you what your ultimate desired outcome should be, and what the issue(s) or associated factors may be that influence it. Those are the things you’re ultimately aiming to change.

Most of the factors influencing the issues or outcomes can be classified as behavioral, lifestyle, or environmental.

The behavior referred to here is a specific, observable, often measurable – and usually customary – action. Some behaviors put people or communities at more or less risk for health or other problems.

• Needle-sharing is a behavior that puts people who use heroin at high risk for hepatitis and AIDS.
• Consistent studying usually lessens the risk of school failure for a student.
• If littering is a common individual behavior, it may have community consequences that range from the aesthetic (piles of trash creating an unattractive scene) to health (breeding of mosquitoes in garbage-strewn lots, water pollution, etc.) to the economic (businesses unwilling to locate in the community because of its physical condition). It may also have social consequences, with neighborhood conditions affecting residents’ self-image, and leading eventually to a breakdown of civic responsibility.

A lifestyle is a collection of related behaviors that go together to form a pattern of living. Some lifestyles may put people and communities at risk of health and other problems.

• An example of a high-risk lifestyle that is often mentioned in the popular media is one that includes very little exercise, a diet high in calories and saturated fats, and lots of stress. Such a lifestyle can lead to heart attack, stroke, cardiovascular disease, and other problems associated with obesity, including diabetes.
• A lifestyle that involves gang membership and regular participation in violent acts has both individual consequences (the constant risk of serious injury or death, an arrest record, detachment from others’ humanity) and consequences for the community (people afraid to use the streets, reduced economic activity, scarce resources spent on extra law enforcement, etc).

The environment of a particular issue or problem can refer to the natural, physical environment – the character and condition of the water, air, open space, plants, and wildlife, as well as the design and condition of built-up areas. But it can also refer to the social environment (influence of family and peers; community attitudes about gender roles, race, childrearing, work, etc.), the political environment (policies and laws, such as anti-smoking ordinances, that regulate behavior or lifestyle; the attitudes of those in power toward certain groups or issues), and the economic environment (the availability of decent-wage jobs, affordable housing, and health insurance; the community tax base; global economic conditions).

In general, behaviors, lifestyles, and environmental factors are what an intervention sets out to change. The changes in these areas in turn affect the crucial issues, and lead to the achievement of the final outcome that was identified in Phase 1 of the model.

So how do you choose which behaviors, lifestyles, or environmental factors to focus on? That’s where analysis comes in. What are people doing – or what are the factors in the environment – that lead to, maintain, or prevent the issue or condition you want to change? Using critical thinking and the “But why?” technique, you should be able to narrow it down to a handful. The criteria for choosing a particular target for your intervention are: (a) Is the potential target an important enough factor to have a real effect on the issue, and thus on the quality of life in the community? and (b) Is it likely that the potential target can actually be changed by an intervention that you have the resources to mount?

A classic example of community change through behavior change is that of reducing the incidence of lung cancer and heart disease in a community by convincing smokers to change their behavior – i.e. quit. Fewer smokers mean less secondhand smoke, less time lost from work because of smoke breaks and smoking-related illnesses, fewer low-birth-weight babies, fewer children with asthma and other respiratory ailments, and lower health insurance costs. Altogether, changing smokers’ behavior adds up to an improvement in the overall quality of life for the community.

Changing smokers’ behavior fits both criteria described above. It has a profound effect on the issue and on the general quality of life; and it is often responsive to change, because of many smokers’ desire to quit, general knowledge about the dangers of smoking, the cost of tobacco products, community support, and already-existing strategies and smoking-cessation groups that can be incorporated relatively cheaply into an intervention.

Phase 3: Examining the factors that influence behavior, lifestyle, and responses to environment. Here, you identify the factors that will create the behavior and environmental changes you’ve decided on in Phase 2.

The terms “healthful behavior” and “risky behavior” below refer not only to physical health, but to any behavior that’s advantageous or harmful to the individual and/or the community, and is likely to have a significant effect on their quality of life.

Predisposing factors are intellectual and emotional “givens” that tend to make individuals more or less likely to adopt healthful or risky behaviors or lifestyles or to approve of or accept particular environmental conditions. Some of these factors can often be influenced by educational interventions. They include:

• Knowledge. You’re more likely, for instance, to avoid sunburn if you know it can lead to skin cancer than if you don’t.
• Attitudes. People who have spent their youth as athletes often come to see regular exercise as an integral part of life, as necessary and obvious as regular meals.
• Beliefs. These can be mistaken understandings – believing that anything low in fat is also low in calories – or closely held beliefs based on religion or culture – as the old saying goes, “Spare the rod and spoil the child,” so it’s important to physically punish your children for mistakes or misdeeds.
• Values. A value system that renounces violence would make a parent less likely to beat a child, or to be physically abusive to a spouse or other family member.
• Confidence. Many people fail to change risky behavior simply because they don’t feel capable of doing so.

Enabling factors are those internal and external conditions directly related to the issue that help people adopt and maintain healthy or unhealthy behaviors and lifestyles, or to embrace or reject particular environmental conditions. Among them are:

• Availability of resources. People experiencing mental health challenges, for instance, are much more likely to get help if services are readily available.
• Accessibility of services. Services do no good if they have waiting lists that run into years, or aren’t physically accessible to those who need them.
• Community and/or government laws, policies, priority, and commitment to the issue. Government laws and policies can both force changes in behavior or environment, and underline the importance of those changes.
• Issue-related skills. People who start out with a work ethic and an understanding of the workplace, for instance, are apt to benefit from job placement programs.

Reinforcing factors, are the people and community attitudes that support or make difficult adopting healthy behaviors or fostering healthy environmental conditions. These are largely the attitudes of influential people: family, peers, teachers, employers, health or human service providers, the media, community leaders, and politicians and other decision makers. An intervention might aim at these people and groups – because of their influence – in order to most effectively reach the real priority group.

Phases 2 and 3 comprise the part of the model where the real planning of an intervention has to take place. What are you trying to change, and what are the factors that will help to bring that change about? Answering these questions should bring you to an understanding of whom and what an intervention should target, who best might conduct the intervention, and what it should look like in order to hit its targets effectively.

Phase 4: Identifying “best practices” and other sources of guidance for intervention design, as well as administrative, regulation, and policy issues that can influence the implementation of the program or intervention. Phase 4 helps you look at organizational issues that might have an impact on your actual intervention. It factors in the effects on the intervention of your internal administrative structure and policies, as well as external policies and regulations (from funders, public agencies, and others).

Design issues: “Matching, mapping, pooling, and patching.” or “Selecting, designing, blending, and supporting interventions.”

The discussion of the ways in which organizational issues, particularly internal ones, interact with a proposed intervention is one that all too often never takes place. For that reason, Phase 4 is particularly important. Such a discussion can avoid mismatches between an organization and its proposed intervention (a strictly hierarchical organization attempting to implement an intervention meant to empower a underrepresented community members, for instance), or to alert an organization to an internal or external regulation or policy that needs to be changed or circumvented for an intervention to proceed as planned.

Administrative issues include organizational structure, procedures, and culture; and the availability of resources necessary for the intervention.

• The organizational structure may be hierarchical, democratic, collaborative, or some combination, and may be more or less rigid or flexible within each of those categories. It should be appropriate to the design of the intervention (e.g., allowing for staff decisions in the field in a gang outreach program), and flexible enough to make adjustments when necessary.
• Organizational procedures are the ways in which the organization actually carries out its work. In order for an intervention to be successful, those procedures have to focus on its goals, rather than on internal convenience or traditional methods. An intake procedure, for instance, should be designed to be as easy and un-embarrassing for participants as possible – otherwise it can be a barrier to participation.
• The organizational culture. Organizations are social groups that develop cultures of their own. Those cultures often dictate, among other things, how staff members interact with one another, how program participants are treated, and how the organization views its work and its mission. (Is it just a job, or is it God’s work?) They also usually determine the fit between an organization and an intervention.
• The resources available for the intervention include not only money – although that’s certainly important – but time, personnel, skills, and space. Now is the time to pinpoint any gaps in resources beforehand, and work to close them. Thus, finding funding and/or the right staff people may be a good part of this phase.

Policy and regulatory issues have to do with the rules and restrictions – both internal and external – that can affect an intervention, and their levels of flexibility and enforcement.

Internal policies:

• Staff members. Organizational policy may treat staff as employees who take orders, as colleagues who contribute to the work of the organization, or as collaborators who jointly own it. The amount of freedom they have to exercise their creativity and to take initiative probably depends on that policy, which may be unstated.
• Participants. Does organizational policy see participants as “clients” that the organization is doing something to or for, or as partners in a change effort? Does it treat participants respectfully, as equals, or does it condescend or act authoritative?

How does the organization treat relationships among participants and staff? In some organizations, they may be friendly; in others, strictly professional. (Romantic or sexual relationships raise some ethical questions, and probably need to be considered separately. See “Professional ethics” below.)

• Specific practices, methods, or programs. Many organizations maintain policies that suggest or mandate certain ways of carrying out their work.
• Collaboration. Some non-profits make it a point of policy to collaborate as much as possible, while others rarely, if ever, work with other organizations.
• Professional ethics. Many organizations expect staff members to adhere to a code of professional ethics – either an internal one, or one set out by a professional association – that governs confidentiality, inappropriate relationships, abuse of position, reporting (or non-reporting) of specific kinds of illegal behavior, etc. There may be organizational regulations about these areas as well.

External policies and regulations that might affect an intervention can come in a variety of forms:

• Funders’ requirements. These may apply to the intervention itself, or they may place restrictions on anything the organization can do, even those areas – such as, perhaps, this intervention – that aren’t funded directly by the funder in question.
• Oversight agency regulations. The organization may be subject to the authority of a state or federal agency whose regulations affect the intervention.
• State or federal laws, or local ordinances
• Unstated community policies. Certain actions may simply be unacceptable to the majority of the community, to coalition partners, etc.

PROCEED: Implementing and evaluating the intervention .

Phase 5: Implementation. At this point, you’ve devised an intervention (largely in Phases 3 and 4), based on your analysis. Now, you have to carry it out. This phase Involves doing just that – setting up and implementing the intervention you’ve planned.

The final three phases take place as the intervention continues, and serve to help you monitor and adjust your work to make it as effective as possible.

Phase 6: Process Evaluation. This phase isn’t about results, but about procedure. The evaluation here is of whether you’re actually doing what you planned. If, for instance, you proposed to offer mental health services three days a week in a rural area, are you in fact offering those services?

Phase 7: Impact Evaluation. Here, you begin evaluating the initial success of your efforts. Is the intervention having the desired effect on the behavioral or environmental factors that it aimed at changing – i.e., is it actually doing what you expected?

Phase 8: Outcome Evaluation. Is your intervention really working to bring about the outcome the community identified in Phase 1? It may be completely successful in every other way – the process is exactly what you planned, and the expected changes made – but its results may have no effect on the larger issue. In that case, you may have to start the process again, to see why the factors you focused on aren’t the right ones, and to identify others that might work.

Some outcomes may not be apparent for years or decades. Lifestyle changes made by young people to stave off heart disease and stroke, for instance, usually won’t reveal their health benefits until those people are well into middle age. If you know that an outcome may not show itself for a long time, you may just have to be patient and continue to monitor the process and impact of your intervention, with the belief that the eventual outcome will become apparent in time.

Phases 6-8 call for formal evaluations of each phase, with controlled studies and detailed findings, but most Community Tool Box users probably don’t have the resources for that, and shouldn’t expect to do it. That doesn’t mean you shouldn’t evaluate, however.

It’s a relatively simple matter, for instance, to keep records and to examine them to find out whether your process was carried out as planned, or simply to look at what you are doing to see whether it matches what you intended to do. The same is true for the other stages of evaluation. Don’t worry if you can’t do a formal study...but don’t let evaluation go, either. It’s an important part of the process.

Remember also that evaluation is ongoing throughout the work. It takes place while the intervention is being implemented, not afterwards. The whole point of evaluation of each phase of the model is to adjust or change what you’re doing in that phase, if necessary, to make it more effective.

At any point in the PROCEED continuum, you should be prepared to revisit your analysis. If you find a gap between your planning and reality, or if you realize that your intervention isn’t achieving the results you aimed at, you should go back to the PRECEDE part of the model, try to determine what needs to be changed, and adjust what you’re doing accordingly. The point of evaluation is not to see whether you pass some kind of test – it’s to make sure that your intervention brings about the outcome that the community wanted or needed in the first place.

In Summary

PRECEDE-PROCEED provides a logic model that can serve as the basis for an individual, one-time intervention or a decades-long community development program or project. Although designed for health programs, it’s adaptable to other community issues as well. As with many models, it’s meant to be a guide, not a prescription.

PRECEDE-PROCEED is community-based and participatory, founded on the premise that changes promoting health (and other community issues) are largely voluntary, and therefore need the participation of those needing to change and others who might influence them or be influenced by them.

A major reason to use PRECEDE-PROCEED is that it is a logic model. As a result, it will provide a structure within which to plan your work, and organize both your thinking and your actions, so that your intervention will be a carefully-planned, coherent whole, rather than cobbled together. As a logic model, it also provides a guide for analyzing the issues involved, and choosing both the most likely areas to address and the most likely avenues to address them.

There are also reasons to use PRECEDE-PROCEED specifically. First, it’s a participatory model. By involving the community, it will both bring more and better ideas about issues and resolving them, and build community ownership of the intervention. Second, since it includes multi-level (ecological) planning and evaluation, PRECEDE-PROCEED builds in monitoring of the intervention, allowing for adjustment and greater effectiveness. And finally, the model allows the freedom to adapt the structure to whatever content and methods meet the needs of your community.

PRECEDE is the diagnostic portion of the model. It starts with the idea that the focus of change must be on its desired outcome, and works backward from that outcome to construct an intervention that will bring it about. It has four phases:

Phase 1: Social diagnosis – determine what the community wants and needs to improve its quality of life.

Phase 2: Epidemiological diagnosis – determine the health problems or other issues that affect the community’s quality of life. Include also the behavioral and environmental factors that must change in order to address these problems or issues. Behavioral factors include patterns of behavior that constitute lifestyles. In considering environmental factors, you should include the physical, social, political, and economic environments.

Phases 1 and 2 identify the goals of the intervention.

Phase 3: Educational and organizational diagnosis – determine what to do in order to change the behavioral and environmental factors in Phase 3, taking into account predisposing factors (knowledge, attitudes, beliefs, values, and confidence); enabling factors (availability of resources, accessibility of services, government laws and policies, issue-related skills), and reinforcing factors (largely the influence of significant others in the social environment).

Phase 4: Designing programs or interventions and the support for them through administrative and policy diagnosis – determine (and address) the internal administrative and internal and external policy factors that can affect the success of your intervention. The former include organizational structure, procedures, culture, and resources; the latter encompass both internal policies and funders’ requirements, oversight agency regulations, state or federal laws, or local ordinances, and unstated community policies.

Phases 3 and 4 set the structure and targets for the planning and design of the intervention.

PROCEED is, in medical terms, the treatment portion of the model, and comprises the implementation and evaluation of the intervention. It consists of four phases:

Phase 5: Implementation – conduct the intervention.

Phase 6: Process evaluation – determine whether the intervention is actually taking the actions intended.

Phase 7: Impact evaluation – determine whether the intervention is having the intended effects on behaviors and/or environment.

Phase 8: Outcome evaluation – determine whether the intervention ultimately brings about the improvements in quality of life identified by the community as its desired outcome.

An unstated but important part of the model is that, at any point, your plan or intervention can and should be revisited and revised, based on continued analysis and the results of the various evaluations.

What is PRECEDE-PROCEED?

___PRECEDE-PROCEED is a community-oriented, participatory model for creating successful community health promotion interventions.

PRECEDE has four phases:

___Phase 1: Social diagnosis

___Phase 2: Epidemiological diagnosis, including behavioral and environmental diagnosis

___Phase 3: Educational and organizational diagnosis

___Phase 4: Administrative and policy diagnosis

PROCEED has four phases:

___Phase 5: Implementation

___Phase 6: Process evaluation

___Phase 7: Impact evaluation

___Phase 8: Outcome evaluation

PRECEDE-PROCEED rests on the following premises:

___Since behavior change is by and large voluntary, health promotion (and, by extension, the promotion of other community benefits) is more likely to be effective if it's participatory.

___Health and other issues must be looked at in the context of the community.

___Health and other issues are essentially quality-of-life issues.

___Health is itself a constellation of factors that add up to a healthy life for individuals and communities.

Why use PRECEDE-PROCEED?

You use PRECEDE-PROCEED because:
___A logic model provides a procedural structure for constructing an intervention.

___A logic model provides a framework for critical analysis.

___PRECEDE-PROCEED is participatory, thus assuring community involvement.

___Community involvement leads to community buy-in.

___PRECEDE-PROCEED incorporates a multi-level evaluation, which means you have the chance to constantly monitor and adjust your evaluation.

___The model allows leeway to adapt the content and methods of the intervention to your particular needs and circumstances.

How do you use PRECEDE-PROCEED?

___In Phase 1, you ask the community what it wants and needs to improve its quality of life.

___In Phase 2, you identify the health behaviors and lifestyles and/or environmental factors that most clearly influence the outcome the community seeks that must be changed to affect the issues, and determine which of them are most likely to be changeable.

___In Phases 1 and 2, you create the objectives for your intervention.

___In Phase 3, you identify the predisposing, enabling, and reinforcing factors that act as supports for or barriers to changing the behaviors and environmental factors you identified in Phase 2.

___In Phases 3 and 4, you plan the intervention.

___In Phase 4, you identify (and adjust where necessary) the internal administrative issues and internal and external policy issues that can affect the successful conduct of the intervention.

___Those administrative and policy concerns include generating the funding and other resources for the intervention.

___In Phase 5, you carry out the intervention.

___In Phase 6, you evaluate the process of the intervention - i.e., you determine whether the intervention is proceeding according to plan, and adjust accordingly.

___In Phase 7, you evaluate whether the intervention is having the intended impact on the behavioral and environmental factors it's aimed at, and adjust accordingly.

A PowerPoint presentation summarizing the major points in the section.

• What is Healthy Cities/Healthy Communities?
• Why use Healthy Cities/Healthy Communities?
• Who should participate in Healthy Cities/Healthy Communities?
• How do you use Healthy Cities/Healthy Communities?

 

In this video, Tyler Norris, Vice President of Kaiser Permanente Center for Total Health, discusses the meaning and impacts of community health. "What is a healthy community? What is healthy, and what is a community?" He asks. In this section, we will explore the concepts of defining, creating, and promoting healthy communities.

What is Healthy Cities/Healthy Communities?

Healthy Cities/Healthy Communities is a theoretical framework for a participatory process by which citizens can create healthy communities. In 1985, at a conference in Toronto organized by Trevor Hancock, Len Duhl spoke about his long-held conviction that health issues could only be effectively addressed through an inclusive, community-wide approach. Ilona Kickbusch, a World Health Organization (WHO) official who was attending the conference, brought the idea back to her superiors at the WHO European office in Copenhagen. Within a matter of weeks, Duhl and Hancock had been hired as consultants to help WHO and Kickbusch start a Healthy Cities movement in Europe. A year later, the attendees of a WHO conference in Ottawa drafted the Ottawa Charter, the “Constitution” of Healthy Cities/Healthy Communities. In the years since that first conference, the concept has spread to hundreds of large and medium-sized cities on all continents, and has also been used in smaller municipalities and rural communities in both the developing and the developed world. It is now the standard way in which the WHO addresses community health, and it encompasses other community issues as well.

A healthy community, as we discussed above, is one in which all systems work well (and work together), and in which all citizens enjoy a good quality of life. This means that the health of the community is affected by the social determinants of health and development – the factors that influence individual and community health and development.

So, what does the Healthy Cities/Healthy Communities model look like? Unlike PRECEDE/PROCEED, it has no flow chart or diagram, largely because its process may be totally different in different communities.It’s a loosely-defined strategy that asks citizens and officials to make becoming a healthy community a priority, and to pursue that end by involving all community members in identifying and addressing the issues most important to them.

We have created an informal logic model in order to connect you to your Community Tool Box resources that can support your effort to implement Healthy Cities/Healthy Communities.

Healthy Cities/Healthy Communities rests on two basic premises:

A comprehensive view of health. As we’ve been discussing, a comprehensive view of health takes in all the elements of a community’s life, since they affect both individual health and the health of the community itself. The Ottawa Charter lays out the prerequisites for health in communities:

Peace. This can be interpreted to cover both freedom from warfare, and freedom from fear of physical harm.

During the Vietnam War, young Black men on the streets of their home neighborhoods in the U.S. were statistically more likely to be killed by gunfire than were young black soldiers in combat. Those home neighborhoods weren’t at peace, by anyone’s definition.

Shelter. Shelter adequate to the climate, to the needs of the occupants, and to withstand extremes of weather.

Education. Education for children (and often adults as well, as in the case of adult literacy) that is free, adequate to equip them for a productive and comfortable life in their society, and available and accessible to all.

Food. Not just food, but enough of it, and of adequate nutritional value, to assure continued health and vigor for adults, and proper development for children.

Income. Employment that provides an income adequate for a reasonable quality of life, and public support for those who are unable to work or find jobs.

A stable ecosystem. Clean air, clean water, and protection of the natural environment.

Sustainable resources. These might include water, farmland, minerals, industrial resources, power sources (sun, wind, water, biomass), plants, animals, etc.

Social justice. Where there is social justice, no one is mistreated or exploited by those more powerful. No one is discriminated against. No one suffers needlessly because she’s experiencing poverty or ill or disabled. All are treated equally and fairly under the law, and everyone has a voice in how the community and the society are run.

Equity. Equity is not exactly the same thing as equality. It doesn’t mean that everyone gets the same things, but that everyone gets, or has access to, what he needs.

If all of these factors are considered, then health must extend far beyond medical treatment to all aspects of community life.

A commitment to health promotion. Health promotion differs from the more familiar medical models of treatment and prevention. Both of these look at health from a negative point of view: there’s something wrong or potentially wrong, and the medical expert will step in to fix it or head it off. Health promotion looks at it from a positive point of view: you can take positive steps to improve and sustain your well-being.

Health promotion – and we’ll use the term here to mean the promotion of healthy communities as well as healthy individuals – is a key both to the thinking behind the Healthy Cities/Healthy Communities concept, and to actually developing healthy communities. It calls for a commitment on the part of all sectors of the community, particularly government, to promote community health by:

Building healthy public policy. Communities can establish policies that foster the health of the community. According to the Ottawa Charter, such policies are “coordinated action that leads to health, income, and social policies that foster greater equity.” Thus, smoking bans in restaurants, local tax policies that encourage businesses to create jobs, training for police and youth workers to help them communicate with youth and curb youth violence, and strong environmental ordinances might all be seen as healthy public policy. Community support of such policy produces an atmosphere that makes it easier for policy makers to make the right choices, because they know the public is behind them.

Like all elements of a Healthy Cities/Healthy Communities strategy, healthy public policy is about a great deal more than simply fostering individual health – it’s about public policy that fosters a healthy society. That means equity, health for all, and attention to such things as supportive environments (see below).

Len Duhl talks about the fact that most public policy doesn’t deal with real needs, but rather with concerns of economics and power.  For public policy to be healthy, it has to reflect reality, rather than what policy makers want to see, or what will get them elected. Objectivity leads to public policy that benefits everyone, not just the influential few.

Creating supportive environments. Community environments run the gamut from the physical to the social to the economic to the political. Some supportive environments can be created by laws or regulations, some by community effort, and some only by changes in attitude (which may or may not be influenced by social and other pressures). Some examples:

The natural environment. Laws and regulations that restore and/or preserve clean air and water; preservation and creation of open space, natural beauty, and wilderness; restrictions on the use and disposal of toxic substances; conservation of natural resources, including plants and animals. All of these can enhance health and reduce stress, provide an aesthetic experience, and affect community life for the better.

The Peak to Peak Healthy Communities Project, based in Nederland, CO, is working on renovating parks and creating a transportation link from downtown to trails and natural areas outside the city.

The built environment. People-friendly design of buildings and spaces (human scale, with pedestrian passageways, gathering places, views, attractiveness, etc.); accessible access / accessibility for people with disabilities; preservation of historic and cultural heritage; cleanliness; safety (lighting, building and bridge design, long views, traffic patterns, bans on the use of toxic materials); good public transportation; traffic-free paths to encourage walking, jogging, and bicycling.

For example, a city that builds or designates traffic-free walking and bike paths will probably see more of its citizens walk and bicycle to work and on errands than one where walking and biking are difficult and dangerous.  Davis, California, for instance, has encouraged bicycling since 1960, when it became the first city in the US to paint bike lanes on its streets.  It has been able to discontinue its school bus service, because it’s so easy for children to bike, walk, or skate to school on its miles of car-free bike paths.

The economic environment. A healthy economic environment is one where there is work for everyone capable of working, where workers are treated as assets (see directly below) and are paid a living wage, where there is equal economic opportunity for all, where those who can’t work are supported, and where money doesn’t buy political power or immunity from the law.

Bethel New Life, a faith-based, grass roots initiative in the Garfield Park neighborhood of Chicago, started out to rehabilitate derelict housing in the area, using “sweat equity” – i.e., the labor of local residents, who could then exchange their work for part of the cost of the home they had rebuilt.  Now, Bethel employs more than 300, mostly local residents, in housing, employment training and job placement, economic development, cultural, family support, and community development programs.  Its board is drawn almost wholly from the community, and its programs are responses to voiced community need. Bethel continues to try to build assets and bring greater economic stability to the West Side of Chicago.

The work environment. The work environment should be a source of stimulation, rather than stress. Respect for employees, good safety precautions and procedures, firm rules forbidding harassment or abuse, adequate pay and/or other compensation, humane and fair production expectations and treatment – all contribute to work environments that nurture creativity and enthusiasm, and improve, rather than detract from, both production and workers’ quality of life.

The leisure environment. The work and home environments can provide time for leisure. The community can provide recreational and cultural opportunities to use in that leisure time: museums, parks and beaches, cultural and sports events, libraries, etc.

The social environment. A healthy community encourages social networks, provides gathering places where people from all parts of the community may mingle, nurtures families and children, offers universal education and other services, strives to forster non-violent an healthy behavior, invites familiartity and interaction among the various groups that make up the community, and treats all groups and individuals with respect.

The North Quabbin Community Coalition, in north central Massachusetts, was concerned, among other things, with the high incidence of child physical and sexual abuse in the area.  A task force on the issue eventually developed into Valuing Our Children, a parent education and family life program, that has trained large numbers of area parents as “parent educators,” and that provides services to area families.

The political environment. In a healthy community, all citizens have a say in how and by whom their community is governed, and have easy access to the information necessary to understand political situations and to make informed political decisions. Political decisions, opinions, and speech are protected. Citizens feel they have the power in the community – that they own it, and can and should control its direction.

Strengthening community action. Communities can encourage and strengthen community action in at least three ways: The first involves encouraging and fostering grass roots planning and action. When issues are identified and addressed by the people affected by them, as well as by others concerned, two things happen: the issues are more likely to be resolved successfully, and the people involved learn how to use their own resources to take charge of their lives and their communities. A second way of strengthening community action is through a commitment from government, community leaders, and other decision makers to encourage action by passing legislation conducive to it, lending public support to it through the media and other communication channels, and including members of all segments of the community in the conception, planning, and implementation of any community initiative. The third is by decision makers and the media ensuring a free and accurate flow of necessary information about the community and community initiatives to all citizens, and providing everyone in the community with learning opportunities about issues and about the quality of life in general.

The latter two of these methods are really top-down conceptions where government and others in power “let” citizens share in the decision-making process. While community members – particularly those with less experience in planning and running projects, or with less education – often need support to learn some necessary skills, the drive for change can and should come from them to begin with. There is a big difference between officials organizing an initiative and inviting citizens to join, and officials approaching citizens with a request to participate in envisioning and organizing an initiative.

Developing personal skills. Healthy communities aid their citizens in gaining the skills necessary to address health and community issues, by providing education and information in school, home (through the media and other sources), work, and community settings. Courses, workshops, billboards and posters, TV and radio ads, newspaper articles, mailings, fliers, community meetings, presentations in social clubs and churches, the use of electronic technology – all might serve to help citizens understand an issue, and make decisions about it.

The education referred to here doesn’t relate only to health and wellness issues and life skills (e.g., parenting).  In fact, it could, and does, apply to all learning that touches on topics related to the life of the community – political, social, environmental, and economic issues, for instance.  Furthermore, the encouragement and accessibility of lifelong learning is a mark of a healthy community.

Reorienting services. To be useful to a Healthy Cities/Healthy Communities strategy, health and other human and municipal services have to change from an individual- and treatment-centered point of view to one that is community-centered and focuses on the promotion of a healthy community.

It’s not only a matter of reorienting health services, but one of reorienting all services to work together toward the goal of a healthy community.  Any community issue has to be viewed through the lenses of both the individual and the community.  It takes a village not only to raise a child, but to pull families out of poverty, to create employment, to improve mental health, to stop violence, to safeguard the natural environment, and to create a just and equitable society.

Why use Healthy Cities/Healthy Communities?

There are a number of reasons to consider using the Healthy Cities/Healthy Communities framework in planning and implementing community action:

• Community perspective. Virtually all health and community issues are affected by (or are the direct result of) economic, social, political, and/or environmental factors that operate at the community level. If you don’t deal with those factors, the chances are slim that you’ll be able to resolve the issue you’re concerned with.
• Participatory planning and community ownership. Planning that includes those who will be directly affected by or benefit from any community initiative is more likely to reflect the real needs of the community than planning done only by one group. Furthermore, the participatory nature of the Healthy Cities/Healthy Communities framework means that citizens themselves create initiatives and goals for the community. Those initiatives and goals are theirs – not imposed by those in power or by outside “experts”. As a result, their commitment to the process and to the goals makes them far more likely to support and work for the outcomes they’ve chosen.
• Range of ideas. Citizen participation leads to the presentation and consideration of a greater range of ideas and possibilities, and is therefore more likely to hit upon effective goals and actions.
• Knowledge of the community. Citizen participation taps the community’s wisdom about its own history, relationships, and conflicts, and can thus steer initiatives around potentially fatal pitfalls.
• Community-wide ties. Involving all segments of the community encourages interaction across social, economic, and political lines. Those ties strengthen the community as a whole, change people’s perspectives for the better, increase community-wide cooperation, and can positively transform how the community works.
• Achievable and measurable goals. Although Healthy Cities/Healthy Communities’ ultimate goals are wide and long-term, each goal is achievable in a manageable amount of time, and its successful achievement can be demonstrated. Each success sets the stage for enthusiasm for the next initiative.
• Identification and use of community assets and resources. A Healthy Cities/Healthy Communities initiative depends to a large extent on human, institutional, organizational, environmental, and other assets and resources already available within the community. Through identifying and using these, communities learn that they can create their own positive change, and reshape themselves in the ways they want to.
• Community commitment to the long-term process. Because of the participatory nature of the process, and because it requires recruiting more people at each new phase, it builds an ever-expanding  core of people with varied skills, talents, and experience committed to the ideal of building a healthy community and improving the quality of life for everyone. That’s important for sustaining the work indefinitely.
• Community self-image. Through the use of the Healthy Cities/Healthy Communities process, the community comes to think of itself as a healthy community, and is concerned with maintaining that image through addressing issues as they come up. Perhaps more important, it is brought to look at the larger picture as well. Holding out an ultimate goal of a totally healthy community, whether attainable or not, keeps everyone working toward it, and means that planning goes on as a matter of course.  The healthy community ideal becomes embedded in the self-image of the community, and people understand that they can take their fate in their own hands and work to improve it. The process itself thus becomes an important element in the definition of a healthy community – one in which citizens work together to identify and solve problems, create and consolidate assets, generate improvements, and raise the quality of life for all.

Who should participate in Healthy Cities/Healthy Communities?

The easy answer to this question is everyone in the community, and that’s in fact the ideal. In a perfect world, everyone everywhere would participate in some way in creating a healthy community. In the real world, while it’s important to try to involve all sectors of the community, you have to work to involve some particular people and groups if your effort is to be successful. Crucial participants include:

• Elected and appointed officials. Although a Healthy Cities/Healthy Communities initiative should not be top-down, it needs the commitment and backing of those with the power to make things happen. Officials can use the media to publicize the effort, pass laws and regulations (and enforce those already existing) that reinforce it, and throw the weight and resources of government behind it. Without official support, a community-wide effort is more likely to fail.
• Those most affected by the issue. A sure recipe for failure is to try to impose an intervention or initiative on a population “for their own good.” All too often, “experts” – often people who have no real knowledge of the group or its issues – formulate plans that might make perfect sense on paper, but make no sense at all in the actual situation for which they’re proposed. The participation of those affected in identifying the issues to address, developing action plans for addressing them, and implementing and overseeing those plans is absolutely crucial to the success of a Healthy Communities initiative. (This is equally true when the group concerned is the whole community.)

There are, unfortunately, many instances of a group resisting and short-circuiting well-meaning changes because they weren’t part of the planning.  The author experienced one as a teacher in Philadelphia, which had, at the time, an innovative and progressive school superintendent.  He tried to institute reforms that probably would have improved the lives of teachers students in the system, but he did it without conferring with them.  As a result, the teachers simply ignored directives from the central office, the reforms failed, and the superintendent was gone within three years.

• The people who will actually administer and carry out the initiative, or whose jobs or lives will be affected by it. It is both unfair and unwise to expect organization staff, community employees (police, firefighters, Department of Public Works personnel, etc.), business people, and others to throw themselves into carrying out an initiative they had no part in devising. It may have elements that ignore the realities of their jobs or their lives, or that make things harder than necessary for them, and they may be the only people who have the information to understand that. In addition, they may regard it as just another foolish imposition to be gotten around, and do as little as possible to make it effective.
• All the agencies and groups that will need to cooperate and to coordinate their activities in order to implement a community-wide effort. Both the ways in which these groups will work together, and which of them will have responsibility for what have to be part of the planning for any community-wide initiative. Without their full participation, there’s no guarantee that they’ll work together at all, let alone that the methods for their doing so will be simple and efficient.
• Community opinion leaders. These are the people whose opinions others trust, and who lead the community by adopting new ideas and pulling others with them. They are seen as level-headed, smart, and serving the best interests of the community. Some may be current or former members of the groups already listed, and others may be clergy, credible institutional or business people (college presidents or faculty, CEO’s), or just average citizens who are known for their integrity and common sense.

If you can gain the participation of members of all these groups, it is more likely that everyone else will follow. If you can’t get people from all these groups to buy in at the outset, an alternative is educating them about the process and persuading them to join it, while you continue to recruit other participants. Ultimately, the combination of education and your momentum will bring in those who were initially reluctant. That may take time and patience, but it’s worth the effort – it can easily mean the difference between a successful long-term Healthy Community movement and a dead-on-arrival, failed attempt at one.

How do you use Healthy Cities/Healthy Communities?

Because the Healthy Cities/Healthy Communities framework is just that – an intellectual framework, rather than a prescription – there is no step-by-step instruction for employing it. It is meant to be adapted to the different needs of different communities. There are, however, necessary components of any Healthy Cities/Healthy Communities initiative:

• Create a compelling vision based on shared values. As with virtually any process that involves planning – and particularly participatory planning – the first step is to create a vision that defines the effort to be made. That vision may be broad (“A community that is truly just and equitable”) or more specific (“A community where every potential worker in the community can find employment that offers a living wage and acceptable working conditions”). Whatever the case, the vision must be compelling – one that motivates people to work for its realization. It must be founded in those values that they hold in common, and must be widely shared and recognized as legitimate and desirable.( Proclaiming Your Dream: Developing Vision and Mission Statements.)

In Orlando, Florida, the Healthy Community Initiative began with meetings of a few influential people. As they learned about healthy communities, the convened a group of about 160, representing all sectors of the city’s population – citizens of all races and economic levels, organizations and institutions, city government, other groups – to hash out a vision. That group, in turn, conducted citizen focus groups and public meetings to hear and understand citizens’ concerns. Ultimately, they drafted a vision, based on their own discussions and the input of hundreds of others from all walks of life, that contained 14 statements about what Orlando should be. That vision became the foundation of the initiative.

• Embrace a broad definition of health and well-being. Health must be seen as not merely the physical health of individuals, but the creation and nurturing of those factors leading to health named in the Ottawa Charter (peace, shelter, education, income, food, a stable ecosystem, sustainable resources, social justice, and equity). A truly healthy community encompasses – or works toward – all those elements and more.
• Address quality of life for everyone. The key word here is “everyone.” A Healthy Cities/Healthy Communities initiative should be aimed at improving the quality of life for all groups and individuals in the community, not just those in a particular priority group or those who began the initiative.
• Engage diverse citizen participation and be citizen-driven. Initiatives should be originated, planned, and implemented with the full participation of citizens from all racial, ethnic, and socio-economic groups and all walks of life. Citizens themselves, rather than a government agency or experts of some sort, should be the force behind both the direction and the implementation of any community initiative.
• Seek multi-sectoral membership and widespread community ownership. All sectors of the community – government, the business and non-profit communities, health care, education, faith communities, cultural institutions and the arts, priority populations, and ordinary citizens – should be represented in an initiative, and the community should feel that it created the initiative and owns it.

In many places in this and other sections of the Community Tool Box, we refer to “ownership” of an initiative or intervention or organization. In most cases, what we mean is that those who take part in creating and/or running such an endeavor feel that it belongs to them. It was their idea, and they therefore see themselves as not only supportive of it, but responsible for it.

True ownership can rarely, if ever, be attached to actions or ideas that are imposed, by others who “know better” or have more power. It comes from within, from the feeling that you’ve made a choice based on your best judgment. That’s why the inclusion of people from all sectors of the community is so important to a successful Healthy Cities/ Healthy Communities process. At the end, perhaps after a lot of argument and soul-searching, participants feel that they’ve had a hand in creating something important that will result in better lives for everyone in the community.  There’s no substitute for that feeling to ensure their doing all they can to make their creation work.

• Acknowledge the social determinants of health and the interrelationship of health with other issues (housing, education, peace, equity, social justice). The research on the social determinants of health points to three overarching factors:
  • Socioeconomic equity.  For developed countries, the economic and social equality within the society or a given community is a greater determinant of death rates and average lifespan than the country’s position with regard to others. The size of the income gap between the most and least affluent segments of the society or community is tremendously important, and determines to a large extent whether people get what they need.
  • Social connectedness. Many studies indicate that “belonging” – whether to a large extended family, a network of friends, a social or volunteer organization, or a faith community – is related to longer life and better health, as well as to community participation.
  • Sense of personal efficacy. This refers to people’s sense of control over their lives. People with a higher sense of efficacy tend to live longer, maintain better health, and participate more vigorously in community affairs and politics.

Like the Ottawa Charter, the World Health Organization, in its publication The Solid Facts, recognizes the need to break these factors down into more manageable pieces. It lists ten factors that affect health and life expectancy, and advocates addressing each within a coherent program that looks at all of them within a society. These ten factors are:

• The social gradient (equity)
• Stress
• Early life
• Social exclusion (the opposite of social connectedness)
• Work
• Unemployment
• Social support
• Addiction
• Food
• Transport

• Address issues through collaborative problem-solving. Given a diverse group, there are bound to be disagreements and conflicts. These should be viewed as opportunities, rather than roadblocks, and people should be encouraged and helped to work together to reach creative solutions.
• Focus on systems change. To be successful, a Healthy Cities/Healthy Communities initiative has to be active, rather than reactive. It’s not enough to “fix” a problem: your goal is to eliminate the causes of that and other problems and improve the long-term quality of life in the community in the process.

In order to address causes, you have to concentrate not on individual problems, but on improving and changing systems – the ways in which the community operates, and the attitudes, assumptions, and policies behind them. That includes identifying, using, and strengthening the assets the community already possesses, as well as changing the systems that pose problem

• Build capacity using local assets and resources. All communities, no matter how troubled, have great real and potential strengths. These vary from community to community, but could include:

Individuals with the talents, skills, leadership, and passion to work to change the community for the better.

Individuals, businesses, and foundations that can provide material resources – money, space, etc. – to a community effort.

• Institutions – libraries, schools, hospitals, houses of worship – that have the capacity to act as both resources for and agents of change.
• Community-based and other organizations whose mission is to work for the betterment of the whole community.
• Governments and individual government officials that can add both official support and legal and regulatory power to an initiative.
• Human resources – the skills and work ethic of the community’s work force, for example.
• Natural and other environmental resources – open space, clean air and water, wilderness, fisheries, historic sites or buildings, housing stock.
• Perhaps most important, the potential for all these individuals, groups, and resources to be joined in a coordinated pursuit of a common vision.
• At least some of these and other assets already exist in virtually every community – usually to a far greater extent than most citizens realize until they start looking for them. They must be identified and included in a Healthy Cities/Healthy Communities effort.
• Measure and benchmark progress and outcomes. Whatever you’re doing, whether it’s a PR campaign or a complex behavioral intervention, you have to monitor and evaluate it in order to be sure that it’s effective. That means setting objectives – benchmarks – to indicate your progress along the road to your goal, and defining clearly the outcome you’re aiming for. Regularly monitoring what you’re doing is crucial, because it allows you to spot problems or inadequacies in goals, methods, procedures, communication, etc. and correct them before they derail your initiative entirely. Even more important, regular monitoring allows you to change what you’re doing to respond to changes in circumstances and community needs, so that you’re always addressing current reality. Communities are dynamic: they develop and change, sometimes in short periods. Your initiative has to be dynamic, too, especially if you expect it to continue for the long term.

Implementing a Healthy Communities strategy

How do you actually put these components together to create a healthy community? There’s no one way to do that – it depends on your community, the issues you want to address, and the ideas and capacities of the groups and individuals that participate in the Healthy Cities/Healthy Communities process. There are, however, some basic procedures that, at least in outline, should be common to any Healthy Cities/Healthy Communities initiative.

• Assemble a diverse and inclusive group. To begin a Healthy Cities/Healthy Communities initiative, people from all parts of the community have to come together to hammer out a vision. That group, as we’ve been saying throughout this section, should be representative of everyone in the community, so that whatever it decides will be seen as legitimate by just about everyone, and will be owned by the community.

Someone has to start the process. That may be a charismatic or persistent individual, an organization, a coalition, or a government office or agency. Whoever it is should be simply a convener, and not necessarily expect to lead over the long term. Leaders should be chosen by the group itself as it forms, and they should be collaborative ( Collaborative Leadership.)

This is not to say that a Healthy Communities effort doesn’t need leadership.  Quite the contrary – leadership and structure are necessary for any successful effort.  But leadership should be collaborative and arise from the community.  The leader may be an individual, or two, or a larger group.  Whatever the situation, the leadership should be one of an equal among equals, and decision-making should be the province of the whole group.  That’s how a participatory process works.

It is assumed that all the other steps listed here will also be carried out by an inclusive group, and that all sectors of the community – including those affected and individual citizens – will be represented and have decision-making power. The group may change from step to step or over time, but should remain inclusive and participatory.

• Generate a vision. A vision of how the community should be, based not on a single issue, but on values shared among all participants and on a high quality of life for everyone in the community, is needed to motivate and inspire participants and to guide the initiative over the long term. Generating such a vision may take time and a great deal of discussion, but it’s absolutely necessary for a successful effort.
• Assess the assets and resources in the community that can help you realize your vision, and the issues that act as barriers to it. Placing assets first is not just an accident here. A Healthy Cities/Healthy Communities initiative is best served by looking at the community through a positive lens, and asking first what’s right with it, rather than what’s wrong with it. The initiative then becomes an exercise in community health promotion, instead of the treatment of a diseased community. Taking a positive perspective affects for the better the attitudes of everyone involved, the community’s self-image, and the perception of whether or not realizing your vision is possible. By the same token, it’s important to be honest and clear-eyed about issues and problems in the community. Once they’ve been identified, they have to be acknowledged and understood, so they can be addressed at some point in the process.
• Choose a first issue to focus on. The best way to sink a long-term initiative is to try to accomplish all your goals at once. It’s vital to choose one issue – or in some cases, perhaps, two or three – to attack, and to make it one that can be resolved, so that your first effort leads to success.

What the issue is doesn’t matter, except in that it must be one chosen by citizens as important to them, and must be one that is specific enough to be resolvable.  Len Duhl talks about the process in a 1993 interview by Joe Flower in Healthcare Forum Journal.

The first thing that happens when the Healthy Cities program develops in a new place is that some persons assume the responsibility of bringing together all segments of the community to deal with the issues: the business community, the government, the voluntary sector and the citizens themselves. ...

Then there are "vision workshops" in which people are asked, "What kind of city do you really want?" My personal surprise is that the clearer I am about what a Healthy City program is, the less likely a community is to develop it. The fuzzier I am in what a Healthy City is, "A Healthy City is what you want to make it," the greater the odds are that they will start.

The various participants define the program. All I say is that you have to start someplace. You have to begin to look at it in an ecological and systemic way. You have to involve people. You have to start thinking of values of equity and participation. Beyond that, you can start wherever you want.

Some cities start on the environment, on pollution, on smoking, seat belts and the quality of life index. Some have government operations, some have newspapers, big organizations, housing. Barcelona linked it to the Olympics. Glasgow linked it to developing itself as the cultural capital of Europe. It is being done every way.

• Develop a community-wide strategy, incorporating as many organizations, levels, and sectors as possible. Here’s where Healthy Cities/Healthy Communities differs most from many logic models and other methods that are clear on exactly how to go about planning and carrying out an initiative. Rather than offering a step-by-step process, HC might use any participatory planning process that incorporates a community-wide approach and that looks at all the possible areas that might affect the issue chosen. Thus, you might use VMOSA, PRECEDE/PROCEED, or some variant, or a less structured process – whatever seems appropriate and works for your community.

It is important, however, that your plan result in a community-wide, multi-pronged approach. If your focus is on youth violence, for instance, it should involve some sort of action or supportive function by local government, parents and parent advocates, schools, law enforcement, the court system, welfare, agencies that deal with youth and families, physical and mental health services, Family Planning, the media, adult literacy (people who left school before graduating), and potentially or formerly violent youth and their victims. All of these groups and individuals should be working together as a team, each referring youth to other appropriate services or agencies among them, and all coordinated and collaborating in their operation. The focus should be on changing the systems that make a problem possible, or that present barriers to the ideal the community is working toward.

• Implement the plan. Once again, this should involve a community-wide effort. Any oversight of the implementation should include a broad range of individuals and groups, representing a cross-section of the community.
• Monitor and adjust your initiative or intervention. Once you’ve implemented your plan, it’s crucial to evaluate the effectiveness of both your process (Are you doing what you set out to do?) and your results (Are you reaching your benchmarks? Are you having the planned effect on the issue?) If an evaluation gives unsatisfactory answers to any of these questions, you can revisit the issue, determine the reasons your plan isn’t working well, and change it accordingly.
• Establish new systems that will maintain and build on the gains you’ve made. Once you’ve reduced youth violence, for example, you still have to do whatever is necessary to make sure it doesn’t rise again, and that it continues to decline. (What’s the ultimate goal here? Is there an acceptable level of youth violence?) That may mean setting up new organizations or programs, working to change or cement changes in community attitudes and procedures, redesigning school curricula, working regularly with the media – whatever it takes to sustain progress.
• Celebrate benchmarks and successes. Public celebration of achievements not only energizes those who have been working toward them, but informs the community that the drive toward a healthy community is moving forward successfully. It helps to establish the idea of a healthy community in the public mind, and to build a foundation for the continuation of the initiative.
• Tackle the next issue(s). The ultimate goal here is the development of a truly healthy community, which translates to improving the quality of life for everyone in the community. After your first success, it’s time to use your momentum to address another (or more than one other) issue. That may be the removal of a barrier to a healthy community, or it may be the creation of a necessary element of a healthy community. In either case, it means sustaining citizens’ commitment to an ongoing and long-term process, the end result of which is a community controlled by its residents, where all systems work toward the public good.

In Summary

The health of a community, like that of an individual, depends on far more than freedom from pain or disease. Health, or its lack, for a community is the result of a large number of factors, often intertwined, that span the social, economic, political, physical, and environmental spheres. Virtually any community issue has an effect on, and is affected by, the overall health of the community as a whole, and therefore should be approached in a community context. Healthy Cities/Healthy Communities provides a philosophical framework for an inclusive, participatory process aimed at raising the quality of life for everyone, and creating a truly healthy community.

Two basic premises underlying the Healthy Cities/Healthy Communities concept are a comprehensive view of health and community issues, covering a broad range of factors that contribute to a healthy community; and a commitment to the active promotion of a healthy community, rather than the “treatment” of problems. By addressing the social and other determinants of health and community issues (including the Ottawa Charter’s list of peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity), and by creating appropriate policy and environments, encouraging social action, providing personal skills, and reorienting services to a more wide-ranging approach, communities can foster citizen empowerment and equity.

Reasons for adopting the Healthy Cities/Healthy Communities approach include:

• Its community perspective, leading to a more effective approach to issues.
• Community ownership of any effort, resulting from community participation in its development and implementation.
• The broad range of ideas gained from a participatory process.
• Its access to citizens’ knowledge of the community, helping to avoid pitfalls caused by ignorance of community history and relationships.
• The forging of community-wide and ties that cross economic, social, racial, and other lines.
• Participatory planning leading to solutions that reflect the community’s real needs.
• The adoption of achievable goals, leading to success.
• The identification and use of community assets and resources which both take advantage of what already exists, and teach the community what it can do with its own considerable resources.
• The fostering of community commitment to the process of building a healthy community.
• The creation of a healthy community self-image.

While a Healthy Cities/Healthy Communities process should involve everyone, some particularly important participants include local government and officials; those affected by the issue(s); those who will actually administer and implement the initiative, or whose lives or jobs will be affected by it; any organizations that will be expected to work together; and opinion leaders.

There are 10 important components of a Healthy Cities/Healthy Communities process:

1. Create a compelling vision based on shared values.
2. Embrace a broad definition of health and well-being.
3. Address quality of life for everyone.
4. Engage diverse citizen participation and be citizen-driven.
5. Multi-sectoral membership and widespread community ownership.
6. Acknowledge the social determinants of health and the interrelationship of health with other issues (housing, education, peace, equity, social justice).
7. Address issues through collaborative problem-solving.
8. Focus on systems change.
9. Build capacity using local assets and resources.
10. Measure and benchmark progress and outcomes.

Although there is no one step-by-step procedure for a Healthy Cities/Healthy Communities initiative – both the content and the structure of the process depend upon your community’s needs, and, particularly on community decisions – there is, given the ten components above, a reasonable way to approach it in most cases.

• Assemble a diverse and inclusive group.
• Generate a vision.
• Assess the assets and resources in the community that can help you realize your vision, and the issues that act as barriers to it.
• Choose a first issue to focus on.
• Develop a community-wide strategy, incorporating as many organizations, levels, and sectors as possible.
• Implement the plan.
• Monitor and adjust your initiative or intervention.
• Establish new systems that will maintain and build on the gains you’ve made.
• Celebrate benchmarks and successes.
• Tackle the next issue.

What is Healthy Cities/Healthy Communities?

___Healthy Cities/Healthy Communities provides an intellectual and philosophical framework for an inclusive, participatory process of developing a healthy community.

The two basic premises upon which Healthy Cities/Healthy Communities rests are:

___A comprehensive view of health.

___A commitment to health promotion.

Why use Healthy Cities/Healthy Communities?

You use Healthy Cities/Healthy Communities because:

___It takes a community perspective on issues and health promotion.

___It brings a sense of community ownership to any initiative.

___It provides a broader range of ideas.

___It gives access to citizens’ knowledge of the community.

___It encourages community-wide ties.

___It assumes participatory planning.

___It sets achievable goals.

___It asks for the identification and use of community assets and resources.

___It establishes a community commitment to the process over the long term.

___It creates a healthy community self-image.

Who should participate in Healthy Cities/Healthy Communities?

___You try to engage everyone in the community.

You make particular efforts to engage:

___Local officials.

___Target populations.

___Anyone who implements or administers, or whose life or job will be changed or affected by, the initiative.

___All the agencies, organizations, and institutions that will need to cooperate or collaborate in order to realize goals.

___Local opinion leaders.

How do you use Healthy Cities/Healthy Communities?

You include the necessary components of a successful Healthy Cities/Healthy Communities initiative by encouraging the community to:

___Create a compelling vision based on shared values.

___Embrace a broad definition of health and well-being.

___Address quality of life for everyone.

___Engage diverse citizen participation and be citizen-driven.

___Encourage multisectoral membership and widespread community ownership.

___Acknowledge the social determinants of health and the interrelationship of health with other issues (housing, education, peace, equity, social justice).

___Address issues through collaborative problem-solving.

___Focus on systems change.

___Build capacity using local assets and resources.

___Measure and benchmark progress and outcomes.

To approach a Healthy Cities/Healthy Communities process, you:

___Assemble a diverse and inclusive group.

___Generate a vision.

___Assess the assets and resources in the community that can help you realize your vision, and the issues that act as barriers to it.

___Choose a first issue to focus on.

___Develop a community-wide strategy, incorporating as many organizations, levels, and sectors as possible.

___Implement the plan.

___Monitor and adjust your initiative or intervention.

___Establish new systems that will maintain and build on the gains you’ve made.

___Celebrate benchmarks and successes

Example 1: The Mayor’s Guide for Promoting the Quality of Life, produced by Maria Teresa Cerqueira, Marilyn Rice, and their colleagues at the Unit on Healthy Settings, the Area of Sustainable Development, Pan-American Health Organization (PAHO)

PAHO is the Americas’ regional arm of the World Health Organization (WHO). In the Mayor’s Guide, it presents an alternative to the top-down model of health care and maintenance, and an example of the ways in which PAHO encourages the building of healthy communities. Rather than setting out a prescription for creating healthy communities, the Guide offers some basic principles and a framework within which municipalities and communities can work to plan and carry out initiatives that meet their unique needs.

While PAHO serves all of the Americas, the Guide is – rightly – oriented toward the countries in the region with the greatest needs and most difficult health situations. Its emphasis on shoring up the “infrastructure” of health – the physical, political, economic, and social conditions whose presence promotes, and whose absence prevents, healthy living and a good quality of life – is likely to benefit most the less developed nations where that infrastructure is weakest. At the same time, its encouragement of participatory process and decision-making speaks to all the countries in the hemisphere.

Rather than simply describing it, we’re including an edited version of the Mayor’s Guide here, as an example of a Healthy Communities framework. Also included are links to relevant Community Tool Box sections and tool kits.

Guide for Mayors and Other Local Authorities

Key Concepts related to the Healthy Municipalities and Communities (HMC) Strategy

This guide is intended to strengthen the implementation of health promotion activities at the local level, placing health promotion on the political agenda of mayors and other local authorities… [I]t is hoped that efforts will be made to ensure healthy public policies, the maintenance of healthy environments, and the promotion of healthy lifestyle.

What is the Importance of Having a Kit for Mayors and Other Local Authorities?

…PAHO offers a basic set of tools with which mayors and other local authorities can begin to implement the HMC strategy…[T]his material does not by any means pretend to be a “prescription for, or key to, success”…Successful experiences have shown that there is no single best way to deal with problems that arise.

[L]ocal government is closest to the people and can use its resources to achieve major improvements in health and the quality of life. As the community’s representative, the municipal government is in the best position to involve politicians, administrators from other sectors, and the community itself in coordinating joint projects. Finally, at the local level it is possible to mobilize the collective will…

What is the Healthy Municipalities and Communities Strategy?

The mission of the Healthy Municipalities and Communities Strategy consists of improving the implementation of health promotion and protection activities at the local level and ensuring that such activities are accorded the highest political priority, thereby encouraging the participation of government authorities and the active participation of the community…[Its] objective is to promote health together with people and communities, in settings where they study, work, play, love, and live.

A municipality begins the process of becoming healthy when its political leaders, local organizations and citizens commit themselves to, and initiate, the process of continuously and consistently improving the health and quality of life of all its inhabitants…It uses local planning as a basic tool, including social participation in management, evaluation, and decision-making. A municipality becomes healthy with sustained long-term improvement in social conditions with a view to ensuring the health and quality of life of all those who live within that particular environment.

What Do We Mean by a Comprehensive Vision of Health?

…WHO regards health as a fundamental human right and defines it as “a state of complete physical, mental and social well-being, and not the mere absence of disease or infirmity.” Several factors have been identified that affect, and often determine, the health of individuals and communities, including:

• Living and working conditions (income, education employment, physical environment, public policies);
• Psychosocial factors (care groups and/or support networks; sense of belonging to a community; the environment in which children develop; social support of family and friends; support for older adults, adolescents, pregnant women, and other vulnerable populations);
• Individual behaviors (lifestyles and behaviors: physical exercise, diet, tobacco use, alcohol and drug abuse); and
• Genetic factors.

Research indicates that living and working conditions have the greatest influence on health. Therefore, health is as much the result of our physical and social environment…as it is a product of the health-care system and social services. [See Chapter 17, Section 5, Addressing Social Determinants of Health and Development.]

What Do We Mean by Health Promotion?

The Ottawa Charter for Health Promotion (1986) defines health promotion as “the process of enabling people to increase control over, and to improve, their health”… Health promotion goes beyond the health-care sector alone, emphasizing that health should be part of the political agenda of all sectors and at all levels of government. Furthermore, the participation of the population/community is essential if health promotion actions are to be sustained.

[F]ive priority action areas are recommended:

• Build healthy public policy;
• Create supportive environments;
• Strengthen community action;
• Develop personal skills; and
• Reorient health services.

What Do We Mean by Community Participation?

…Members of a community may or may not reside in the same geographical area. What is important is that they consider themselves to be a community. An organized community is not necessarily a participatory community. To facilitate participation, the community should be given the right and opportunity to make effective decisions regarding issues affecting the lives of its members.

Steps in Developing Community Participation:

1. Become familiar with the community…This step permits technical personnel and local government to comprehend how the community understands and explains the world, whether through its beliefs, folklore, or other ways of looking at life, and to know its assets. [See Chapter 3, Sections 1, Developing a Plan for Identifying Local Needs and Resources, 2, Understanding and Describing the Community, and 8, Identifying Community Assets and Resources.]
2. Build a common vision. [See Chapter 8, Section 2, Proclaiming Your Dream: Developing Vision and Mission Statements.]
3. Utilize language and communication resources appropriate to the cultural context of the community. [See Chapter 6, Sections 1, Developing a Plan for Communication, and 19, Handling Crises in Communication; Chapter 27, Section 1, Understanding Culture and Diversity in Building Communities; and Chapter 45, Section 5, Promoting Awareness and Interest Through Communication.]
4. Keep the community informed and ensure that it takes part in decision-making throughout the process. [See Chapter 18, Section 2, Participatory Approaches to Planning Community Interventions.]
5. As the community members perceive and establish a relationship between the HMC goals and their personal lives, their health, education, housing, and other conditions, they are also able to set personal goals and feel a sense of responsibility, not just for a community initiative but for their lives in general.

What Do We Mean by Creating Effective Strategic Alliances?

Strategic alliances are relationships and agreements between different stake-holding sectors, organizations, and actors in order to achieve a desired goal. The most common strategic alliances are carried out with government agencies; health institutions and other related sectors such as education, judicial, transportation and agriculture; nongovernmental organizations (NGOs); schools and universities; the mass media; religious groups and public and private organizations. [See the CTB Toolkit 1: Creating and Maintaining Partnerships, as well as Chapter 5, Sections 5, Coalition Building I: Starting a Coalition, and 6, Coalition Building II: Maintaining a Coalition; Chapter 7, Encouraging Involvement in Community Work; and Chapter 9, Section 3, Developing Multisector Task Forces or Action Committees for the Initiative.]

What Do We Mean by Healthy Public Policies?

Healthy public policies are those that have a significant positive influence on people’s health status through their influence in the areas of education, housing, food, human resources, employment, mental health, and sustainable development. [They are] characterized by an explicit concern for health and equity…[,and] the recognition and effective exercise of the rights of the people, based on equality, with no restrictions imposed on access to, or use of services provided by different social sectors.

Healthy public policies should be translated into legislation that safeguards the conditions necessary for developing healthy lifestyles…:guaranteeing the human rights and fundamental liberties of members of the community; protecting communities, families, and individuals from risk factors; and promoting conditions that ensure that the healthiest options are those that are most accessible and most easily attainable.

Why Has the HMC Strategy Been So Successful and Appealing in the Region of the Americas?

[It] has helped to support and focus the decentralization process that many countries have been undergoing, and in light of the democratization of local decision-making, it has provided a platform on which all local stakeholders can participate in defining priorities and key interventions in a collaborative manner…Health promotion programs are more cost-effective than treatment…By coordinating the efforts of different sectors and actors, resources can be maximized and duplications eliminated.

What are the Essential Elements of a Healthy Municipality and Community?

• Building public commitment by the mayor and municipal council, local government (key sectors), nongovernmental and private sectors and the community (leaders and representatives of organizations and social groups) to the process of improving the quality of life through the HMC strategy. [See Chapter 7, Section 6, Involving Influential People in the Initiative.]
• Ensuring and continuously strengthening community participation during the planning, implementation, and evaluation phases. The HMC Strategy calls for strong community involvement and action and offers a genuine chance to strengthen and consolidate democratic processes at the regional level, especially through the participation of civil society in making decisions about priorities, activities, and the use of resources. [See Chapter 7, Encouraging Involvement in Community Work; Chapter 13, Sections 5, Developing a Community Leadership Corps, and 11, Collaborative Leadership; and Chapter 18, Section 2, Participatory Approaches to Planning Community Interventions.]
• Developing a strategic plan to overcome obstacles and threats to developing and maintaining a healthy municipality or community. This plan highlights the need to mobilize internal and external resources, provide adequate support and technical cooperation, and create healthy spaces. The participatory, multi-sectoral development process encourages decentralization and should enhance the ability of local communities to make decisions and control resources. [See the CTB Toolkit 5: Developing Strategic and Action Plans, as well as Chapter 8, Developing a Strategic Plan.]
• Building consensus and forming partnerships through various networks and projects comprised of a wide range of institutions and organizations, both within the health sector itself and with other sectors. Efforts are made to reach consensus among participants with opposing views. The strategy strongly supports the inclusion of local governmental representatives, NGOs and the private sector. “A partnership for health promotion is a voluntary agreement between two or more partners to work cooperatively toward a set of shared health outcomes.” [See the CTB Toolkit 1: Creating and Maintaining Partnerships, as well as Chapter 1, Section 7, Working Together for Healthier Communities: A Framework for Collaboration Among Community Partnerships, Support Organizations, and Funders.]
• Encouraging leadership and the participation of all social sectors including the health sector, as many strategies and activities extend beyond the capacity of the health sector alone. At the same time, reorienting health services to include health promotion and illness prevention is both a major challenge and a fundamental opportunity that should be pursued. Care should be taken to guard against excessive control by the health sector. [See the CTB Toolkit 6: Building Leadership, as well as Chapter 13, Section 5, Developing a Community Leadership Corps, and Section 11, Collaborative Leadership.]
• Formulating healthy public policies at the local, regional, and national levels. This process enables capacity building of those involved in a more democratic form of governance; it gives people the opportunity to participate in public decision-making that affects them, their families, and their communities. [See the CTB Toolkit 11: Influencing Policy Development, as well as Chapter 25, Sections 1, Changing Policies: An Overview, and 10, Modifying Policies to Enhance the Quality of Services.]
• Conducting ongoing monitoring and evaluation to track and assess progress of the initiative, and to identify the intended and the unintended results. It is critical that information and surveillance systems are strengthened and are used to rethink and revise the activities of the initiative. [See the CTB Toolkit 12: Evaluating the Initiative, as well as Chapter 36, Introduction to Evaluation and Chapter 38, Some Methods for Evaluating Comprehensive Community Initiatives.]

Sustainability: How to Guarantee the Continuity of a Healthy Municipality and Community Initiative

Lessons learned from previous experiences have shown that initiatives that are initiated and/or motivated from outside the community often fail to sustain themselves or continue over time. …Experience shows that in communities where social participation and community organization are high, there is greater opportunity to ensure the continuity of the HMC Strategy and for social organizations and new authorities to negotiate its continuation. The key then is to motivate all community actors sufficiently so that they become involved in and make a commitment to a medium- and long-term process. …Securing the support of the municipal council or legislature is essential in guaranteeing a regulatory framework for the sustainability of HMC because it helps to ensure that the HMC initiative will remain effective and operational regardless of any institutional changes that may occur in the local authority. [See the CTB Toolkit 16: Sustaining the Work or Initiative as well as Chapter 45, Social Marketing of Successful Components of the Initiative, and Chapter 46, Planning for Long-Term Institutionalization.]

Establishing HMC Networks

At the Second Latin American Congress on Healthy Municipalities and Communities held in Boca del Rio, Mexico, in 1997, 18 nations signed an agreement to create the Latin American Network of Healthy Municipalities and Communities to build and strengthen their national networks and ensure their sustainability. Networks make it easier to share information about successes and challenges and facilitate addressing the needs of other groups and at different levels, such as the private sector, government, and international organizations, and can play a major role in the development of new experiences. … In some countries of the region, such as Mexico, Costa Rica, Chile, and Cuba, national networks have already been established and have been working for a number of years with good results.

Why Are Evaluation and Monitoring Important?

Evaluation and monitoring play a fundamental role in the health promotion and protection process because they empower individuals and communities to make informed decisions, justify the expenditures and the contributions of donors, improve the initiatives, and contribute to the health promotion knowledge-base. Making informed decisions contributes to empowerment – one of the basic concepts of the health promotion strategy – which means achieving the power to make decisions concerning individual or collective actions, with a view to improving the quality of life and social justice. In monitoring it is particularly important to strengthen the information and surveillance systems at the community level in order to collect data and information, and make sure that it is reviewed appropriately by all involved groups, including the community. Evaluation examines how an undertaking meets the standards and objectives of a project, whereas monitoring is concerned with the “continuous overseeing of the implementation of an activity to make sure that inputs, schedules, targets, and other actions required are proceeding according to plan.”

It is through monitoring that a thorough understanding of a project can be grasped, and all impacts planned and unplanned can be observed. Policy monitoring allows decision-makers and community members to have a thorough grasp of the policies that are being implemented, and how they are affecting the community in order to adjust, modify, or change actions to best serve their own local needs. Evaluation is important because it enables members participating in initiatives to reflect on the work being carried out in terms of its limitations and achievements, determine whether municipalities and communities are indeed adhering to initial proposals, and refine actions or activities in keeping with their needs. It is an important feedback mechanism for all participants in the process, and can also increase the legitimacy of health promotion activities.

Phases of the Healthy Municipalities and Communities Strategy

Initial and Organizational Phase (1 to 3 Months)
Expected Outcome:
An approved proposed HMC strategic plan

Suggested Strategies:

• Conduct a participatory assessment with the community to ascertain the health and quality of life situation of the municipality or community by identifying needs, enabling conditions, obstacles and resources. [See the CTB Toolkit 2: Assessing Community Needs and Resources, as well as Chapter 3, Assessing Community Needs and Resources, and Chapter 18, Section 2, Participatory Approaches to Planning Community Interventions.]
• Create an intersectoral and municipal committee to carry out a consultation with the community and together define a common vision and mission. Also, it is important to designate a focal point on the municipal council for the HMC Strategy. [See Chapter 5, Sections 5, Coalition Building I: Starting a Coalition, and 6, Coalition Building II: Maintaining a Coalition; and Chapter 9, Section 3, Developing Multisectoral Task Forces or Action Committees for the Initiative.]
• Develop a proposed strategic plan through a participatory and intersectoral process – which should include local authorities, community (including men and women of all ages and ethnic groups) and other organizations – that defines objectives, goals, expected results, and targets. [See Chapter 8, Developing a Strategic Plan.]
• Gain approval and assign resources for the plan by the Municipal Council. [See Chapter 7, Section 6, Involving Influential People in the Initiative.]
• Present, discuss, and disseminate the approved plan through a public forum. [See Chapter 3, Section 3, Conducting Public Forums and Listening Sessions.]

Planning Phase (4 to 6 Months)
Expected Outcome:
A work group and detailed work plan

Suggested Strategies:

• Designate members of the intersectoral municipal committee to be part of a working group for activity implementation and monitoring.
• Develop a detailed work plan based on the community assessment (Initial Phase) with activities, assigned responsibilities and resources, a timeline, and indicators for monitoring and evaluation. [See the CTB Toolkit 7: Developing an Intervention, as well as Chapter 19, Choosing and Adapting Community Interventions.]
• Identify strategies to encourage sustained participation and partnerships for the implementation of the plan and resource mobilization.

  [See the CTB Toolkit 5: Developing Strategic and Action Plans and Chapter 8, Developing a Strategic Plan.]

Action Phase (2/3 years and beyond…):
Expected Outcome:
A Healthy Municipality and Community

Suggested Strategies:

• Promote local healthy public and institutional policies and intersectoral actions.
• Develop a policy framework and infrastructure to support and sustain the implementation of the Healthy Municipalities and Communities Strategy. [See the CTB Toolkit 11: Influencing Policy Development, as well as Chapter 25, Changing Policies.]
• Create a range of healthy spaces.
• Encourage politicians and other decision-makers to commit themselves to community capacity-building, strengthening the HMC Strategy and ensuring its sustainability and intersectoriality. [See Chapter 33, Sections 10, General Rules for Organizing for Legislative Advocacy, and 11, Developing and Maintaining Ongoing Relationships with Legislators and Their Aides.]

Expected Outcome:
Community Participation

Suggested Strategies:

• Involve the community (including women and men of all ages and ethnic groups) in the entire process, from initial assessment of the situation, to actions to identify resources and possible solutions, to implementation, monitoring, and evaluation.
• Identify strategies to mobilize the community effectively while respecting the cultural and social values of each specific population.

  [See Chapter 7, Encouraging Involvement in Community Work; Chapter 18, Section 2, Participatory Approaches to Planning Community Interventions; and Chapter 27, Sections 1, Understanding Culture and Diversity in Building Communities, and 8, Multicultural Collaboration. See also the CTB Toolkit 9: Enhancing Cultural Competency.]

Expected Outcome:
Communications

Suggested Strategies:

• Use all forms of communication available in the community (mass media, interpersonal discussions, organized groups and all forms of cultural expression including events, songs, dances, story telling, etc.) [See Chapter 6, Communications to Promote Interest.]
• Ensure that messages and information are shared with the community on a continuous basis.
• Adapt health promotion messages (addressing action throughout the life cycle) to specific target audiences, taking into account reaching vulnerable population groups.
• Promote the messages of the HMC Strategy, utilizing existing positive examples and influential personalities. [For more information on how to carry out this and the previous strategy, see Chapter 45, Social Marketing of Successful Components of the Initiative, as well as the CTB Toolkit 13: Implementing a Social Marketing Effort.]

Expected Outcome:
Capacity-Building

Suggested Strategies:

• Use multiple channels to offer capacity-building (i.e., courses, Internet meetings, etc.)
• Include orientation and skill development for each aspect of HMC development.

Expected Outcome:
Monitoring and Evaluation

Suggested Strategies:

Cover process, outcome, and impact, including quantitative and qualitative indicators. Make it participatory and interactive. [See the CTB Toolkit 12: Evaluating the Initiative.]

Guidelines for Evaluating Healthy Municipalities and Communities

[PAHO considers evaluation so important that it devotes a separate part of the Mayor’s Guide to it. The Guide explains that, since “[e]valuation should be a continuous cycle of ongoing feedback,” monitoring is an ongoing activity, and that the term “evaluation” includes it. Evaluation is not something that only takes place once a year or at the end of a project, but an ongoing part of the HMC Strategy. The Community Tool Box supports relevant to all of these guidelines for evaluating a healthy municipalities initiative are the Toolkit 12: Evaluating the Initiative and Chapters 36, Introduction to Evaluation; 38, Some Methods for Evaluating Comprehensive Community Initiatives; and 39, Using Evaluation to Understand and Improve the Initiative.]

Why and What to Evaluate

Evaluation of healthy municipalities and communities is very important for many reasons, including:

• Providing the stakeholders the opportunity to reflect on the HMC initiative.
• Designing the best HMC initiative in the context of the community health resources and needs.
• Creating accountability, or determining/gauging if the healthy municipality is doing what was proposed, and redirecting efforts when needed.
• Contributing to general knowledge development; sharing what works and what doesn’t work with other communities.
• Sustaining the work of HMC over time.
• Creating opportunities for intersectoral multidisciplinary dialogue, and strengthening participatory efforts within the municipalities.
• Developing networks, links, and contacts between different community processes.
• Convincing decision-makers and policy-makers that HMC is a beneficial strategy.

… Because of the participatory nature of healthy municipality initiatives, it is suggested that participatory evaluation play an important role in the evaluation of healthy municipality initiatives. …[I]t is a collaborative approach that builds on strengths and values the contribution of everyone involved.

[A PAHO] working group on healthy municipality evaluation in the Americas…recommended different areas that should be taken into account when evaluating HMC initiatives, such as context, planning and implementation of the evaluation, and evaluation methodologies:

Context

• Evaluation must factor in the different political, economic, social, and cultural contexts of the country, municipalities, and communities involved in the evaluation. It is important to consider the influence of the following:
  
  • Socioeconomic and political situation (national and local)
  • Local and national policies
  • Local health situation
  • Administrative structures and management styles, both national and local
  • Geographical, ecological, and demographic characteristics
  • Stage in the development process of the healthy municipality
  • Sociocultural aspects

Considerations for Planning and Implementing Evaluations

• The conception and development of the evaluation as a formative process originating from the municipalities and the stakeholders. This implies adopting the rigor and complexity required by the topic and the collective definition of the variables and indicators to be used.
• The definition of work processes that ensures: a) a broad and diverse commitment that reflects a consensus of joint evaluation objectives, and b) clearly identified ways to disseminate this work to other relevant groups.
• The relationships between health and well-being and between health and development.
• The conceptual definitions of what “healthy” means in the context of the psychosocial and physical aspects of the environment, health promotion, human and social development, and equity.

Evaluation Methodologies

• Utilize an evaluation methodology that integrates qualitative and quantitative approaches.
• Develop qualitative indicators constructed with the actors involved in the process itself – this requires intersectoral and participatory work. [See Chapter 3, Section 15, Qualitative Methods to Assess Community Issues.]
• Aim for an evaluation that covers structures, processes, and outcomes.
• Take advantage of the information available in each municipality, strengthening the existing databases with qualitative data (and creating databases where they do not exist).
• Conduct the evaluation recognizing the influence of the various levels (international, national, and local, and, at the local level, institutional/government and community forces or social groups) and contexts (geographical, demographic, political/administrative, economic-environmental, social, and cultural). [See Chapter 36, Section 2, Community-Based Participatory Research.]

Areas for Evaluation

The following areas have been identified as key in the evaluation of healthy municipalities:

• Public Policies
• Social Participation
• The Intersectoral Approach
• Sustainability
• Development Process Undergone by the HMC Initiative

Evaluating the Process

…[I]t is wise to think about evaluation from the very beginning…Good evaluation goes hand in hand with planning. A planning approach that works well with for participatory evaluation is one in which evaluation, implementation, and planning activities interact with each other at any point in the life of the endeavor.

[E]valuation should review the various steps of the process itself: its successes, difficulties, strengths, and weaknesses. It should not simply register, describe, or quantify attainments and products.

Evaluating Results

Results in health promotion are dynamic and diverse in nature, and measuring these results can include information from the following areas:

• Health education
• Influence and social action
• Healthy public policies and organizational practices
• Healthy living conditions and lifestyles
• Effectiveness of health services
• Healthy environment and spaces
• Social results
• Health outcomes
• Capacity-building and development

[The following] is a list of suggested guidelines [for evaluating healthy municipalities initiatives] but it is not comprehensive; it is recommended that each HMC advisory group or committee review, adapt and augment the guidelines based on the evaluation needs and particular context.

Describe the context

• Clearly define the vision of the healthy municipality initiative. What does the community understand by the phrase “healthy municipalities”? What do the various sectors involved understand by the phrase? What activities are being carried out in order to achieve this goal? How will people know when those objectives have been met? [See Chapter 8, Section 2, Proclaiming Your Dream: Developing Vision and Mission Statements.]
• Use the logical framework method to illustrate the steps involved in the process as well as the expected results. [See the CTB Toolkit 4: Developing a Framework or Model of Change, as well as Chapter 2, Section 1, Developing a Logic Model or Theory of Change.]
• Establish an intersectoral group comprised of community representatives to coordinate and perform the evaluation. [See Chapter 36, Section 4, Choosing Evaluators.]
• When will the evaluation be carried out? Within what timeframe?

Indicate causes for concern

• What is the purpose of the evaluation? What are the main concerns of the various parties involved?
• How will the results of the evaluation be used?
• What are the specific questions that need to be addressed by the evaluation within the context of the healthy municipalities initiative?
• Are public policy, the intersectoral approach, social participation, and sustainability addressed in the questions and the objectives?
• Do the evaluation’s questions and objectives address the basic principles of the HMC movement (the concern for equity, the intersectoral approach, social participation, and strengthening local capacities)?

Organize the data-collection process

• What methodologies will be used? (This will depend on the responses to the questions above.) Have a range of qualitative methods been considered?
• Are the methods appropriate to the local context? Have both process and results been taken into account?
• Is the methodology understandable to those involved?
• Have pilot studies been conducted, using the same tools that will be used in the evaluation?
• Have the tools to be used in the evaluation been validated?
• How will broad participation be achieved?
• Is care being taken to include marginalized groups or individuals (both from among those who are the object of the evaluation and those in charge of conducting it) in the proposed evaluation? [See Chapter 36, Section 2, Community-Based Participatory Research.]

Compile the data

• This task should be carried out using the methods established in the previous steps.
• This task should be monitored to ensure that the data compiled are of good quality.

Describe, analyze, and evaluate the data

• What was learned through the evaluation?
• How different are the results from what was expected?
• Were the qualitative and quantitative methods complementary?
• How can discrepancies be addressed and resolved?
• Consider the possibility of using other qualitative methods in order to provide more information about unexpected results.
• Promote the participation of interested parties in the interpretation of the results.
   
  [See Chapter 17, Analyzing Community Problems and Solutions.]

Make recommendations

• What are the short- and long-term implications of the conclusions?
• What changes might be made to address negative results? Analyze recommended changes, taking their costs and benefits into account.

Disseminate conclusions

• Communicate conclusions, recommendations, and anticipated actions to donors, all interested parties, networks, etc.
• Use the Internet to share experiences wherever appropriate.

Make changes based on the results of the evaluation

• Obtain feedback from all evaluation participants.
• Adapt initiatives wherever necessary.
• Continue to monitor evaluations.
   
  [See Chapter 39, Using Evaluation to Understand and Improve the Initiative.]

The steps listed might also be presented as a continuous cycle.

Other principles for evaluation [agreed upon at a 2001 conference by the Working Group on the Evaluation of Healthy Municipalities and Communities Initiatives in the Americas]

Value

The evaluation process must reveal any theoretical, ideological, or political assumptions and explicitly indicate any power relationships (including those in which the evaluator is involved). The evaluation should also respect and value experience and local knowledge, recognizing the people as the principal health resource. The evaluation should embody a spirit of hope, happiness, love, and fun, while never forgetting equity, social justice, and solidarity.

Empowerment

Evaluation of Healthy Municipalities initiatives should:

• be based on the community’s strong points;
• support local problem-solving;
• ensure equity by allowing all voices to be heard, including the voices of the most vulnerable and least powerful; and
• make it possible for information about the evaluation to be used by those concerned to lobby for and promote Healthy Municipalities.

Usefulness

Evaluation of Healthy Municipalities initiatives is useful when:

• it answers the questions of who, why, and how;
• it is integrated into the planning process and oriented toward action and change;
• it contributes to the creation of resources in the community;
• it has practical and political relevance;
• it helps define the healthy municipality as an investment; and
• it recognizes the need for a range of dissemination methods and feedback mechanisms.

Learning

Evaluation of Healthy Municipalities initiatives should:

• promote a joint learning process;
• promote dialogue and reflection, and encourage all means of developing knowledge by those affected and influenced by the process, including any external evaluators;
• recognize that learning is the key to the community and to increasing the capacity for local organization; and
• lead to action and change.

 

Adolescence is a time of experimentation. Teenagers test themselves physically, intellectually, socially, and emotionally, all in the service of learning what it means to be an adult. A majority of children/young people make it through their teen years without serious problems. They may have some close calls, and have their hearts broken once or twice, but, by and large, they survive. They go on to college or to work, and to raise families and make reasonable lives for themselves.

Then there are the children/young people that everyone worries about. They’re the ones who chain-smoke, drink to excess, use every drug they can get their hands on, engage in random violence, get in trouble with the law, become parents at 15 or 16, and perhaps even die – frequently by suicide or in a drunk-driving accident.

We often view the children/young people who have difficulty in a negative way: they have “problems,” or are at fault because they’ve never developed some basic traits – intelligence, self-control, empathy, or persistence, for instance. There’s another way to consider the issue, however: perhaps these teens simply haven’t had enough of the factors in their lives that adolescents need in order to grow into successful, caring, productive adults.

A child needs caring parents, of course, but she’s also helped by having positive parental lessons and values reinforced by what she sees and hears from other adults in the community, and by the behavior of the society as a whole. It really does take a village to raise a child.

Chapter 2 of the Community Tool Box is about models of community change – ways to introduce changes that will continue improving the quality of life for everyone in the community indefinitely. In this section, we’ll discuss using a model of community change that focuses on youth. It assumes that the fostering of those internal and external assets that contribute to the healthy development of children and adolescents is the task not only of parents, but of the whole community, and proposes that communities be organized to accomplish it. And it assumes that improving life for the community’s children will also improve it for the community as a whole.

What is asset development?

Developmental assets are those positive characteristics and factors that form the foundation of the healthy development of children and adolescents. A community engaged in asset development for youth is committed to identifying the needed developmental assets that children and adolescents in the community are lacking, and to work to provide those assets. The Search Institute (SI) of Minneapolis, Minnesota has surveyed over a million 6th-to-12th graders from more than 600 communities since 1993, and has found what it believes are 40 crucial developmental assets for adolescents (the 40 assets are listed and explained in greater detail later in the section).

SI’s studies show that the more of these assets an adolescent has in his life, the less likely he is to engage in risky behavior or experience situations that put him at risk.  The risky behaviors and situations in question are:

• Substance use/abuse (alcohol, drugs, tobacco).
• Sex. Being sexually active, although it’s common teen (and even pre-teen) behavior in many communities, can take an emotional and physical toll on adolescents. That toll is compounded when their sexual activity is indiscriminate or they have multiple sexual partners unprotected.
• Violence. This can mean anything from being a victim of bullying and abuse to carrying and using a gun.
• Anti-social behavior, acting out. The range here extends from defying teachers to serious trouble with the law.
• Depression/suicide. Not all depression leads to suicide, of course, and not all depressed teens consider suicide. But teens do commit suicide in alarmingly large numbers, and adolescent depression is much more widespread than is commonly realized.
• School problems. Academic difficulties, truancy, absence, etc.
• Driving and alcohol. A mixture that can lead to arrest, destruction of the driver’s and others’ property, and the deaths of the driver and others.
• Gambling. In addition to the possibility of losing large sums of money, gambling can put teens and their parents in harm’s way if they can’t pay their debts.  Loan sharks and bookies are notoriously unforgiving when they don’t get their money.

Thriving indicators are the traits or conditions that indicate positive development. Search Institute studies also show that the more developmental assets an adolescent can claim, the more thriving indicators she is likely to have. The thriving indicators measured:

• School success. Good grades, mostly A’s or A’s and B’s.
• Helping others. Spending at least one hour a week helping others not in your own family.
• Valuing diversity. Having friends from different ethnic and racial groups, and interest in their experiences and cultures.
• Good health. Engaging in behavior – exercise, adequate sleep, good nutrition, regular medical and dental attention – that promotes and maintains good physical health.
• Leadership. Taking a leadership position at school, in extracurricular activities, or in the community.
• Resistance to danger. The ability to resist both your own impulses and the pressure of peers in order to avoid dangerous behavior and situations.
• Delaying gratification. The ability to save for a future (large) purchase, or to otherwise put off immediate pleasure in favor of a larger or more important gain later.
• Overcoming adversity. The capacity to keep going after a failure, or to continue a task or effort in the face of difficulty.

The original list of developmental assets SI compiled numbered 30, but it was increased to 40 as a result of the information received in the first 350,000 or so surveys. The list was derived both empirically – i.e., as a result of information gathered directly by the Search Institute itself – and from the theories and research of others.

While SI’s studies seem to show that the ideal number of assets for adolescent success on the educational, social, and personal development fronts is 31 or more, fewer than 10% of adolescents actually have that many. The average number that teens in most communities have – regardless of such other factors as the community’s socio-economic status or level of education – is only 18-20, and over 60% of youth surveyed report 20 or fewer. (The 600+ communities surveyed were largely white – about 80 percent – but varied in economic status, education, types of employment, urban/suburban/rural characteristics, etc.)

The survey itself consists of 156 items, each meant to elicit information about a specific asset, risk behavior, or thriving indicator. It is meant to be administered only to students (or non-students, in some cases) in grades 6-12. While SI estimates the average completion time at 50 minutes, it emphasizes that allowances should be made for age/grade level, reading skill, fluency in English, and any other factors that might argue for a longer administration time. The point is not to finish in a particular amount of time, but to provide accurate information, and participants should be allowed as much time as necessary to do so.

Half of the 40 assets are labeled external, provided directly by parents, teachers, the community, or environmental factors. The rest are considered internal, coming from within the adolescent herself. In reality, however, the distinction is less clear. Internal assets are often specifically taught by parents and other significant adults, for instance, or are fostered by community norms and attitudes. External assets may have much to do with the child’s or adolescent’s effect on others, or with her natural tendencies.

External assets are further divided into four categories:

• Support. People significant to the adolescent encourage, help, and respect her.
• Empowerment. The adolescent has the opportunity to exercise responsibility, and to feel in control of important parts of his own life.
• Boundaries and expectations. The adolescent is expected to adhere to clear rules and meet high standards.
• Constructive use of time. The adolescent has opportunities to engage in meaningful and productive activity.

Internal assets are also divided into four categories:

• Commitment to learning. The adolescent understands the value of learning and education, and can apply herself in school and other areas of learning.
• Positive values. The adolescent has developed and internalized a positive value system.
• Social competencies. The adolescent possesses the personal and interpersonal skills to conduct his own life and to engage in positive relationships with others.
• Positive identity. The adolescent sees herself in a positive light, and has good self-esteem.

What are the characteristics of an asset development program?

The Search Institute’s participation in asset development is limited. A community organizes to conduct the SI survey (usually through the schools), purchases (from SI) and administers the survey, sends it off to be analyzed by the Search Institute, and receives a written report of the analysis. SI’s involvement ends with the analysis, and it’s up to the community to figure out how to meet its own needs. Many communities use their initial organization to mount a participatory effort to act on the analysis.

Communities that have surveyed their students have placed their resulting plans on the Internet. Among these are Benton County, Oregon and Wayne County, OH.

Once a community (or, more likely, a school system, community-based organization, parents’ group, or community official or governing body) has decided to try to establish an asset development approach, what should that approach look like? There are some specific characteristics that are common to a careful asset development effort.

• The effort demands a commitment from the whole community. The Search Institute believes that, to resolve youth problems, it isn’t enough to focus on individual teens at risk. A community must make a commitment to developing the 40 assets for all its youth. In broadest terms, that commitment includes
  • A commitment to administering either the Search Institute survey, or to a similar study that questions children and teens themselves – and, in some cases, the adults important in their lives and in the community – about the assets they believe they possess.
  • A commitment by community leaders – elected and appointed officials, school personnel, the business community, opinion leaders, etc. – to support an asset development effort, both with their voices and their resources.
  • The acceptance by the community of the idea that asset development is a community-wide activity that demands a commitment from all adults, whether they are parents or not.
• The effort should be participatory. As with most types of community efforts, asset development works best if it is conceived, planned, and implemented through a process that involves all sectors of the community, particularly those most directly affected (youth, in this case). A participatory process often involves the formation of a coalition or other leadership body that includes representation from all sectors of the community, including youth, to plan, coordinate, monitor, and oversee asset development efforts.
• The effort should be based on what’s actually needed in the particular community. The SI survey or some other assessment should be conducted to determine which assets the community already provides for most of its youth, and which are lacking. Then strategies can be devised to develop those assets that are missing, while maintaining those that are already strong.
• The effort should focus on the positive. Like the other health and community development models we’ve discussed so far in this chapter, asset development has a proactive, positive thrust. It is based on building assets, rather than fixing deficits. An asset-developing community is engaged in positive actions that are meant to become an integral part of the life of the community, and to affect the quality of that life for generations to come.

At the same time, it must be understood that needed assets may reflect deficits – uncontrolled youth violence, poor school performance, adolescent substance use, etc. Asset-building may be accompanied by, or expressed through, strategies that seek to correct problems as well as keep them from recurring. While appropriate assets may drastically cut the incidence of youth violence over time, for instance, it’s also important to control it now, so that more young people don’t die in the meantime. You can keep a positive and future-oriented spin on the overall effort and still deal with immediate concerns. Don’t let ideology steer you away from reality.

• Asset development demands a coordinated, community-wide effort. This means something slightly different from community commitment, although that commitment is probably necessary for a community-wide effort to be mounted. An asset development effort needs to be carefully coordinated so that all sectors of the community – concerned youth and adults, health and human service and other community-based and nonprofit organizations, community officials and agencies, businesses, etc. – are working together toward the same goals and sending the same messages.

A community-wide effort also implies that everyone in the community is taking responsibility for asset development, and, by extension, for the community’s children. It means adults speaking up in some way – either directly, or calling a teen’s parents or the police, for example – when they see a youth doing something likely to get him in trouble. It may also mean parents and non-parents alike volunteering time with adolescents or younger children as coaches, supervisors of after-school activities, community-service mentors, etc.

In the working-class urban neighborhood where the author grew up, for instance, the adults knew all the children/young people, and wouldn’t hesitate to yell at you or call your mother if they caught you doing something wrong. While that made childhood mischief a problem, it also meant that children felt fairly safe. They knew that adults would intervene to keep them from getting hurt, and they also knew that the rules would be enforced equally throughout the neighborhood. In that environment, virtually all the adults felt responsible for the children, even if they themselves weren’t parents at all.

What are the developmental assets that children/young people need?

The following list of the 40 developmental assets, divided into their categories, with their brief descriptions, comes directly from the Search Institute (1997).

External Assets

• Support
  • Family Support – Family life provides high levels of love and support.
  • Positive Family Communication – Young person and her or his parent(s) communicate positively, and young person is willing to seek advice and counsel from parents.
  • Other Adult Relationships – Young person receives support from three or more nonparent adults.
  • Caring Neighborhood – Young person experiences caring neighbors.
  • Caring School Climate – School provides a caring, encouraging environment.
  • Parent Involvement in Schooling – Parent(s) are actively involved in helping the young person succeed in school.
• Empowerment
  • Community Values Youth – Young person perceives that adults in the community value youth.
  • Youth as Resources – Young people are given useful roles in the community.
  • Service to Others – Young person serves in the community one hour or more per week.
  • Safety – Young person feels safe at home, in school, and in the neighborhood.
• Boundaries and Expectations
  • Family Boundaries – Family has clear rules and consequences and monitors the young person’s whereabouts.
  • School Boundaries – School provides clear rules and consequences.
  • Neighborhood Boundaries – Neighbors take responsibilities for monitoring young person’s behavior.
  • Adult Role Models – Parent(s) and other adults model positive, responsible behavior.
  • Positive Peer Influence – Young person’s best friends model responsible behavior.
  • High Expectations – Both parent(s) and teachers encourage the young person to do well.
• Constructive Use of Time
  • Creative Activities – Young person spends three or more hours per week in lessons or practice in music, theater, or other arts.
  • Youth Programs – Young person spends three or more hours per week in sports, clubs, or organizations at school and/or in the community.
  • Religious Community – Young person spends one or more hours per week in activities in a religious institution.
  • Time at Home – Young person is out with friends “with nothing special to do” two or fewer nights per week.
  • Internal Assets
• Commitment to Learning
  • Achievement Motivation – Young person is motivated to do well in school.
  • School Engagement – Young person is actively engaged in learning.
  • Homework – Young person reports doing at least one hour of homework every school day.
  • Bonding to School – Young person cares about her or his school.
  • Reading for Pleasure – Young person reads for pleasure three or more hours per week.
•  Positive Values
  • Caring – Young person places high value on helping other people.
  • Equality and Social Justice – Young person places high value on promoting equality and reducing hunger and poverty.
  • Integrity – Young person acts on convictions and stands up for her or his beliefs.
  • Honesty – Young person “tells the truth even when it is not easy.”
  • Responsibility – Young person accepts and takes personal responsibility.
  • Restraint – Young person believes it is important not to be sexually active or to use alcohol or other drugs.
• Social Competencies
  • Planning and Decision Making – Young person knows how to plan ahead and make choices.
  • Interpersonal Competence – Young person has empathy, sensitivity, and friendship skills.
  • Cultural Competence – Young person has knowledge of and comfort with people of different cultural/racial/ethnic backgrounds.
  • Resistance Skills – Young person can resist negative peer pressure and dangerous situations.
  • Peaceful Conflict Resolution – Young person seeks to resolve conflict nonviolently.
• Positive Identity
  • Personal Power – Young person feels he or she has control over “things that happen to me.”
  • Self-Esteem – Young person reports having a high self-esteem.
  • Sense of Purpose – Young person reports that “my life has a purpose.”
  • Positive View of Personal Future – Young person is optimistic about her or his personal future.

Why would you (and why would you not) use an asset development approach?

Advantages to the asset development approach

• It’s based on extensive research. The asset development concept, as well as the contents of the asset list, are the result of research conducted on over a million adolescents, as well as the latest research and theory by others in the field.

As mentioned above, SI has given its survey to over a million adolescents. It has found that most have far fewer than the 31 or more assets estimated to be necessary for optimal development. It has also found connections between the number of assets an adolescent possesses and both high-risk behavior and thriving assets.

While the average number of assets seems to be fairly steady across communities, the particular assets present or lacking for most of the youth in a given community is a function of the nature of that community. Thus, although the teens in five surveyed communities chosen at random may all possess an average of 19 of the 40 developmental assets, the actual assets in question are likely to be significantly different for each community. By the same token, teens in each community may exhibit different risky behaviors, and different thriving indicators as well. The survey will allow each community to understand exactly which assets, risky behaviors, and thriving indicators are common among its youth.

What the research doesn’t seem to explain is which assets are connected to which risky behaviors and which thriving indicators, although common sense can probably point a community toward at least some logical connections.

• Its participatory approach to planning and implementing the effort encourages community buy-in, and puts many minds to work. The emphasis on an inclusive and widespread process increases the chances that the community will see the effort as its own, and thus work as hard as possible to make it succeed.  Including all sectors of the community, particularly youth, in planning and implementation affords a broad range of knowledge and ideas to work with, and increases the ultimate effectiveness of any action.

Including youth, and especially those at risk, reduces the probability that the effort will be seen by those youth as just another ineffective attempt by adults who may lack understanding of youths’ experiences to reach youth experiencing increased risk who already distrust adults and other teens who don’t share their culture. If they’re involved from the beginning, and if they’re treated with respect and their opinions are valued, they’re more likely to respond.

• Placing the accent on positive asset development makes tackling youth issues seem more possible. Often, a community faced with rampant youth violence, drug use, or pregnancy sees no clear solution to the problem. If the issues are multiple, they seem even more difficult to address. A positive approach – the active building of assets and the engagement of adolescents by adults – allows the community to exercise some control over the situation, and to feel that there are positive steps it can take to effect change.
• Each community develops its own scheme for asset development, based on the assets it needs, and other factors unique to it. Rather than taking a cookie-cutter approach, asset development encourages the examination of each community as a unique entity. Each community examines its own situation, and comes up with asset-building strategies designed specifically for its own needs.
• Data can be analyzed in numerous ways. It may be that a particular school draws students whose asset needs are greater than those from other schools in the community. It may be that students from a particular neighborhood or population have different needs than others. SI can break down survey data to bring out these differences, allowing a community to strategize accordingly.
• Asset development aims at long-term social change. With its focus on the next generation, and on a change of attitudes and behavior on the part of all community members, an asset development approach can have long-term and lasting positive effects.
• Asset development can address a broad range of issues. School failure, the dropout rate, youth crime, adolescent substance use, teen pregnancy – all of these and more can be positively affected by the current and ongoing provision of more assets for youth, and by the resulting changes in community attitudes and behavior.
• Asset development can increase community cohesiveness. Because it concentrates on continuity and on preparing the next generation, an asset development approach can pull in virtually the whole community to work toward preparing for its future. That not only heightens the awareness of the meaning of a community among those involved, but creates a sense of purpose as well. People aren’t just solving a problem – they’re moving forward into the future as a community.
• Healthy Youth helps to foster a Healthy Community. SI calls its asset development approach Healthy Community/Healthy Youth. If you focus on the ideal development of all youth in the community, you’re focusing on the ideal development of the community as well. A healthy community is one where all children and adolescents get what they need. If that happens, the chances are that equity is being nurtured in other spheres as well.

Despite these excellent reasons to pursue asset development, there are also some cautions before proceeding with it.

Potential disadvantages to the asset development approach

• The data that assets are based on are limited to a largely white population of only youth. The fact that the over 1,000,000 SI survey participants are almost 80% white is hardly representative of a country whose “racially and ethnically minoritized” populations is fast approaching 50%. Furthermore, surveying only youth creates a number of problems:
  • First, although the survey attempts to correct for intentionally false answers, it can’t necessarily correct for false perceptions. An adolescent’s view of her own life and situation may not necessarily mirror objective reality, or may at least be enough at odds with others’ perceptions to raise questions.
  • Second, the fact that most of those surveyed seem to be in-school youth, when youth who are no longer enrolled in school are likely to be the children/young people with the fewest assets and the greatest needs, raises a red flag. Are youth who are no longer enrolled in school – who may account for a large percentage of youth 16 and over in some urban school systems – simply to be ignored?
  • Finally, do adult perceptions count for nothing? CADY (see #3 below) also surveys the adults who are significant in most adolescents’ lives, and thus may receive a more balanced view of the situation in a community.
• There’s no real guidance as to how to develop assets. While the ability of each community to plan for its own unique needs is definitely an advantage, having no guidance to best practices or other how-to information is definitely not. If you use the Search Institute survey, all you get is the analysis. There’s no follow-up or consultation about how to proceed from there, and no advice about how to develop the specific assets you’ve chosen to concentrate on.
• The community is dependent on SI (or another entity, if you use a different system – see box below) to analyze the surveys. That means paying fees, which may be a problem for some communities, and waiting as much as three months before survey results are available. The larger the community – or the more detailed analysis it needs – the greater the cost.

CADY (Community Asset Development for Youth), a Michigan State University program, attempts to address some of these issues. It focuses more narrowly, concerning itself specifically with reducing substance use and violence and bullying among youth.

CADY has identified a number of assets, fewer than but similar to those named by SI, but joins them with 11 deficits that communities might seek to correct. Its survey pinpoints deficits, and links them to the assets that seem to correct them.

It surveys school personnel, parents, community leaders, and community members as well as youth, and promises technical assistance for the life of the asset development project. Furthermore, it posts its survey analysis on line, and provides one-click access to such information as which assets seem to affect which deficits, and best practices for developing particular assets.

At the same time, CADY’s model, unlike SI’s, leaves out any input by youth in the planning or coordination of an asset development program, and is generally top-down. Leadership comes from the schools and/or agencies, officials, and organizations, not the community as a whole. And, like SI, CADY requires a financial investment from the community, which may make it an unrealistic choice for some. (Information about CADY) The program doesn’t seem to have its own website, but another possibility is to contact its designer, Prof. William Donohue, donohue@msu.edu.)

• Small communities or small schools may not have large enough populations to identify assets and gaps accurately. Statistics demand a certain number of participants in order to come up with a reliable analysis. SI warns that analyses of groups of under 100 will probably have gaps in them, and won’t analyze surveys from groups of fewer than 50. Rural communities, particularly, may have to join with others in order to produce enough surveys to be analyzed. The problem with this, of course, is that a small community or school may only be able to obtain reliable information about the whole group, and not about itself alone.
• There is no guarantee that asset development will address current problems. Asset development is largely a future-oriented approach. The children/young people who are currently experiencing difficulties – or causing them – may not be reached by it, although it may have great effects on younger children, and therefore on the community’s future.
  • When is it too late in an adolescent’s life for the addition of assets to mean anything? Can seniors in high school benefit? 20-year-olds? At what point have the results of asset deprivation simply become part of someone’s personality? In other words, there’s probably a point when asset development has become irrelevant for particular adolescents, and is unlikely to affect their attitudes or behavior.
• Most adolescents do all right despite the fact that they don’t have the ideal number of assets. Even though only about 8% of all adolescents have the 30 or more assets that SI sees as necessary for optimal development, that certainly doesn’t mean that the other 92% are experiencing significant challenges or at risk (or that that fortunate 8% are necessarily all happy and doing well). Are these 40 developmental assets really the key to success in life, or do they simply show that most of those with fewer than 30 assets may have a tougher adolescence, but ultimately turn out OK as adults?

The SI picture of an adolescent with all the desired assets often seems like one of an ideal kid from an adult’s point of view (good grades, likes school, helps others, doesn’t experiment with anything potentially harmful). Sometimes we lose sight of the fact that teens need to rebel, to question, to flounder – that that’s the job of adolescence, and is necessary for building identity. The ideal is to provide a way for them to do that safely...but not all adolescents are willing to do it safely, assets or not.

Then there are the poets, the dreamers, the rule-breakers who refuse to be bound by convention. They may spend their adolescence in torture, often because they don’t have support for who they are from either their families or society. Some of them grow up to frustration and failed lives – and others of them literally change the world. They may not fit the ideal asset profile, but they may be developing internal assets that point them toward great achievement and influence later.

There is no question that children and adolescents need and benefit by these 40 developmental assets, particularly the support of caring adults. But the internal assets that SI sees as so important may simply develop later, as older adolescents test themselves against the adult world. The fact that they don’t yet seem to have them may be a function of that testing, and may be a necessary part of many children/young people's adolescence. It’s not entirely clear that the asset development approach addresses the adolescent need for rebellion and testing – and occasional failure – that creates an adult identity.

• When they are considered together, the advantages listed here seem to outweigh the potential disadvantages. Perhaps an overriding reason to consider asset development as a means of community building is that the raising of the next generation is one of the most important functions of a community. An argument can be made that an inclusive, participatory community effort to provide youth with support and internal ideals and self-discipline will sharpen citizens’ focus on what a community is and does. The result should improve the quality of life, not only for youth, but for the whole community.

How do you use an asset development approach?

A note about asset development approaches:

This section examines a specific logic model – that of addressing the 40 developmental assets necessary for adolescents’ growth and success – proposed by the Search Institute. SI’s conception of that model includes engaging its services by purchasing the necessary number of copies of its survey and purchasing as well the analysis and reports of the results of administering the survey. The problem here is that not all communities have the resources – or the desire – to approach asset development in so formal a way.

There are ways around this. One – perhaps the best (and the most common, judging by the number of community websites that seem to reflect it)  – is to focus on developing and/or strengthening all developmental assets. Another is to focus on a particular area that you know represents a gap for your community – recruiting youth to participate in town government and community service (empowerment), for instance, or creating or strengthening mentoring programs for parents and teens (support). Still a third is to develop your own method of identifying assets and gaps – more likely if you have the help of a university, but not beyond the bounds of possibility for a community with the right resources.

A fourth possibility is that you can employ asset development as part of a larger healthy community initiative. You may want to take SI’s 40 fundamental assets into account, but not use them as the foundation for your effort.

Much of what follows assumes you’ll use SI’s methods, and perhaps its services as well. It’s important to realize, however, that that’s not necessarily the only way to address developmental assets in your community.

Once you’ve decided to employ an asset development approach in your community, how do you go about it? Because a successful effort has to involve the whole community, it’s not just a matter of starting and picking up support as you go along.

Someone has to take the initiative. Whether or not you plan to use SI’s survey, the community has to be educated about developmental assets and prepared to focus on them. Existing efforts seem most often to be spearheaded by the schools, but one could be led by other entities as well:

• A pre-existing coalition
• Civic officials or a civic agency – the mayor or the police department, for instance
• A parents’ group
• A community-based or other non-profit organization, particularly one that works with, or is concerned with, youth
• A community-wide non-profit, such as United Way
• A faith-based organization or clergy association
• A business or a business group, such as the Chamber of Commerce

Form a coalition or other group to introduce asset development (and the idea of the survey/asset assessment) to the community. The group should contain people from all sectors of the community, including youth, and should be participatory, involving everyone in decision-making.

Whoever takes the initial lead should expect to be a collaborative leader, and allow for the possibility of sharing leadership with or relinquishing leadership to a community member or group.

Good communication by this group – in speaking, in writing, and through the media – is crucial to the success of an asset development effort, especially if the SI survey is to be part of it. (Please see Communicating Information about Health and Community Issues and Promoting Awareness and Interest Through Communication) People are often suspicious of surveys, and question what will be done with their results. In order to dispel any suspicion, the coalition or group here has to make sure that it provides all the information people need, that it’s absolutely candid and straightforward in answering questions, and that it tries to anticipate and answer most questions before they’re asked. Some questions people in most communities might have include:

• Who’s behind the survey? What is the Search Institute, what are their credentials, where are they from?
• What other communities have used the survey, and what did they do with it?
• Is the survey anonymous and confidential?  What will happen to the results after they’re tabulated? Can children/young people, or their parents, opt out?

This last question, if not carefully considered, can cause huge problems. Assuming that you go through the schools, the school system may have its own rules regarding parental permission, and/or research on human subjects, and may also be subject to laws regarding the process. Will parents be asked to take some positive action to allow their children to participate, such as signing a permission form (active permission)? Or will they be informed that their children will participate unless they formally request otherwise (passive permission)? This may seem like a minor issue, but it’s just the kind of thing that can stall or even prevent a community effort if it’s not handled well.

• What will this cost the community and how does that translate to the tax rate?
• Who will be responsible for setting up the survey and transmitting, receiving, and publicizing the results?

Once the community agrees to pursue use the survey, its logistics have to be worked out. Will the survey be carried out in school? Will all youth be surveyed, or just those in certain schools or at certain grade levels (SI’s survey is valid for students in grades 6-12 only), or just a random sample?  Remember that you need a certain number of surveys (a minimum of 100 for any one group about which you want information – e.g., a particular school or neighborhood) in order for the results to be statistically accurate and complete. SI won’t prepare a report at all for a block of fewer than 50 surveys.

• If the school system isn’t able or willing to actually administer the survey, it could perhaps be done in school by a local organization, members of the coordinating coalition, or some other group. SI strongly urges that a single coordinator be chosen to act as administrator and contact person for the survey process.

Implement the survey. The survey now has to be administered, collected, and sent off for scoring. If you’re using the SI survey, you’ll almost undoubtedly need at least the cooperation, if not the leadership, of the school system. Although you may want to administer surveys in other ways as well – to contact youth who are no longer enrolled in school and home schoolers, for instance, or those in private and parochial schools – going through the public schools is by far the easiest way to reach most children and adolescents in a community.

Analyze the report of the survey results. SI, within ten weeks of receiving all surveys from a community, returns an 80-page report for each group requested.  This details not only which assets are available and which are lacking to how many youth, but also the incidence of 24 risk-taking behaviors, 10 high-risk behavior patterns, and 8 thriving indicators, and how they interact with different asset levels. Results are reported by gender and grade, as well as for the total group. SI also includes an executive summary, a bibliography, and other information and suggestions.

• It’s now up to your community to analyze the report. While CADY provides some consultation and technical assistance with and after the submission of its report, the Search Institute doesn’t, except as contained in its report. It provides some pre-survey help, and also offers – separately, at a cost – various workshops and trainings to help organizations and communities prepare for and respond to the survey. It also includes with survey reports a list of its resources. Information on all of this can be obtained on the SI website.

By this point, more people may want to be part of your coordinating or planning group. It’s probably a good idea to keep the group open to new membership in some way, although a group that’s too big can become unwieldy. The formation and use of subcommittees or task forces may be one way to keep the planning group to a reasonable size and still accommodate nearly everyone who wants to help.

Depending on how and whether you split up the population surveyed for reporting purposes, an examination of the report can tell you:

• Which assets are most often lacking for youth in your community.
• Which risk factors are greatest for youth in your community.
• Which groups of youth (by socioeconomic status, neighborhood, school, age, gender, etc.) are at greatest risk in which areas.
• Which thriving indicators are most often found, and among whom.

Communicate your findings to the community. If this is to be a community-wide effort, the community has to have as much information as possible. The coordinating group or individual should communicate the results of the survey through the media, through public meetings, through gatherings in citizens’ living rooms, through handouts in the supermarket – by whatever means will get the information to as many people as possible. The goal here is to prepare members of the community to take part in planning the next steps if they so choose, and to think about their eventual participation in an asset development program.

Plan your next steps. The character of your plan will depend on which developmental assets your community decides to address, but there are some general steps that can be helpful in any planning process.

• Convene a diverse, inclusive, and participatory planning group (or, as mentioned above, a number of task forces or committees, perhaps one for each related group of assets you plan to address), representing all sectors of the community, including youth. It might be the same group that has guided the process so far, that group with members added, or an entirely different group. Some people may be invited to join because of their skills or influence; others may volunteer solely out of interest and dedication to the community.
• Determine what assets you’ll focus on. A community with considerable resources – money, people, space, available expertise, etc. – might decide to tackle all the assets, or all of the assets most of its youth seem to be lacking. Another with fewer resources might choose to focus initially on only one area – support, for instance – and/or on only a portion of the youth population.

Many communities feel that the appropriate focus here is all adolescents and/or children in the community. A “community,” however, could be a relatively homogeneous neighborhood as well as a diverse city or a whole rural county. How the community is defined may have a great deal to do with where its focus lies.

• Do your research. Find out what other communities have done, and how. Look at best practices, and at the research on the areas you’re addressing. Enlist faculty and students at local colleges and universities to help.

CADY, as part of its technical assistance, connects communities with information on best practices and other research. Links to research in various areas of asset and child/adolescent development are also available on the Search Institute’s website. In addition, there is a great deal of information in various SI publications, also available on the website.

• Develop a strategic plan for building assets. The strategic plan is long-range, and should serve as a guide to what may be a decades-long process of community change.  This is your conception of how you’ll build and maintain developmental assets in your community over time, including which you’ll approach first, how you’ll keep the community involved, how you’ll measure your success, etc. It should include a timeline, with benchmarks to check your progress against.
• Design an action plan. In general, each benchmark will require some kind of action – often an effort or program designed to address a particular developmental asset or group of assets. Each of these actions will need its own action plan, describing exactly what you’re going to do and how. Issues to consider here are cultural differences in the community and the actual practice of promoting the development of various assets. The Community Tool Box, deals with the specifics of interventions and initiatives in a number of different areas, many focused specifically on youth.

Strategic and action plans can be devised regardless of whether you choose to use SI’s survey or not. Developing and strengthening all 40 assets should be seen as a goal even if many or most are already strong among the community’s youth. They won’t stay strong unless you continue to support parents and adolescents, teachers and other adults significant in children/young people's lives, and community members in general, in focusing on the needs and futures of youth in the community.

Present the plan to the community. Communication is again the key here. Citizens should have a chance to digest, discuss, and react to the plan. Their feedback should then be incorporated into a final version.

Implement your initial action plan. Once you’ve finalized how you’re going to approach developing assets, it’s time to get to work. The first phase of your plan may, as we’ve discussed, involve only one small group of assets, or it may address changing your community in many ways.

Continue to monitor, evaluate, and adjust your action plan. As with any type of intervention or action, it’s vital to make sure that you’re doing what you planned, and that it’s having the results you aimed for. If either of these is not the case, or if circumstances in the community change, you may need to alter what you’re doing, or even rethink it completely. Even if it’s working well, careful monitoring and evaluation can often show you ways to make it better.

Continue to form, implement, monitor, and adjust new action plans, and to maintain the gains you’ve made. As you make progress in asset development, remember that the goal is to transform the community over the long term. Once assets have been made available to most adolescents and children in the community, that availability has to be maintained indefinitely. The work of making your community a place where all children are valued and successful has no end.

In Summary

Asset development is the fostering of the developmental assets that children and adolescents need to become healthy, caring, productive, successful adults. The Search Institute of Minneapolis has identified 40 assets that are necessary for proper adolescent development, and linked the presence or absence of these assets to both high-risk behavior and “thriving indicators” in surveys of more than a million 6th to 12th graders over 15 years.

Assets are divided into eight categories. Four are external (support, empowerment, boundaries and expectations, and constructive use of time), and four are internal (commitment to learning, positive values, social competencies, and positive identity).

While the Search Institute’s research indicates that the ideal number of assets for an adolescent is 31 or more, fewer than 10% of adolescents actually have that many.  The average number is between 18 and 20 in most communities, and more than 60% of all youth surveyed report 20 or fewer.

Asset development is a community enterprise that demands commitment from everyone in the community, from school and civic officials to businesses, institutions, and organizations to private citizens to youth themselves. An asset development effort, because it has to be seen as the responsibility of everyone in the community, should be inclusive and participatory, to foster community ownership. It should be focused on the actual needs of the particular community (asset needs are different in different places, even if the average number of assets available to youth is similar), and emphasize the positive – the proactive building of assets as opposed to the reactive fixing of a problem. The effort should also be community-wide, so that it takes in everyone.

• A strong base in both empirical research and theory.
• Community ownership and diverse, broad-ranging input stemming from a participatory process.
• An accent on positive asset development making youth issues seem more resolvable.
• The ability of each community to design its own asset-building solutions.
• The ability to analyze data in numerous ways and by different populations.
• An emphasis on long-term social change.
• The capacity to address a broad range of issues.
• The possibility of increasing community cohesiveness.
• The emphasis on what’s best for youth leading to what’s best for the community.

Disadvantages to the asset development approach:

• A data base that’s 80% white and all youth for the Search Institute’s 40 assets.
• No real guidance as to how to develop assets.
• Community dependence on the Search Institute or CADY to analyze the surveys.
• Statistical limitations that may make accurate analysis difficult for small communities or schools.
• The lack of any guarantee that asset development will address current problems.
• The question of how necessary assets actually are for eventual success for most youth.

In sum, the advantages of focusing on youth seem to far outweigh the disadvantages, but the disadvantages still shouldn’t be ignored.

Although each community’s approach to asset development will be different, based on the needs and resources of the community, there are some basic steps that can be used to structure the process. (These steps are based on the assumption that a community will use either the Search Institute or the CADY survey.)

• Someone has to take the initiative.
• Form a coalition or other group to introduce asset development (and the idea of the survey/asset assessment) to the community.
• Once the community agrees to pursue asset development, work out the logistics of the survey.
• Implement the survey.
• Analyze the report of the survey results.
• Communicate your findings to the community.
• Plan your next steps.
  • Convene a diverse, inclusive, and participatory planning group (or, as mentioned above, a number of task forces or committees, perhaps one for each related group of assets you plan to address), representing all sectors of the community, including youth.
  • Determine what assets you’ll focus on.
  • Do your research.
  • Develop a strategic plan for building assets.
  • Design an action plan.
• Present the plan to the community.
• Implement your initial action plan.
• Continue to monitor, evaluate, and adjust your action plan.
• Continue to form and implement new action plans, and to maintain the gains you’ve made.

What is asset development?

___You work to build the 40 developmental assets that will support and enhance the healthy development of children and adolescents in your community.

___You seek to develop assets that will help youth guard against high-risk behaviors and patterns.

___You seek to enhance the assets that encourage thriving indicators in youth:

What are the characteristics of an asset development program?

___You seek commitment from the whole community.

___You create an inclusive, participatory effort.

___You base your effort on what’s needed in the community.

___You focus on the positive.

___You seek a comprehensive, community-wide effort.

What are the developmental assets kids need?

___You are familiar with the 40 developmental assets listed in the section.

Why (and why not) should you use an asset development approach?

___You are familiar with the advantages of an asset-building approach:

• A strong base in both empirical research and theory.
• Community ownership and diverse, broad-ranging input stemming from a participatory process.
• An accent on positive asset development, making youth issues seem more resolvable.
• The ability of each community to design its own asset-building solutions.
• The ability to analyze data in numerous ways and by different populations.
• An emphasis on long-term social change.
• The capacity to address a broad range of issues.
• The possibility of increasing community cohesiveness.
• The emphasis on what’s best for youth leading to what’s best for the community.

___You know the potential disadvantages to the asset development approach:

• A data base that’s 80% white and all youth for the Search Institute’s 40 assets.
• No real guidance as to how to develop assets.
• Community dependence on the Search Institute or CADY to analyze the surveys.
• Statistical limitations that may make accurate analysis difficult for small communities or schools.
• The lack of any guarantee that asset development will address current problems.
• The question of how necessary assets actually are for eventual success for most youth.

How do you use asset development?

___You find someone to take the initiative (or do it yourself).

___You form an inclusive, participatory group to introduce the asset development concept and the idea of the survey of developmental assets to the community.

___You work out the logistics of administering the survey.

___You implement the survey.

___You analyze the survey results.

___You communicate the survey results and analysis to the community.

___You plan your next steps.

___You develop an initial action plan.

___You implement your action plan.

___You monitor, evaluate, and adjust your plan.

___You continue to develop, implement, monitor, and adjust action plans, and to maintain the gains you’ve made.

A PowerPoint presentation summarizing the major points in the section.

 

Many funders and health and human service organizations aim to make progress on large and complex social problems – such as improving educational outcomes for all children, reducing homelessness, or improving community health outcomes.  This has proved challenging for all of us.

This community-level work goes by different names and associated models—including collaborative action, community mobilization, and comprehensive initiatives. One version of this approach is known as “collective impact.” Collective impact refers to the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem at scale. Like other models in Chapter 2 of the Community Tool Box, this section aims to provide an overview of this approach and links to resources for its implementation.

 

WHY USE A COLLECTIVE IMPACT APPROACH?

A premise of the collective impact approach is that not all problems are created equal – some are simple, some are more complicated, and some are truly complex.  Each type requires a somewhat different approach to solving them.

• An example of a simple problem is baking a cake – the right “recipe” is essential, but once you’ve discovered it, replication will get you almost the same result every time.
• An example of a complicated problem is sending a rocket to the moon – the right “protocols and formulas” are needed, as are high levels of expertise and training.  Experience is built over time to get to the right result, which can be repeated over time with the expectation of success.
• An example of a complex problem is raising a child - there are no “right” recipes or protocols that work in every situation. There are many outside factors that influence the situation, and every situation is unique. Experience helps, but in no way guarantees success.

A single service program may be quite appropriate to addressing problems that are simple or only somewhat complicated. Collective impact, however, is an approach to solving complex social problems.

Taking a collective impact approach requires moving away from the traditional, more isolated ways that service organizations attempt to solve problems. Traditional, isolated approaches to making an impact on outcomes often look like this:

• Funders select individual grantees
• Organizations seeking to implement change work separately and often compete against each for funding
• Evaluation is structured to isolate a particular organization’s impact to show progress
• Large-scale change is assumed to depend upon scaling individual organizations or interventions
• Corporate and public sectors are not heavily involved in the process

Like other approaches to collaborative action, the collective impact approach engages multiple players in working together to solve complex social problems:

• Funders and implementers understand that social problems – and their solutions – arise from the interaction of many organizations within a larger system
• Organizations actively coordinate their actions and share lessons learned
• Progress depends on working toward the same goal and measuring the same things
• Large-scale change depends on increasing cross-sector alignment and learning among many organizations
• Corporate and public sectors are essential partners

​What Is Collective Impact?

As noted above, collective impact is the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem at scale.

Organizations have been implementing collective impact for a long time. These successful collective impact initiatives often assure five conditions that are associated with their relative success:

• Common Agenda
  • All participants share a vision for change that includes a common understanding of the problem and a joint approach to solving the problem through agreed-upon actions.
• Shared Measurement
  • All participating organizations agree on the ways success will be measured and reported, with a short list of common indicators identified and used for learning and improvement.
• Mutually Reinforcing Activities
  • A diverse set of stakeholders, typically across sectors, coordinate a set of differentiated activities through a mutually reinforcing plan of action.
• Continuous Communication
  • All players engage in frequent and structured open communication to build trust, assure mutual objectives, and create common motivation.
• Backbone Support
  • An independent, funded staff dedicated to the initiative provides ongoing support by guiding the initiative’s vision and strategy, supporting aligned activities, establishing shared measurement practices, building public will, advancing policy, and mobilizing resources.

Below is a select list of Community Tool Box resources supporting implementation of a collective impact approach.

Common Agenda

• Toolkit 3: Analyzing Problems and Goals
• Toolkit 7: Developing an Intervention
• Chapter 2, Section 9: Community Readiness
• Chapter 2, Section 13: MAPP: Mobilizing for Action through Planning and Partnerships
• Toolkit 5: Developing Strategic and Action Plans
• Chapter 8, Section 1: An Overview of Strategic Planning or “VMOSA” (Vision, Mission, Objectives, Strategies, and Action Plans)
• Chapter 8, Section 2: Proclaiming Your Dream: Developing Vision and Mission Statements

Shared Measurement

• Chapter 3, Section 9: Developing Baseline Measures of Behavior
• Chapter 3, Section 18: Creating and Using Community Report Cards
• Chapter 3, Section 19: Using Public Records and Archival Data
• Chapter 8, Section 3: Creating Objectives

Mutually Reinforcing Activities

• Chapter 1, Section 7: Working Together for Healthier Communities: A Framework for Collaboration Among Community Partnerships, Support Organizations, and Funders
• Chapter 1, Section 8: Some Lessons Learned on Community Organization and Change

Continuous Communication

• Chapter 6, Section 1: Developing a Plan for Communication
• Chapter 6, Section 2: Using Principles of Persuasion
• Chapter 6, Section 3: Preparing Press Releases
• Chapter 6, Section 4: Arranging News and Feature Stories
• Chapter 6, Section 6: Preparing Guest Columns and Editorials
• Chapter 6, Section 7: Preparing Public Service Announcements
• Chapter 6, Section 8: Arranging a Press Conference
• Chapter 6, Section 9: Using Paid Advertising
• Chapter 6, Section 10: Creating Newsletters
• Chapter 6, Section 11: Creating Posters and Flyers
• Chapter 6, Section 12: Developing Creative Promotions
• Chapter 6, Section 13: Creating Brochures
• Chapter 6, Section 15: Creating Fact Sheets on Local Issues
• Chapter 6, Section 16: Creating a Website
• Chapter 6, Section 17: Using Email Lists
• Chapter 6, Section 18: Using Direct Mail
• Chapter 6, Section 19: Handling Crises in Communication
• Chapter 4, Section 5: Making Community Presentations
• Toolkit 13: Implementing a Social Marketing Effort
• Chapter 4, Section 2: Communicating Information about Community Health and Development Issues

Backbone Support

• Toolkit 1: Creating and Maintaining Partnerships

The term “collective impact” was first referenced in a 2011 article in the Stanford Social Innovation Review. 

Momentum around collective impact is building. Collective impact initiatives continue to pursue social change in a variety of areas and momentum around the approach continues to grow. Some examples of collective impact in different fields or domains can be seen below:

In education

• Strive
• CCER

In public health

• Shape Up Somerville
• LiveWell Colorado
• Global Alliance to Improve Nutrition (GAIN)
• Tackling Youth Substance Abuse

In addressing homelessness

• Calgary
• Home Again 

In youth development

• NYJJ
• Project U-Turn
• Communities That Care

In economic/urban development

• Fund for our Economic Future
• Memphis Fast Forward
• Living Cities Integration Initiative

In community development

• Magnolia Place

In addressing environmental issues

• Elizabeth River Project

When Is a Collective Impact Approach Appropriate?

You can use the following readiness assessment to determine if a collective impact approach is appropriate for your situation. This assessment is most valuable when completed by a group of stakeholders committed to addressing a specific social or environmental issue, and the results and implications are discussed together.

• Is a collective impact approach appropriate for pursuing your goals?
  • There are many forms of collaboration, each suited to address different types of social and environmental issues. Consider whether you are addressing complex, large-scale social and environmental issues at scale. Do you have the time and resources required?
• Do the pre-conditions exist for the potential success of a collective impact approach?
  • Do you have present: influential champions, sufficient resources to support the planning process and infrastructure, and the urgency to address the issue in new and different ways.
• Are the nuts and bolts for a collective impact approach already in place?
  • If your group has determined that this collaborative approach is appropriate to use, and the pre-conditions are in place, we suggest using the following in-depth readiness assessment to take stock of the extent to which the nuts and bolts are in place to begin your work.

Collective impact is not right for every problem. The process can take a long time and requires significant resources to sustain – resources from partners making new investments and changing their practices, as well as from supporting the underlying backbone infrastructure.

How Do You Implement a Collective Impact Approach?

Before implementation of this approach can begin, the organizations and individuals involved must embrace the logic of collaborative, adaptive and servant leadership.

• Pay attention to adaptive work, not just technical solutions: The group has to move away from thinking about technical solutions, which are best suited for simple and complicated problems, and begin to think about adaptive solutions to problems which require continuous learning.
• Look for silver buckshot instead of the silver bullet:  Achieving population-level change, the ultimate goal for collective impact initiatives, requires all stakeholders to abandon the search for a single silver bullet solution. Instead, they must shift their mindset and recognize that success comes from the combination of many interventions.
• Sharing credit is as important as taking credit: Seeking to take direct credit is extremely difficult in large-scale collaborations where change is being created by many actors simultaneously.  Organizations should think about their decisions in the context of others, and share credit with the group to encourage greater collaboration and cohesion.

PHASES OF A COLLECTIVE IMPACT APPROACH

Collaborative action of this type can generally be categorized by levels of maturity, or phases. (Every initiative is unique, however, and should be rooted in the local context and readiness of stakeholders.) Some generalizations about phases:

• Phase  1: Assess Readiness
  • Conduct a readiness and landscape assessment (assess complexity and urgency of problem, assess history of collaboration, identify existing local collaborations, identify potential champions, determine resources)
• Phase 2: Initiate Action
  • Kick off steering committee
  • Begin community outreach
  • Create baseline landscape and data mapping
  • Secondary research on other collaboratives
• Phase 3: Organize for Impact
  • Create common agenda: clear  problem definition, common vision, population level goal, basic theory of change
  • Develop high level population goal
  • Solicit and incorporate community perspectives and input
• Phase 4: Begin Implementation
  • Determine shared measurement and aligned strategies to create mutually reinforcing activities
  • Develop working groups to implement strategies (note we’ll talk more about who is on working groups in the next section)
  • Select backbone organization
  • Introduce the initiative to the broader community; share what you are trying to accomplish
  • Create/select a backbone organization to sustain the work moving forward
• Phase 5: Sustain Action and Impact
  • Begin implementing strategies and measuring indicators
  • Collect and use data to learn and refine strategies, and identify quick wins
  • Evolve steering committee and working group composition to match adaptive strategies
  • Continue ongoing activities to share initiative progress and gain community input

Who Should Be Engaged By Your Collective Impact Effort?

As we noted earlier in this chapter, one of the common features of a collective impact is that it is cross-sector. Complex problems can be solved only by cross-sector coalitions that engage those outside the nonprofit sector (or any other single sector).

However, it isn’t just who you bring together, but how you bring them together. The structures that collaborative efforts create enable people to come together regularly to look at data and learn from one another, to understand what is working and what is not.  The main key structural components of a collective impact approach are the steering committee, working groups, backbone support, and community engagement.

Steering Committee

Collaborative action almost always begins with the establishment of an oversight group, often called a steering committee or executive committee. The key responsibilities of the steering committee are to:

• Provide long term strategic direction to the initiative
• Oversee the work of the backbone
• Determine staff and resource needs to ensure sustainability, in coordination with the Executive Team,
• Monitoring progress against common agenda goals and indicators to ensure continued advancement and to uncover any obstacles
• Review data and using it to inform changes in stakeholder engagement, working group composition, or strategies
• Provide guidance to working groups’ efforts
• Champion the effort broadly in the community

The composition of the steering committee is vital to the success of the initiative, as they will set the initiative’s strategic direction. There are a few key characteristics to look for when selecting steering committee members:

• Decision Makers: Members should be at the CEO/President Level and able to drive systems change relevant to effort
• Representative: Geographic coverage of effort (counties and subregional steering committees) as well as sector
• Influential Champions: Command respect of broader set of stakeholders (and perceived so). Can bring stakeholders to the table and keep them there. Can champion the strategy with the broader community
• Content Expertise/Practitioners: Familiar with subject matter to contribute substantively
• Passion and Urgency: Passionate about issue and feel real urgency for the need to change
• Focused on the Greater Interest: Represent needs of their own organizations but able to think and act in the greater interest of the community
• Commitment: Willing and able to commit time and energy to attend meetings and get work done
• Lived Experience: Residents or community members with lived experience on the issue being addressed by the initiative

The highest functioning steering committees tend to have two co-chairs, each from a different agency/organization; meet at least quarterly (often monthly at first); have diverse, cross-sectoral membership drawn and rotational leadership; coordinate activity with working groups and other coalitions via the backbone leadership and working group chairs; communicate regularly within the Steering Committee based on agreed upon schedule and methods; and report processes, findings, and concerns to stakeholders.

Working Groups

Once the strategic action framework is agreed upon, different working groups—also known as action committees—are formed around each of its primary leverage points or strategies. The key responsibilities of the working groups are to:

• Identify effective strategies to support achievement of goals:
  • Collect research on effective evidence-informed strategies
  • Use data to inform identification of strategies
  • Suggest refinement of indicators based on strategy development (as needed)
  • Identify funding sources and local  agencies to support strategies
• Community engagement:
  • Convene relevant stakeholder dialogues and other forms of community engagement
  • Coordinate communications messages and strategy with other working groups
• Implementation:
  • Coordinate activities among working group member agencies and others in the community to implement strategies
  • Dedicate time to tactics of planning events, identifying volunteers, and other tasks

The highest functioning working groups tend to have at least two co-chairs, each from a different agency; meet at least monthly, sometimes more often at first; have diverse, cross-sectoral membership and rotational leadership; coordinate activity with other working groups via the backbone leadership and other working group chairs; communicate regularly within working groups based on agreed upon schedule and methods; and report processes, findings and concerns to the steering committee.

Backbone Support

Backbone support is provided by an independent funded staff and dedicated to the collective impact initiative. Backbones provide ongoing support in the following six areas:

• Guide Vision and Strategy:
  • Build a common understanding of the problem that needs to be addressed
  • Provide strategic guidance to develop a common agenda; serve as a thought leader / standard bearer for the initiative
• Support Aligned Activities:
  • Ensure mutually reinforcing activities take place, i.e.,
    • Coordinate and facilitate partners’ continuous communication and collaboration Convene partners and key external stakeholders
    • Catalyze or incubate new initiatives or collaborations
    • Provide technical assistance to build management and administrative capacity (e.g., coaching and mentoring, providing training and fundraising support)
    • Create paths for, and recruit, new partners so they become involved
    • Seek out opportunities for alignment with other efforts
• Establish Shared Measurement Practices:
  • Collect, analyze, interpret, and report data
  • Catalyze or develop shared measurement systems
  • Provide technical assistance for building partners’ data capacity
• Build Public Will:
  • Build public will, consensus and commitment:
    • Frame the problem to create a sense of urgency and articulate a call to action
    • Support community member engagement activities
    • Produce and manage communications (e.g., news releases, reports)
• Advance Policy:
  • Advocate for an aligned policy agenda
• Mobilize Resources:
  • Mobilize and align public and private resources to support initiative’s goals

It is vitally important that a backbone is viewed as neutral by the stakeholders on the steering committee and in the wider community.  However, when understanding backbones, it is just as important to understand what backbones are not. Backbones do not set the agenda for the group, do not drive all the solutions, do not receive all the funding, cannot be self-appointed rather than selected by the community, and is not “business as usual” in terms of staffing, time, and resources. They are a facilitative support team who can plan, manage, and support the initiative through ongoing facilitation, technology and communications support, data collection and reporting, and handling the myriad logistical and administrative details needed for the initiative to function smoothly.

There is no one model of backbone support. We’ve identified five potential models, although this is not necessarily an exhaustive list:

• Funder-Based: One funder initiates a collective impact strategy as planner, financier, and convener
• New Nonprofit: New entity is created, often by private funding, to serve as backbone
• Existing Nonprofit: Established nonprofit takes the lead in coordinating strategy
• Government: Government entity, either at local or state level, drives the effort
• Shared Across Multiple Organizations: Numerous organizations take ownership of the wins

Community Engagement

In collaborative action, it is vitally important to include multiple organizations or sectors – business, nonprofit, government, and philanthropy. However, it is equally important to engage the community. Effective community engagement is a critical factor in the long-term success of collective impact initiatives.

When considering community engagement, it is important to do both broad based community engagement – which seeks to reach a large and varied set of stakeholders within a community, including the general public rather than a targeted group of experts, leaders, or special interest groups – and targeted community engagement – which seeks to engage a particular group, often one that is under-represented or otherwise not engaging in an initiative without such a specialized effort.

How the community is engaged depends upon the goals of the initiative and how the community can best plug into those goals. A few of the ways a community can be engaged, based on thinking from Tamarack Institute, are shown below:

• Understand pressing systemic community challenges
  • Begin a process of understanding the issue
  • Clarify questions that arise during the process
• Co-create solutions
  • Spark innovative problem-solving rooted in the “lived-experience” of the community
  • Identify and spread unique solutions that exist within the community
• Verify the direction
  • Get feedback on specific strategies and indicators from selected communities
• Expand the reach of involvement
  • Expand the reach of adoption of initiative strategies
  • Evoke and sustain the will to take aligned action
• Build community capacity to lead and sustain change
  • Train stakeholders in skills of effective collaboration and strategy execution (e.g., shared measurement)
  • Share resources, and learning across the community to support scaling best practices

Shared Measurement

Creating and using shared measures is a key component of a rigorous collaborative effort. Shared measurement means identifying a targeted set of indicators that everyone signs onto and pursues and then using that data both to track progress and also to improve efforts over time. This is different from the traditional paradigm of evaluation that the social sector (and other sectors) are used to, which typically focuses on isolating the impact of a single organization or grant, rather than assessing multiple organizations working together to solve a common problem.

Clearly there are many common challenges to shared measurement:

• Competing priorities among organizations when establishing common measures
• Capacity for data collection and analysis within organizations involved
• Willingness to invest the time, and sometimes money, in developing a shared measurement system
• Ability to create a culture shift from using data to prove to using data to improve, which requires overcoming the fear that organizations will be compared negatively. 

There are some simple keys to success when it comes to overcoming these challenges and successfully implementing shared measurement:

• Effective relationship with funders - Successfully implementation of shared measures requires not only a commitment from collaborators, but also from their funders to re-align funding requirements to reflect those of the initiative; this means: strong leadership and substantial funding (multi-year) and independence from funders in devising indicators, managing system
• Broad and Open Engagement – There needs to be broad engagement (with voluntary participation open to all organizations) during the shared measurement design process with clear expectations about confidentiality/transparency
• Infrastructure for Deployment – Infrastructure means technological and human infrastructure – there both needs to be effective use of web-based technology, but also ongoing staffing to train people to use the measures, facilitate the shared measurement process, and make sure the data is accurate.
• Pathways for Learning and Improvement – The power of shared measurement comes from testing and continuously improving through constant feedback; this requires a facilitated process for participants to share data and results, learn, and better coordinate efforts

For organizations that choose to take the leap and embrace shared measurement, the benefits far outweigh the costs, and they include:

• Improved data quality
• Greater alignment across organizations
• The ability to track progress toward a shared goal
• More collaborative problem-solving
• Learning that benefits all organizations looking to solve a problem, and allows for course corrections that lead to better results

Evaluating Collective Impact

Evaluating the overall impact of an initiative is an important part of the process for all parties. Practitioners seek timely, high-quality data that enables reflection and informs strategic and tactical decision making. Funders and other supporters require an approach to performance measurement and evaluation that can offer evidence of progress toward the initiative’s goals at different points along the collective impact journey.

The change process typically involves three stages of development, each of which requires a different approach to performance measurement and evaluation:

The initiative’s early years are typically focused on understanding context and designing and implementing the initiative. This includes establishing the five core conditions of collective impact, as well as the coordinated implementation of multiple programs, activities, and campaigns, according to the initiative’s overarching strategy or theory of change.

• Recommended approach to performance measurement: Partners should agree on a set of early performance indicators to track their progress in establishing key elements of the initiative’s infrastructure.
• Recommended approach to evaluation: Developmental evaluation, aimed at helping partners understand their initiative’s context and learn more about how the initiative is developing.

The work of evaluating a comprehensive initiative’s context and carefully assessing the quality of its design and implementation in its early years is critically important and should not be dismissed as mere focus on process. The successful reorganization and alignment of the system of actors that are addressing a problem is itself an important outcome of the change process.

The initiative’s middle years, in which partners should expect to achieve some significant changes in patterns of behavior (e.g., changes in professional practice, changes in individual behavior) and in the way systems operate (e.g., changes in cultural norms, funding flows, public policy). These changes serve as the gateway to the initiative’s ultimate, population-level outcomes and are thus an important area of focus for both performance measurement and evaluation.

• Recommended approach to performance measurement: Partners should use data from their initiative’s shared measurement system to determine if, where, and for whom the initiative is making progress.
• Recommended approach to evaluation: Formative evaluation to help partners refine, improve, and fine-tune this work, as well as developmental evaluation to explore newer aspects of the initiative.

The initiative’s later years, in which CI partners should expect to achieve meaningful, measurable change with regard to the initiative’s ultimate goal(s). At this time, the initiative may be ready for a summative evaluation to assess its impact, merit, value, or significance.

In Summary

Collective impact—like other models in Chapter 2 of the Community Tool Box—offers a  promising approach to addressing complex social problems at scale.

Contributor

This section was contributed by Jennifer Splansky Juster, Director of the Collective Impact Forum, FSG. Visit the CI Forum.

Collective Impact – Progress Assessment

Is There a Common Agenda?

_____ Do we have all of the necessary stakeholders at the table?

_____ Does the group have an explicit definition of the problem in agreed-upon language to refer to?

_____ Has the group agreed upon the scope of the landscape it is focusing on? (i.e., Which stakeholders need/do not need to be involved?)

_____ Has the group written a vision and mission statement?

_____ Does the group have agreed upon goals, and measurable targets related to those goals?

Does Backbone Support Exist?

_____ Has a structure for the backbone been clearly decided (e.g., existing organization, new organization, hybrid)?

_____ Is there a funder willing to fund the creation of backbone infrastructure over several years?

_____ Is the backbone actively supporting aligned activities through convening partners, providing technical assistance, and recruiting new partners?

_____ Has the backbone organization begun to build public will with consensus and commitment through communications management, articulating the call to action, and supporting community member engagement activities?

Is a Shared Measurement System in Place?

_____ Is ongoing staffing assigned and funding allocated to develop and implement a shared measurement strategy?

_____ Have we decided what metrics and benchmarks to use to gauge our progress?

_____ Have we established processes to ensure that measurement remains aligned to hold all organizations accountable? Is this data accessible enough so that organizations can easily course-correct?

_____ Have we established a web-based technology tool for bringing shared measurement to scale?

_____ Is that web-based tool easily accessible to stakeholders, customizable, and inexpensive?

_____ Are stakeholders sharing results and learning from each other using the tools and processes we’ve created?

Have Mutually Reinforcing Activities Been Established?

_____ Is there an up-to-date map of the players, strategies and work underway?

_____ Is it clear who is responsible for the different strategic elements of the initiative?

_____ Has overlap and redundancy between organizations been identified and minimized?

_____ Have sub-groups been established by locality and type of activity?

_____ Has a list of prioritized activities and next steps been written so that the different groups are coordinated around common agenda?

Is There Continuous Communication?

_____ Have meeting schedules been established for activity-focused sub-groups? Will these meetings occur yearly? Monthly? Weekly?

_____ Have meeting schedules been established for community-focused sub-groups? Will these meetings occur yearly? Monthly? Weekly?

_____ Have vertical and horizontal reporting processes been established? (i.e., How will sub-groups report out to the steering committee? How will groups report to each other?)

_____ Have decision-making processes been established?

Collective Impact – Readiness Assessment

Use the following gauges to determine “readiness” for Collective Impact by identifying which preconditions the group is well prepared for or will need further investment in:

Progress Gauges:

Significant Investment Needed – The group does not currently have these elements/processes in place. There is an incomplete or unclear plan to accomplish this goal and/or significant time and resources will need to be allocated to either begin or complete this process.

Some Investment Needed – While these elements/processes are not fully in place, significant thought and planning has gone into these elements. Time and resources have been allocated and clear progress is being made.

Current Situation Strong – These elements/processes are either fully in place or sufficient progress has been made in them so that they are operationally functional in the context of the initiative.

 

Download a Microsoft Word version of this assessment here.

Example #1: Early Wins in Early Childhood - A Case Study in Seeding Systems Change

Southeast Virginia has long been home to numerous early care and education programs. However, operating traditionally in silos, these programs were not seeing the results they desired.

In 2016, Hampton Roads Community Foundation initiated a region-wide process involving nearly 100 stakeholders to scope and plan Minus 9 to 5, an initiative designed to unite previously disparate programs and people together for greater impact through systems change. This case study details the opportunities, highlights, and lessons learned in the first two years of the initiative. Read more from FSG Reimagining Social Change.

Example #2: Collective impact in different fields or domains:

In education

• Strive
• CCER
• Ready by 21

In public health

• Shape Up Somerville
• LiveWell Colorado
• Global Alliance to Improve Nutrition (GAIN)
• Tackling Youth Substance Use

In addressing homelessness

• Calgary 
• Home Again 

In youth development

• NYJJ
• Project U-Turn

In economic/urban development

• Memphis Fast Forward

In community development

• Magnolia Place

In addressing environmental issues

• Elizabeth River Project

Example #3: How collective impact is being used to solve homelessness:

The Collective Impact Forum's September 18th, 2023 podcast covers how complex issues such as homelessness can feel unsolvable or intractable, but that through a commitment to a collective approach and strategies, communities can end homelessness.

Speaking with Community Solutions' (a nonprofit that is dedicated to ending homelessness) president Rosanne Haggerty, the program Built for Zero is discussed, which is a program network of more than 100 cities and counties working to ensure that homelessness can be rare or brief in their regions.

The Institute of Medicine (IOM) is an independent, non-profit research and public information organization that’s a component of the National Academy of Sciences. IOM would like you to think about something. Suppose you mount a community effort to deal with an important local issue – let’s say domestic violence. You put together a group to spearhead your effort, study the issue in the community, and come up with a plan.

You realize that domestic violence has many dimensions. It’s not just the result of someone losing his temper once in a while, but rather part of a recurring pattern. In addition, it has ties to substance use, unemployment and other economic circumstances, and a social climate that makes it acceptable, at least up to a point.

So your group sets out to address all the aspects of the problem. Police may have to be trained, and they and the courts may have to change their attitudes toward domestic violence. Safe havens have to be established for family members who’ve been violently abused or attacked. Families – including the abusers, people experiencing abuse, and witnesses to the abuse – need counseling. Substance use has to be addressed and treated. In addition, attention has to be paid to job training, not to mention the overall economic situation of the community. Finally, there has to be a public education campaign to convince the community that domestic violence is not a normal part of a relationship.

Each element of your plan requires an action, and each action requires someone to carry it out. Furthermore, you’ll need someone or some group in the coalition to coordinate and oversee the whole process. A complex plan won’t work unless everyone does what is expected.  That’s a major concern of the IOM. It believes that accountability is often overlooked in community health and development planning, and is a crucial ingredient in creating a healthy community.

This section will describe CHIP (Community Health Improvement Process), the IOM model, which is similar to others in this chapter in many ways – it’s participatory; takes a community perspective; embodies a broad view of health; calls for community assessment, strategic planning, and evaluation in intervention, etc. – but features an accountability component. IOM believes that performance monitoring – starting off with a clear statement of everyone’s responsibilities, and then checking regularly, using quantitative measures of performance, to make sure that those responsibilities have been carried out and have been effective – can make the difference between success and failure in a drive to build a healthy community.

What is a CHIP?

CHIP is a framework for a process for building community health. As explained above, it has a performance monitoring element built in. It is specific about process – the way you go about creating a community health effort – but not about content – the issues you might tackle or the methods you might use to tackle them. Content is left up to individual communities.

You could read the words “Community Health Improvement” in two ways: (1) the improvement of the overall physical health of the individuals who make up a community; or (2) the improvement of the health of the community itself. IOM largely concerns itself with the first possibility, but we’ll concentrate on the second, in keeping with the fact that the Community Tool Box is concerned with all aspects of community functioning. Striving for a healthy community, instead of community health, doesn’t change the CHIP framework at all, but gives us the leeway to address various aspects of community life, rather than health alone.

The diagram below describes the CHIP model using graphics. The text that follows explains the components of the model and how they relate to one another.

From J.S. Durch, L.A. Bailey, and M.A. Stoto, eds. Improving Health in the Community, Washington, DC: National Academy Press, 1997.

As the model diagram shows, a CHIP has two cycles – cycles because each is seen as a sequence that can and should be repeated over the course of time. A cycle can be initiated in any of its phases, although the implication of the diagram seems to be that there is a “most logical” sequence that most communities will use, and that we’ll use here.

The problem identification and prioritization cycle

In this cycle, you start with an area of concern – health in the original IOM conception, but as we’ve discussed, it could as easily be the overall quality of community life – assess the situation, identify areas that the community needs to work on, and decide where you’ll put your energies.

• Form a community coalition to address community health/quality of life. There has to be some coordinating body for such an effort. A coalition satisfies the demands of the IOM model for inclusiveness and broad participation. It implies a relationship of equals working toward a common goal, and makes it easier to bring people and organizations together than would a more hierarchical structure.
• Prepare and analyze community profiles. This is the process of examining the various factors that could influence community well-being. Looking at the results of your analysis should highlight the problem areas that most need to be addressed. IOM suggests five areas to examine:
  • Sociodemographics. Age, geographic distribution, race/ethnicity, income, employment, housing, etc.
  • Status of the issue. The frequency and seriousness of issues in the community, whom they affect, related issues and their effects and frequency. Frequency and seriousness are both important. A very large number of cases of small, easily cured skin cancers may be a matter of concern, for instance, but not as much concern as a somewhat smaller number of cases of lung cancer, many or most of which prove fatal.
  • Risk and protective factors. The factors already existing in the community that make people more or less likely to be affected by particular issues. The absence of laws prohibiting children and teens from purchasing cigarettes may be a risk factor for that lung cancer epidemic; enforced no-smoking laws in restaurants and public buildings may be a protective factor.
  • Resource consumption on issues. The community resources (services, funding, etc.) already devoted to particular issues.
  • How people view the issues with respect to themselves. To what extent do they report being affected by them? If people don’t see an issue as a problem that affects them in some way, or as something important, it’s difficult to involve the community in action on that issue.
  • This profile will help you decide what issues to work on, and will be useful to the community in examining itself in many ways, and in continuing the work of the CHIP after the initial effort has been completed.
• Identify the critical issues (the problem). What are the most critical needs in the community? What issues motivate – or could motivate – citizens to work on them?  What does the community have the resources to do? On what issues can you actually make a difference? These are the questions to ask in deciding what issues you’ll address.

The “problem” here is assumed to be an aspect of a larger concern (specifically health, in the original IOM conception). It may be an actual specific problem – pregnancies among adolescents, people experiencing homelessness, tuberculosis, violence, the school dropout rate – but could also be a community asset that needs to be developed – youth leadership, an empty historic building – or the creation of something new that contributes to the health and well-being of the community – a community arts center, a well-baby program.

• Once you’ve identified the issues you plan to work on, you move on to the next cycle, that of analysis and implementation. The diagram above describes the second cycle of the process for one issue. If the CHIP has identified and means to address several issues – domestic violence, gang activity, and child sexual assault, for example – then it will go through an analysis and implementation cycle for each of them.

The analysis and implementation cycle.

Here, you work out both a long-term strategy and an action plan to effectively resolve the issue at hand, assign responsibility for each element of the plan, put it into effect, and then monitor your results to determine whether everything is working properly, and whether all partners are fulfilling their responsibilities.

• Analyze the issue. Using the information it has gathered, its knowledge of the community, reports of best practices, and the available research, the coalition analyzes the issue. IOM’s model, like PRECEDE/PROCEED. Healthy Communities, and others, emphasizes that both individual and community health are greatly influenced by a combination of social, physical, and genetic environmental factors, as well as by economic and political conditions. Thus, the natural environment, the gap between the top and bottom of the community economic ladder, the racial or ethnic groups in the community, the employment situation, and the attitudes of those in power toward the role of government may all have a profound effect on a particular issue or on the general quality of community life.
• The goal here is to understand the particular factors that cause or lead to the issue you’re concerned with, how they play out in the community, and how they can best be approached. You should be careful to consider all possible factors, not just those that are obviously related to the issue.
• Inventory your resources. What do the coalition and the community have available to address issues?
  • Local assets. Organizations and institutions, local foundations and other funders, expertise, current services, etc
  • Protective factors within the community. Family, social, and faith networks; community norms and values, physical environment, community activities, etc.
  • Human resources. “Natural helpers,” academic researchers, links to particular groups in the community, people with skills in relevant areas.
  • Resources from outside the community. Nation- and statewide public and private funding sources, for instance, or sources of technical assistance.
• Develop a strategy. Understanding the issue and having a clear sense of available resources will help you to come up not only with a short-term plan for addressing the specific issue you’re currently focusing on, but also with a strategy for promoting and maintaining community well-being over the long term. Your strategy should be geared to your community, and should be arrived at through an inclusive, participatory process.
• Identify accountability. Your coalition or partnership – with the input and collaboration of those who will be carrying out the plan (if all has gone well, they’ll be involved already) – determines who will be responsible for which elements of the plan.  You should identify who will oversee each part of the process, who is responsible for carrying out the actual work of a particular intervention or piece of an intervention, who will evaluate and provide feedback, etc. There are some important considerations as you agree on accountability:
  • It should be realistic. Before individuals or groups take on responsibility for a part of the process, you should make sure that they have the resources, capacity, and support to accomplish what they’re attempting. To assign accountability to someone who can’t succeed is both unfair and counterproductive.
  • It should be voluntary. If accountability is to mean anything – and if it is to lead to results – it must be taken on willingly. Individuals or groups that accept accountability for an element of the strategy are also agreeing to think carefully about what they do, to be willing to change course if their efforts aren’t working or if community needs change, to accept constructive criticism without defensiveness, and to see themselves as integral parts of a larger effort. If they accept accountability under pressure, or disagree with the accountability process, they’re unlikely to agree to any of that, and their supposed accountability won’t make much difference.
  • It should involve clear and observable responsibilities. Both the accountable individuals/organizations and the coalition should understand exactly what they’re agreeing to, and how they’ll determine whether and how responsibilities have been met. Clarity makes performance itself and its monitoring easier, confirms that you’re operating with a coherent and understandable plan, and – because everyone knows exactly what he’s supposed to do – increases the chances of success.

No matter how carefully you plan, you can’t anticipate everything that might or will happen, and you should expect surprises. If you plan carefully, however, and try to be as clear as possible, there will be fewer of them, and they’ll breed less bad feeling among those who find themselves surprised. As long as everyone agrees at the beginning that the responsibilities they’re taking on are reasonable and achievable, unexpected events and circumstances can be weathered.

• Develop a set of performance indicators in order to be able to monitor the process, outcomes, and performance. Accountability should be measurable, and should be based on what needs to be accomplished. Its point is not to single out or punish those who don’t reach their intended goals, but rather to:
  • Help those who are having difficulty improve their performance. This might be through better support, redefining goals, changing methods or techniques, switching staff around, focusing on a different group of participants, changing to a more realistic timeline – whatever it takes to make sure that what they do has the desired effect.
  • Identify problems in the system. It may be that performance is ineffective because the reasons for it are simply invalid, or because you conceived of the issue in the wrong way to begin with. Performance problems can often shed light, not on the failures of those responsible, but on the inadequacy of the system within which they are working.
  • Help everyone learn and improve both action plans and the overall strategy.

IOM specifically suggests that indicators should be quantitative – i.e. tied to numbers, such as the number of people served, or the average time participants spend in a program – but there are other ways to assure that accountability is measurable. Qualitative measures such as observation, participants’ own reports, and community impressions may also provide accurate and important information relating to accountability. Numbers don’t always tell the whole story.

The point of accountability here is not to make it easier to assign blame if something doesn’t get done or go as planned. Rather, it is to make it possible to improve your strategy and actions so that they become more effective. If there’s a failure in the system, clear accountability enables you to figure out where it happened and why. Then you can take action to correct it, whether that’s providing better support to whoever’s responsible, or rethinking your strategy entirely.

• Implement your strategy. Do whatever you’ve decided is necessary – intervention, program, community education initiative, etc.
• Monitor the process and outcomes. As with other models (PRECEDE/PROCEED, for example), the concern here is both with process and outcomes.
  • Process: Did you do what you set out to do (e.g., deliver a specific service to a specific number of people in a specified time frame)? If not, why not?
  • Outcomes: What effect did your actions have? Was it the desired effect, or at least positive? If not, why not?

If the process broke down, or the outcomes weren’t satisfactory, you should be able to analyze the situation, and pinpoint what went wrong and how by using the performance indicators that you developed in phase 5. Then you can choose from a number of possible courses of action to correct mistakes or misconceptions, bolster the performance of an organization that wasn’t able to accomplish what it expected to, etc. Among the possibilities:

• Change your strategy or action plan.
• Shift responsibility elsewhere.
• Provide more support and/or resources to those accountable.
• Eliminate a particular action or element of strategy.
• Start the cycle again, with another issue or group of issues. What you’ve done so far may have resolved some issues, or may have only made clear how complex they are. Whatever the result, you’re not done: the ultimate aim here is long-term, fundamental change that improves life in the community. Whether you’re moving up to a larger concern, or merely addressing a different issue, there will always be a next step in the process.

Why use a CHIP?

Why would you employ the CHIP model as opposed to another? There are a number of reasons why this model might be a good one for many communities.

•  It takes a community perspective. CHIP asks you to consider the whole community when you address an issue. That broad perspective is most likely to encompass the real causes – and best resolutions – of issues that need to be addressed.
• It’s inclusive and participatory. The CHIP model not only considers but involves the whole community in generating strategy and carrying it out. That means that a wide range of opinions, viewpoints, and ideas go into a strategy, and that the community owns the eventual effort. Community ownership in turn leads to enthusiastic community support, and a willingness to work for the effort and see it through.
• It demands a comprehensive view of health. Again, like many of the other models in this chapter, CHIP sees health as not only the absence of disease or a chronic condition. Community health is health in all senses – social, economic, political, ecological, etc. (The Evans and Stoddart field model illustrated earlier provides an example of this comprehensive view.) This view allows you to consider all community issues when addressing community health, making it far more likely that they will be resolved.
• It sees equity as a key. Equity – the condition of everyone in a community getting what she needs for a decent quality of life – has been shown to be a prime factor in both individual and community health by the World Health Organization. The fostering of equity is crucial to the creation of a healthy community, and to the establishment of social justice in a community or a society.
•  It’s flexible. The model leaves the community to determine the structure and content of its strategic and action plans, based on its own analysis and knowledge of its own needs.
• It builds in accountability. As discussed above, that makes it possible to structure an effort clearly, and to identify gaps in it as they appear.
• It builds in performance monitoring. Not only does performance monitoring make accountability a reality, but it allows pinpoint course correction as it identifies problem areas in strategy or in the implementation of an effort.
• It can incorporate or fit in with other models. CHIP can be used as the framework for a healthy community effort, for instance. Its flexibility in form and content makes it adaptable to a wide range of circumstances.
• It sees the process as ongoing and long-term. Real change is not a one-shot affair. It takes place over time, and as a result of constant, steady effort. CHIP recognizes that, and its cyclical model is one that is meant to be used over the long term.

Perhaps the model’s biggest drawback is that, while it advocates inclusiveness and participatory planning, it’s essentially top-down. It assumes that the initial planning and spearheading of the effort will be done by “experts” of some sort – public health officials, medical administrators, legislators, etc. Although others are invited to join, the group that does the inviting will have already formed, and will undoubtedly have its own ideas about how things should go. This is different from gathering a large number of participants from diverse backgrounds at the very beginning, and hashing out where to start and how to proceed.

Who should be part of a CHIP?

A CHIP should involve all stakeholders, i.e. those who are in any way affected by or involved in a community health or development effort. These include:

• Those who are directly affected by the issue at hand. They may, for example, be perpetrators or survivors of violence, subject to a particular disease or physical condition, unemployed because of community economic circumstances, homeless, etc.
• Those whose lives or jobs will be affected by the CHIP effort. In addition to those at whom any intervention or program is directly aimed, this group includes anyone who is involved in carrying out the effort (health and human service staff, police, teachers, etc.), and anyone who is indirectly affected (landlords, property owners, public agencies, employers, etc.)
• Change agents. Those with the power and authority to create change: public officials, lawmakers, potential funders, and opinion leaders.
• Influential people. The business community, clergy, leaders of various groups, ordinary citizens who have the respect of the community.
• Community members at large. Since the process demands commitment by and accountability to the community, it makes sense to involve community members in it.

How do you implement a CHIP?

IOM guidelines

As we’ve discussed, the CHIP model, by design, offers no specific methods or techniques, so that a community can design a strategy that fits its needs. IOM does, however, recommend some basic guidelines for successfully implementing a CHIP.

The following is from J.S. Durch, L.A. Bailey, and M.A. Stoto, eds., Improving Health in the Community. Washington, DC: National Academy Press, 1997.

• Communities should base a health improvement process on a broad definition of health and a comprehensive conceptual model of how health is produced within the community.
• A CHIP should develop its own set of specific, quantitative [i.e., number-based] performance measures, linking accountable entities to the performance of specific activities expected to lead to the production of desired health outcomes in the community.
• A CHIP should seek a balance between strategic opportunities for long-term health improvement and goals that are achievable in the short term.
• Community coalitions guiding CHIPs should strive for strategic inclusiveness, incorporating individuals, groups, and organizations that have an interest in health outcomes, can take actions necessary to improve community health, or can contribute data and analytic capabilities necessary for performance monitoring.
• A CHIP should be centered in a community health coalition or similar entity.
• State and local public health agencies should assure that a community health improvement process is in place in all communities. These agencies should at a minimum participate in CHIP activities, and, in some communities, should provide its leadership and/or organizational home.
• In support of community-level health improvement processes, state health agencies, in cooperation and collaboration with local health departments, should assure the availability of community-level data needed for health profiles.
• States and the federal government, through health departments or other appropriate channels, should require that health plans, indemnity insurers, and other private entities report standard data on the characteristics and health status of their enrolled populations, on services provided, and on outcomes of those services, as necessary for performance monitoring in the community health improvement process.

The last four of these guidelines demonstrate the top-down nature of the IOM concept, and the last would seem to question the voluntary nature of accountability discussed earlier. If yours is a grass roots or community-generated effort, an inclusive coalition – either one that already exists, or one that forms to address community need – could provide collaborative leadership for a CHIP-type process. Data, both for community assessments and performance monitoring, can be gathered by participants from the Internet, organizational and community records, and other public documents, without the intervention of government agencies. In other words, a community-change process modeled on CHIP could easily be conducted collaboratively by the community, rather than under the oversight and leadership of a public health or other similar agency.

Steps those guidelines imply for implementing a CHIP

• Assemble a broad-based, inclusive, participatory coalition or coordinating council to guide the CHIP process, if one does not already exist.
• Do your research. Depending on the circumstances, that research will probably include examination of some or all of the following:
  • Census data, for demographic information.
  • Information on the issue(s) in the community. Some of this may be available from census data, some from public records of various sorts, some from the records of community-based and other non-profit organizations, some from interviews and surveys of the community, some from academic or other studies, etc. It should include the interaction of demographic information and the issue(s). (What’s the relationship of race, for instance, or gender to the frequency of the issue? Is it experienced more by the old than the young, or more by people in specific geographic areas? Is it evenly spread throughout the community?  Is it related to employment, economic status, education, genetics, living conditions, etc.?)
  • Community attitudes about the issue(s). You’ll learn about these from a community survey, from group or individual interviews, from focus groups, and/or from reliable community informants (people in the community whom you trust to give you an accurate reading of what you’re looking for).
  • The trends and realities of the issue(s). Are things getting better or worse? How do particular issues affect the lives of real people? How are the details of the issue likely to change in the foreseeable future (a move from cocaine toward heroin among people who use high-risk substances, for instance)? Most of this information will probably come from organizations that deal with the issue, and from people affected by it (substance use treatment programs and people who use drugs, for example, in the case of drug use trends).
  • The theories and formal research results of those who have studied the issue(s) (commonly called “the literature” – the information that’s been published about the issues).
• Identify the issue(s) you’re going to work on, if you haven’t started with a specific issue in mind.
• Analyze the issue(s) carefully. That means looking at their possible root causes, the consequences – intended and unintended – of addressing and not addressing them, how they might be approached, etc. In order to conduct an accurate analysis, you’ll need to consider all the factors that impinge on health and other issues:
  • The social determinants of health. In broad terms, these fall into three categories: socio-economic equity, social connectedness, and sense of personal efficacy.
  • The nine factors – subsets of the broader social determinants listed above – that determine community health, as set out in the Ottawa Charter, the “Constitution” of the Healthy Communities movement: peace, shelter, food, education, income, a stable ecosystem, sustainable resources, social justice, and equity.
  • Factors that are fixed in one way or another: genetics, geography, demographic information, population patterns, etc.

An understanding of these factors and their interactions with one another and with the issue as it plays out in the community will help you carry out your analysis, and will also shed light on another important consideration: Are you in fact addressing the right issue(s) to create the changes you’re aiming for? It’s sometimes the case that an issue that seems self-contained is in fact a small part of a larger issue. That usually means that you won’t resolve your issue without tackling the larger one.

In doing an analysis of this sort, it’s often helpful to remember the story of the blind men and the elephant. Several blind men are introduced to an elephant and asked to describe it. The one who grasps the elephant’s trunk exclaims that the elephant is like snake. Another feels its leg and says that the elephant is like a tree. The man at the elephant’s tail says the animal is like a rope. And the one who feels its side says the elephant is like a wall. All of their analyses are correct as far as they go...but none of them go far enough. Make sure that you go beyond your first impression: don’t assume you’ve seen all there is to see about the issue.

• Take stock of potential resources, particularly those already available in the community. There are really three courses of action you should be taking here:
  • Start with a positive, proactive stance, and assume that the community already possesses many of the resources necessary to address its own issues and improve its quality of life. Then find and enlist the community assets – people, organizations and institutions, funding, etc. – that can contribute to your effort.
  • Decide whether more resources will be needed, and strategize about how – and from where – to get them.
  • Approach potential funders, and draw them into your CHIP process as participants, if you haven’t already.
• Develop a strategic plan and action plans to carry it out.The strategic plan should be devised by a group representing all sectors of the community, so that it will both respond to the realities of the community situation and be seen as belonging to the community.

There are really two plans needed:

• A long-term strategic plan to address systemic change in the community. Carrying out this plan will lead not only to the permanent resolution of your issue, but to lasting improvement in the well-being of the community. At the same time, it may cover a decade or more, which is a long time for people to wait for results.
• Shorter-term strategic goals that allow for some reasonably quick success. These are necessary not only to address immediate problems, but to keep people enthusiastic about the long term, and to benchmark your progress toward your eventual outcomes.

This is where the IOM guideline about striking a balance between long-term and short-term achievable goals becomes relevant.

• Agree on who will be accountable for which parts of the plan. As discussed above, accountability should be voluntary, involve realistic expectations, and be based on clearly defined and observable responsibilities.

Accountability doesn’t always mean that those accountable are responsible for doing what needs to be done, but rather that they are responsible for seeing that it gets done. Thus, an organization may take on accountability for something not in its area of expertise with the understanding that it will find and recruit the appropriate provider or practitioner to see that it gets done.

• Work out how accountability will be monitored. Here’s where you develop performance indicators to monitor the process and outcomes of your effort, and to see whether everyone did what they agreed to, and accomplished what they expected to. While IOM demands quantitative measures, it’s actually probably more informative and more accurate to use both quantitative and qualitative measures. Qualitative measures such as observation and participant self-reports often give information that the numbers either hide or fail to pick up entirely.
• Implement your strategy. By this point, you should have both a long-term strategy and an immediate action plan. It’s the action plan (or the first of your action plans, depending on what your overall strategy looks like) you’ll start out with, and it should include clear goals, a process, a clear statement of who’s accountable for what, and ways of measuring both performance and the success of your plan.
• Monitor both the process and the outcomes of your effort. Monitoring has two purposes: to make sure everyone’s doing what they’ve agreed to do and that it’s working (performance monitoring); and to see whether your overall plan is effective (outcome monitoring).

The point of performance monitoring, as mentioned earlier, is not to find someone to blame for not doing his job, but rather to find weak points in the system and strengthen them. If some organization, for instance, isn’t playing its part in the process, it may need more resources, technical assistance, or some other support. If the process is going as planned (everyone’s doing just what they’re supposed to do) and there are still no results, then someone might need to change methods, or address another facet of the issue.

Performance monitoring will tell you what you need to know about accountability and about whether the process is working. Outcome monitoring will tell you whether you need to adjust and refine – or rethink – your strategy and action plans. You may have misread the needs or attitudes of the community, banked on techniques that simply don’t work, or failed to respond to a change in the situation. Whatever the issue, if there’s no evidence of your hoped-for outcomes, it’s time to alter your approach.

Even if things are going well, there’s always room for improvement. Monitoring may also show you ways that you can tweak your effort to make things work better: improved communication and coordination, for instance, or increased concentration on a particular area might make success quicker and easier for everyone.

• Maintain your gains. No matter how successful an action plan is, it won’t amount to much if its successes aren’t maintained. The job isn’t over once an issue is resolved – it has to stay resolved, and that takes ongoing effort. Once you’ve accomplished something, you have to work indefinitely to keep it accomplished, even as you tackle the next task.

Maintenance is best accomplished through system change. The ideal solution is to put a new system in place, or change the community climate so a new behavior or condition is sustained automatically.  If that’s not possible – and it may not be, especially early in a long-term effort – then you simply have to keep paying attention to it, or you’ll lose what you’ve gained.

• Start the cycle again, with another issue. As we made clear at the beginning of this section, a CHIP isn’t a one-shot deal.  It’s meant to be an ongoing, long-term effort to change the community in fundamental ways. The cycles continue, tackling different issues, changing systems, and working to improve well-being and the quality of life for everyone in the community.

In Summary

The Institute of Medicine’s Community Health Improvement Process (CHIP) is a framework for promoting community health which may be used also as a model for creating healthy communities. It is similar to many of the other models in this chapter in that it takes a comprehensive, community-based view of health and starts with an inclusive, participatory, community-based coalition or coordinating group. In the first cycle of the (two-cycle) process, that group assesses and analyzes the community to identify the critical issues that impact the health of the community as a whole.

In the second cycle – a cycle duplicated for each issue that the CHIP addresses – the coordinating group analyzes the issue, inventories the resources available to address it, develops long-term and short-term strategy, identifies accountability for carrying out the strategic plan, develops measurable indicators for measuring both the performance of those accountable and the plan’s overall success, implements the strategy, monitors its process and outcomes, makes whatever adjustments and changes are necessary, and then repeats the cycle, with the same or another issue.

A CHIP has a number of advantages. It takes a community-based and comprehensive perspective on health, allowing it to consider any factor that is relevant as a contributor or barrier to the building of a healthy community. It’s inclusive and participatory, and sees equity as a key factor in community health, thus involving and paying attention to all the voices and interests in the community. It’s flexible, encouraging communities to create solutions that reflect the real needs and circumstances of individual communities.  It builds in accountability and monitors performance to assure that accountability is honored. It can incorporate or fit in with other models. And perhaps most important, it sees the process as ongoing and long-term, one that aims to change systems and attitudes in the community in fundamental ways.

A CHIP’s biggest drawback from the point of view of the Community Tool Box is that, although it incorporates people from all sectors, it sees the process as being initiated and led by health or public health professionals. However, a community doesn’t necessarily have to accept that particular aspect of the model, and can choose to establish a more collaborative process. Indeed, a CHIP should involve all stakeholders, from those who are most affected by the issues, to those who will be indirectly affected by an intervention, to those who control policy and/or have influence in the community, to citizens who are interested simply out of concern for the public good.

Implementing a CHIP is different for each community, but IOM provides some guidelines:

• Communities should base a health improvement process on a broad definition of health and a comprehensive conceptual model of how health is produced within the community.
• A CHIP should develop its own set of specific, quantitative performance measures, linking accountable entities to the performance of specific activities expected to lead to the production of desired health outcomes in the community.
• A CHIP should seek a balance between strategic opportunities for long-term health improvement and goals that are achievable in the short term.
• Community coalitions guiding CHIPs should strive for strategic inclusiveness, incorporating all individuals, groups, and organizations that are either stakeholders or can contribute to the process.
• A CHIP should be centered in a community health coalition or similar entity.
• State and local public health agencies should assure that a community health improvement process is in place in all communities.
• State health agencies, in cooperation and collaboration with local health departments, should assure the availability of community-level data needed for health profiles.
• States and the federal government should require that appropriate private entities report standard data on their enrolled populations, to facilitate the CHIP.

In addition, using the CHIP model, the steps to implementation might be:

• Assemble a broad-based, inclusive, participatory coalition or coordinating council to guide the CHIP process, if one does not already exist.
• Do your research.
• Identify the issue(s) you’re going to work on, if you haven’t started with a specific issue in mind.
• Analyze the issue(s) carefully.
• Take stock of potential resources, particularly those already available in the community.
• Develop a strategic plan and action plans to carry it out.
• Agree on who will be accountable for which parts of the plan.
• Work out how accountability will be monitored.
• Implement your strategy.
• Monitor both the process and the outcomes of your effort.
• Maintain your gains.
• Start the cycle again, with another issue.

What is a CHIP?

___A CHIP is a Community Health Improvement Process that can also be used for building a healthy community.

___CHIP is slightly different from other similar processes in that it incorporates accountability into the planning, implementation, and evaluation of the community health efforts it fosters.

Why use a CHIP?

___It takes a community perspective.

___It’s inclusive and participatory.

___It demands a comprehensive view of health.

___It sees equity as key.

___It’s flexible.

___It builds in accountability.

___It builds in performance monitoring.

___It can incorporate or fit in with other models.

___It sees the process as ongoing and long-term.

Who should be part of a CHIP?

___Those who are directly affected by the issue at hand.

___Those whose lives or jobs will be affected by the CHIP effort.

___Change agents.

___Influential people.

___Community members at large.

How do you implement a CHIP?

___Incorporate IOM’s general guidelines.

• Define health broadly.
• Develop specific quantitative measures and hold responsible groups accountable to them.
• Balance long- and short-term goals.
• Include all stakeholders and other potential contributors to the work in assessment, planning, and implementation.
• A CHIP should be centered in a community health coalition or similar entity.
• State and local public health agencies should assure that a community health improvement process is in place in all communities.
• State health agencies, in cooperation and collaboration with local health departments, should assure the availability of community-level data needed for health profiles.
• States and the federal government should require that appropriate private entities report standard data on their enrolled populations, to facilitate the CHIP.

___Form an inclusive, participatory coalition or coordinating group, or tie into one that already exists.

___Do your research.

___Identify the issue(s) you’re going to work on.

___Analyze the issue(s) carefully.

___Take stock of potential resources, particularly those already available in the community.

___Develop a strategic plan and action plans to carry it out.

___Agree on who will be accountable for which parts of the plan.

___Work out how accountability will be monitored.

___Implement your strategy.

___Monitor both the process and the outcomes of your effort.

___Maintain your gains.

___Start the cycle again, with another issue.

A PowerPoint presentation summarizing the major points in the section.

Before you read this section's information about the Ten Essential Services, we invite you to take a quiz. Answers are provided at the bottom of this page. See how well YOU do!

As you read the front page of the local paper, you notice an alarming article about an outbreak of “disease X” in your community. You read on to learn about the scientifically established cause of “disease X”, and precautionary measures for avoiding exposure.

This valuable information was published as a front-page story because:

• The local football team lost its game last night
• The front-page columnist is on vacation
• State and local health officials and their staff have worked for weeks to gather data, conduct laboratory and statistical tests, generate hypotheses, and collaborate with the media to alert and educate the public about “disease X” as effectively as possible.

On your way into the local grocery store, you notice a flier advertising a toll-free hotline number for enrolling uninsured children in a federally funded health insurance program.

This insurance program is being offered because:

• The federal government has a budget surplus and is looking for a way to spend it
• A leading telephone company offered the state health department a great deal on 1-800 numbers
• Public health professionals have documented the numbers of uninsured children in their states, and worked with federal and state policymakers to institute outreach and “wrap around services” that assure the universal provision of health care.

While shopping in the local mall, you come across a group of nurses offering free blood pressure and cholesterol screenings.

The nurses are offering these screenings because:

• They need to moonlight
• They enjoy people watching at the mall
• They are public health nurses dedicated to community health promotion, including the prevention of heart disease

You and your sweetheart share a romantic dinner at your favorite restaurant. Not only is the meal delicious – you do not get food poisoning!

This enjoyable experience has been brought to you by:

• The restaurant management
• Your local health department
• A joint effort of the restaurant management and your local health department

In an urban area, prevalent liquor stores are slowly being replaced by grocery stores. The mass transit system has been re-routed to guarantee store access to urban residents without vehicles.

This change in the community’s planning and development is probably a result of:

• The Department of Transportation needing to increase revenue
• The liquor storeowners deciding that they weren’t doing enough business and moving elsewhere.
• A collaborative effort of citizens, public health professionals, city planners, and local government officials who share

the common goal of preventing substance use and alcohol use disorder among members of their urban community.

Answers: 1. c; 2. c; 3. c; 4. c; 5. c

What, besides the same answer, do the quiz scenarios above have in common? They are real life, everyday examples of some of the Ten Essential Public Health Services that public health professionals strive to deliver in the counties and states that they serve.

This Tool Box section will teach you what the Ten Essential Public Health Services are, and illustrate the function of those Services in public health. When you have completed the tool, you will be able to identify under which Essential Service public health activities in your community are implemented. More importantly, we hope that you will understand how the synergy of efforts within all ten Essential Service areas can contribute to the health of your community’s populations.

To help you get started with identifying how the Ten Essential Public Health Services are reflected in day-to-day public health activities, Table 1 below matches five of the Ten Essential Public Health Services with their corresponding quiz scenarios.

Table 1: Examples of How Essential Services Are Reflected in Day-to-Day Public Health Activities

Quiz Scenario	Essential Public Health Service Implemented
Informing the public about an epidemiological outbreak investigation in the community	“Investigate, diagnose, and address health hazards and root causes”
Promoting enrollment in a federally subsidized health insurance program	“Enable equitable access”
Health education and health promotion to prevent heart disease	“Communicate effectively to inform and educate”
Maintenance of a sanitary restaurant environment for public well-being	“Utilize legal and regulatory actions”
Shaping health policy, city planning, and transportation routes to create an environment that fosters positive health behavior	“Create, champion, and implement policies, plans, and laws”

We hope that you want to read on and learn more. But before we discuss each of the Essential Services, we will visit the broader concept of defining the purpose and function of public health.

What is public health?

As you probably concluded from the quiz scenarios, public health is everywhere – it is a part of the infrastructure that keeps our communities safe and healthy.

Depending on which resource you read, you will find varying definitions of the mission of public health.  However, the most current and widely accepted mission definition is:

“Promote physical and mental health, and prevent disease, injury, and disability.”

Public health services may go unnoticed within a community because they are often (but not always) preventive versus reactive.  For example, which community service are you more likely to notice - an environmental health specialist inspecting the safety of a local university’s food service establishments, or a fire truck speeding down the street with its lights and sirens on?

Despite having a relatively ‘low profile’ status, public health services play a key role in assuring the health and well being of communities.  Throughout the 1900s, the average lifespan of persons in the United States increased by more than 30 years.  According to an article by Bunker, Frazier, and Mosteller (1994), 25 years of this are attributable to advances in public health.

Who is the typical public health professional?

There really is no “typical” public health professional. The public health workforce in the United States consists of approximately 500,000 individuals with diverse professional training and experience.

• Some are nurses, physicians, or laboratory technicians by training.
• Some are educators, nutritionists, or social workers by training.
• Some are biostatisticians or epidemiologists.
• Others are economists or lawyers.
• Community-based or “grassroots” workers might include concerned parents, grandparents, or civic leaders who volunteer their time.

How do all of these people with a unified purpose but different skills work together successfully to carry out the mission of public health? They have a logic model to consult: the Ten Essential Services of Public Health.

The Ten Essential Services of Public Health differ in some ways from other logic models presented in Chapter 2 of the Tool Box. Other logic models discussed incorporate prescribed processes (e.g., from planning to implementation to evaluation) diagrammed in a flow chart that can then be applied to one priority goal like prevention of pregnancies among adolescents. In contrast, there is no prescribed order of implementation for the Ten Essential Services—no flow chart, and no one specific outcome that results from implementing all ten Essential Services. Rather, the Ten Essential Services have the potential to create a comprehensive infrastructure that can provide a supportive context for any public health priority in a community.

Although the more prescriptive logic models may be narrow in scope once applied to one goal, they can also undertake a comprehensive approach within a community.  For example, a planning phase might involve stakeholders from non-public health sectors of the community, in an effort to foster the most supportive context for change. This is not unlike the impact of the Ten Essential Services.

You may be wondering,

“Why do people need a logic model for direction if they are already working towards the same mission?”

Because of their diverse backgrounds, some professionals have been trained to follow different paradigms (models) in their specialties.  One example is the “medical model” versus the “public health model.”  The most significant difference between the two models is that public health activities focus on entire populations, while clinical activities focus on individual patients.  Table 2 below summarizes key differences between the paradigms that are typically used to train clinical and public health professionals.

Table 2:  Public Health versus Medical Models of Professional Training

Public Health Model	Medical Model
Primary focus on population	Primary focus on the individual
Public service ethic, tempered by concerns for the individual	Personal service ethic, conditioned by awareness of social responsibilities
Emphasis on prevention and health promotion for the whole community	Emphasis on diagnosis, treatment, and care for the whole patient
Paradigm employs a spectrum of interventions aimed at the environment, human behavior and lifestyle, and medical care	Paradigm places predominant emphasis on medical care

The Ten Essential Public Health Services provide a common ground for professionals trained in either paradigm, as well as grassroots workers and non-public health civic leaders, so they can work collaboratively towards fulfilling the public health mission:

“To promote physical and mental health, and prevent disease, injury, and disability.”

Now that you have a better understanding of public health, let’s talk about the origin, purpose, and function of the Ten Essential Public Health Services.

What are the Ten Essential Public Health Services?

From 1988 to the early 1990s, the recognized “core functions” of public health were:

• Assessment
• Policy development
• Assurance

In 1993, with a new presidential administration and federal and state attempts to reform the health care system in the United States, public health leaders decided to set forth a more detailed and utilitarian consensus statement that would “speak with one voice” to public health professionals, the general population, and the policymakers who would shape health care reform.

Public health leaders worked to define a more detailed logic model of core public health functions.  The end result was a consensus statement that included the Ten Essential Public Health Services, adopted in 1994.

Why is it important to implement and monitor the Ten Essential Public Health Services?

The Ten Essential Public Health Services are really about actualizing the public health paradigm that we presented in Table 2.  Let’s review the key principles involved:

• A primary focus on the population
• A public service ethic, tempered by concerns for the individual
• An emphasis on prevention and health promotion for the whole community
• The paradigm employs a spectrum of interventions aimed at the environment, human behavior and lifestyle, and medical care

The theme of prevention is the most powerful element in the implementation of the Ten Essential Public Health Services.

• Through prevention, countless injuries, illnesses, and even chronic diseases can be avoided.
• Through prevention, lives can be saved.
• Through prevention, health care cost can be contained.
• Through prevention, individuals, their families, and their communities can benefit from the population-based reach of the Ten Essential Public Health Services.

It is important to not only implement but also monitor—or track, assess, and modify, as needed—the Ten Essential Public Health Services.  With data or other information about the Services’ costs or expenditures, implementation, and impact, monitoring can contribute to informed policy decisions about public health program development and funding at local, state, and national levels.

How are the Ten Essential Services used in community practice?

On the pages that follow, each Essential Service is discussed in order from 1 to 10.  Each discussion includes a definition of the Service and some examples of national or community practice.  Keep in mind that the Services do not necessarily need to be implemented in the “1 – 10” sequence, or even independently.

The Ten Essential Services are independent yet complementary goals for communities to work toward.  You should actually strive to implement the services simultaneously in your community as a means of carrying out the mission of public health.  However, you may find that you identify with only one or two in terms of your role in your community’s public health initiatives as you read through this section.

Essential Service #1:  Assess and monitor population health.

Public health surveillance—the ongoing, systematic collection, analysis, and interpretation of health related data—is at the core of this Essential Service.

Essential Service #1 encompasses public health activities such as:

• Identification of threats to health and assessment of health service needs;
• Timely collection, analysis, and publication of information on access, utilization, costs, and outcomes of personal health services;
• Attention to the vital statistics and health status of specific groups that are at higher risk than the total population; and
• Collaboration to manage integrated information systems with private providers and health benefit plans.

National level, population-based surveillance systems administered by the Centers for Disease Control and Prevention (CDC) include:

• The Behavioral Risk Factor Surveillance System;
• National Vital Statistics System;
• National Health Interview Survey; and
• Cancer registries;

You can access CDC data electronically at the Centers for Disease Control and Prevention website. You may not immediately think to use national level data when working at the community level.  However, national level surveillance data can provide trend data to use as a benchmark as you assess health status measures (e.g., the number of children immunized prior to entering preschool) in your community. Prior to investing resources and time in a program, it is often necessary to conduct a needs assessment.  Community data collected via a needs assessment can be compared to existing data at the national level.  If you discover that your community actually has an excellent rate for a health status measure as compared to 75% of the states in the country, you may shift your prevention program priorities to a different measure or priority population!

If you do not have the time or resources to conduct your own needs assessment, you can search for community level data in resources including:

• State-level ‘report cards’ on maternal and child health indicators (see the federal Title V Information System with data for all U.S. states and territories).
• School health reports; and
• Law enforcement agency surveillance, such as the number of DUI arrests

Essential Service #2:  Investigate, diagnose, and address health hazards and root causes.

Essential Service #2 encompasses public health activities such as:

• Epidemiologic identification of emerging health threats;
• Public health laboratory capability using modern technology to conduct rapid screening and high volume testing;
• Active infectious disease epidemiology programs; and
• Technical capacity for epidemiologic investigation of disease outbreaks and patterns of chronic disease and injury.

At the national level, the United States Department of Health and Human Services oversees the Agency for Toxic Substances and Disease Registry (ATSDR).  The Agency’s overall function is to “serve the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and disease related to toxic substances.”

Via grants and cooperative agreements, ATSDR provides funding and technical assistance for states to identify and evaluate environmental health threats to communities, as well as educate the communities about health risk or other findings.

At the local level, public health laboratories provide diagnostic testing, disease surveillance, applied research, laboratory training and other essential services to the communities they serve.  Laboratory work is diverse, yet accomplished by highly trained and skilled professionals.

Public health laboratory professionals and epidemiologists are the ones working behind the scenes on the issues that you hear about in the news.  These include:  newborn screening; Lyme disease; West Nile virus; food borne illness outbreak investigations; and bio-terrorism threats. The Association of Public Health Laboratories was founded by state and territorial public health laboratory directors serving communities across the United States.  You may want to visit this website to learn more about the public health laboratory expertise and services available in your own community.

Essential Service #3:  Communicate effectively to inform and educate.

You have probably come across—and even participated in— health promotion and social marketing efforts in your community.

Essential Service #3 encompasses public health activities such as:

• Social marketing and targeted media public communication (e.g., Toll-free information lines);
• Providing accessible health information resources at community levels (e.g., free, mobile health screening initiatives);
• Active collaboration with personal health care providers to reinforce health promotion messages and programs; and
• Joint health education programs with schools, churches, and worksites (e.g., stress reduction seminars; parenting support groups for enhancing mental health; and health fairs).

You may have noticed national media campaign advertisements on television, billboards, or even posters or fliers in your doctor’s office.  Some examples include the “Back to Sleep” campaign to prevent Sudden Infant Death Syndrome, or the anti-substance use campaign, “Just Say No.”

Many national awareness weeks also relate directly to public health efforts.  The American Public Health Association, headquartered in Washington, D.C., actually sponsors a “National Public Health Week” each spring.  You can find additional information, and links to free tools and resources for National Public Health Week.  You may decide to sponsor an event such as a fun run or health fair to raise public health awareness in your own community!

Essential Service #4:  Strengthen, support, and mobilize communities and partnerships.

These activities represent a comprehensive approach to community health, in which professionals and even entire sectors of a community collaborate to plan, implement, monitor, evaluate, and subsequently modify activities, and repeat the process as needed.

Essential Service #4 encompasses public health activities such as:

• Convening and facilitating community groups and associations, including those not typically considered to be health-related, to undertake defined preventive, screening, rehabilitation, and support programs; and
• Skilled coalition-building ability in order to draw upon the full range of potential human and material resources in the cause of community health.

This is not unlike the PATCH logic model – the Planned Approach to Community Health

Included in the PATCH strategy are five elements that are fundamental to the success of any community health promotion process:

• Community members participate in the process.
• Data guide the development of programs.
• Participants develop a comprehensive health promotion strategy.
• Evaluation emphasizes feedback and program improvement.
• The community capacity for health promotion is increased.

You can read about a similar process for mobilizing community partnerships to identify and solve health problems in the Community Tool Box's Community Action Guide: A Framework for Addressing Community Goals and Problems.

The overall goal of action planning is to increase your community’s ability to work together to affect conditions and outcomes that matter to its residents—and to do so both over time and across issues of interest.

As your community works towards a broad vision of health for all, creating supportive conditions for change requires comprehensive efforts among diverse sectors of the community.  These include health organizations, faith communities, schools, and businesses.  Representatives of each sector come together to form a community coalition.  Your community coalition can strive to influence systems changes—programs, policies, and practices that can enhance or detract from the community’s capacity to be a supportive environment for healthy living.

Essential Service #5:  Create, champion, and implement policies, plans, and laws.

Because state and local public health programs are often funded at least in part with Federal dollars, accountability is often a key issue.  Public health programs therefore document progress towards positive change in health behavior or health status indicators.  For example, the Federal Maternal and Child Health Services Block Grant, which imposes a $3 state match for every $4, requires annual reporting of “performance measures.”  Some of those are state-negotiated to allow for flexibility in tracking health behavior or health status indicators that are unique to a state’s populations. Data such as these can be presented to policymakers to document the value or effectiveness of a program. Those data can also be used for continued program planning and modification.

Essential Service #5 encompasses public health activities such as:

• Leadership development at all levels of public health;
• Systematic community-level and state-level planning for health improvement in all jurisdictions;
• Development and tracking of measurable health objectives as a part of continuous quality improvement strategies;
• Joint evaluation with the medical health care system to define consistent policy regarding prevention and treatment services; and
• Development of codes, regulations, and legislation to guide the practice of public health.

Active Living by Design is a national program of The Robert Wood Johnson Foundation, and is a part of the University of North Carolina at Chapel Hill School of Public Health.  The program establishes and evaluates innovative approaches to increase physical activity through community design, public policies, and communications strategies.  The program funds community partnerships to develop, implement and sustain collaboration among a variety of organizations in public health and other disciplines, such as city planning, transportation, architecture, recreation, crime prevention, traffic safety and education, and key advocacy groups.  Collaborators focus on land use, public transit, non-motorized travel, public spaces, parks, trails, and architectural practices that advance physical activity.

One example of an Active Living by Design initiative is:  “Obesity and The Built Environment:  Improving Public Health through Community Design.”  You can learn more about this and other initiatives by visiting Active Living by Design.

Essential Service #6:  Utilize legal and regulatory actions.

While you may not always be conscious of how public health regulations have influenced your community environment, think about some of the things that you see or experience when you visit restaurants.  You may have noticed a framed certificate hanging on the wall, with “Sanitation Grade A.”  This certificate is a result of local health department inspections to assure that the restaurant is in compliance with food storage, handling, and preparation regulations.

While at that same restaurant, you may also notice a sign that says, “No smoking.”  This may be a direct result of a statewide law that was designed to improve the environmental health conditions in your community.

If you have school-aged children and have had to prepare them for entrance into the public school system, you know that the full series of immunizations is required.  Immunizations are required for school-aged children in the United States because when widespread immunizations are in place, we all benefit from what is referred to as “herd immunity.”  When a group of people (e.g., an entire community, state, or nation) is immunized against an infectious disease, it makes it more difficult for the disease to spread and cause an epidemic.

Essential Service #6 encompasses public health activities such as:

• Full enforcement of sanitary codes, especially in the food industry;
• Full protection of drinking water supplies;
• Enforcement of clean air standards;
• Timely follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings;
• Monitoring quality of medical services (e.g., laboratory, nursing homes, and home health care); and
• Timely review of new drug, biologic, and medical device application.

Essential Service #6 may be implemented in your community as a result of either state or federal legislation.  Not only can you take on a leadership role in your community to assure that public health regulations are enforced; you can be a catalyst for change by identifying and prioritizing new issues, and sponsoring new regulations through public health advocacy.

Essential Service #7:  Enable equitable access.

Essential Service #7 encompasses public health activities such as:

• Assuring effective entry for people experiencing social and economic disadvantage into a coordinated system of clinical care;
• Culturally and linguistically appropriate materials and staff to assure linkage to services for populations with specific needs;
• Ongoing “care management;”
• Transportation services;
• Targeted health information to populations experiencing increased risk; and
• Technical assistance for effective worksite health promotion/disease prevention programs.

The implementation of this Essential Service is inherently linked to the social, economic, and political climate in communities, states, and the nation.  To assure the provision of health care when it is otherwise unavailable, the United States federal government funds two “safety net” programs: Medicaid and the State Children’s Health Insurance Program (SCHIP).

Medicaid is the largest source of funding for medical and health-related services for people and families with low incomes and resources.  This program became law in 1965, and is jointly funded by the federal and state governments (including the District of Columbia and the Territories) to assist states in providing medical long-term care assistance to people who meet certain eligibility criteria.

The Balanced Budget Act of 1997 created a new children's health insurance program called the State Children's Health Insurance Program (SCHIP).  SCHIP is a state administered program, and each state sets its own guidelines regarding eligibility and services for children up to age 19 who are uninsured. Families who earn too much to qualify for Medicaid may still be able to qualify for SCHIP.

To learn more about the Medicaid and SCHIP programs and how they can benefit members of your community, please visit: Centers for Medicare and Medicaid Services.

The availability of programs like Medicaid and SCHIP is not sufficient.  Public health professionals also have to provide outreach services to the populations in need of these programs.  Outreach might include:

• Consumer education about the existence of a program;
• Assistance with applying for a program;
• Linking enrollees to related health programs (for example, people who are pregnant, infants, and children under the age of 5 enrolled in Medicaid also qualify for the Federal Supplemental Food Program for Women, Infants, and Children—WIC, and vice versa);
• Physically transporting clients to the medical services that they need.

Culturally and linguistically appropriate materials are a critical component of outreach efforts in a country in which many immigrant languages are spoken.  Public health professionals can use decennial census data or community level needs assessments to determine how many and which languages are spoken in a geographic region.  To provide outreach and other services in a culturally responsive manner, public health professionals can apply guidelines developed by the National Center for Cultural Competence.  The Center produces publications that teach people how to adapt health promotion materials already developed and written in English.

Essential Service #8:  Build a diverse and skilled workforce.

Essential Service #8 encompasses public health activities such as:

• Education and training for personnel to meet the needs for public and personal health service;
• Efficient processes for licensure of professionals and certification of facilities with regular verification and inspection follow-up;
• Adoption of continuous quality improvement and life-long learning within all licensure and certification programs;
• Active partnerships with professional training programs to assure community-relevant learning experiences for all students; and
• Continuing education in management and leadership development programs for those charged with administrative / executive roles.

There are many opportunities for certified education, training, and continuing education in public health. The Association of Schools of Public Health is a membership organization of the 27 accredited schools of public health that prepare people for a public health profession. The accrediting body, an independent agency recognized by the United States Department of Education, is the Council on Education for Public Health.

Continuing education opportunities abound at professional conferences and in professional journals.  Furthermore, the advent of the Internet has brought new access to continuing education through the availability of online certificate and other training programs. These distance-based programs—particularly the ones offered through accredited schools of public health—offer an invaluable alternative to the sometimes-prohibitive costs and time commitment of travel for state and local public health professionals.

The Centers for Disease Control and Prevention sponsors many training and continuing education opportunities on site and in the accredited schools of public health across the country.  One example is Academic Centers for Public Health Preparedness (A-CPHP). These centers work together to improve the capacity of the front line public health and health care workers to quickly respond to bioterrorism, infectious disease outbreaks, and other public health threats and emergencies.The network of Centers represents a unique partnership between the schools of public health, the Association of Schools of Public Health, the Centers for Disease Control and Prevention, and representatives from state and local public health agencies, and the Association of State and Territorial Health Officials (ASTHO) and National Association of County and City Health Officials (NACCHO).

Other programs meet the education and training needs of rising public health professionals while simultaneously enhancing workforce capacity in the field.  One example is the Federal Maternal and Child Health Bureau’s Graduate Student Internship Program, which places Maternal and Child Health graduate students in state health departments for summer internships via a competitive process for both health departments and students.

Essential Service #9:  Improve and innovate through evaluation, research, and quality improvement.

Evaluation helps public health professionals continually refine or revise program approaches in future years of funding.  Furthermore, evaluation data provide information about the relative costs and effort for tasks so activity and budget adjustments can be made.

Essential Service #9 encompasses public health activities such as:

• Ongoing evaluation of health programs based on analysis of health status and service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs.

The process of evaluation helps public health professionals and their collaborators assess the success of community health initiatives. Evaluation normally requires that data be collected and analyzed. Surveillance data from Essential Service #1 can be used for this purpose. For example, because surveillance efforts are often (but not always) annual, your community could access retrospective and current or “baseline” data before planning a public health initiative.This baseline data could then also be used to document the health behavior or health status outcome measure(s) of interest both before and after implementation of the initiative.

Evaluation plans and concepts are addressed in several chapters and sections of the Community Tool Box. These include:

Chapter 36-39, all of which fall under the broad topic,“Evaluating Community Programs and Initiatives”

Essential Service #10:  Build and maintain a strong organizational infrastructure for public health.

In order to implement the 10th Essential Service, state and local health department staff might carry out health services research via many different efforts including:

• Continuous linkage with appropriate institutes of higher learning and research;
• An internal capacity to mount timely epidemiologic (e.g., outbreak investigations) and economic analyses (e.g., cost-benefit studies); and
• An internal capacity to conduct needed health services research (e.g., survey design; conducting interviews and facilitating focus groups; conducting clinical trials; and accessing and using public records).

This list of research activities further illustrates the need for skills-specific training and education prescribed in Essential Service number 8. For example, anyone can create a survey and interview a group of people.  However, there are prescribed methods for creating an “instrument” that collects information that can be summarized into a coherent and even statistically significant conclusion about a population of interest.  Local health department staff may have had formal academic or on-the-job training in questionnaire design, survey methodology, or biostatistics.  Some staff may even be “specialists” who can be called upon to complete complex data analyses for research purposes. However, both generalists and specialists in the local health departments contribute to the base of knowledge and experience that are critical to maintaining an internal capacity to conduct needed health services research.

Even when local health department staff have adequate training, a strain on staffing capacity or limited resources may prompt collaboration with other “specialists.”  Within the public health community, it is not difficult to find examples of health departments working with neighboring universities to conduct research and identify solutions. One example is the Association of Schools of Public Health’s Academic Health Departments (AHD) grant program.  The AHD program fosters collaboration among local health departments across the country and 14 neighboring universities that house accredited schools of public health.  The exchange of student and other resources can enhance the capacity of local health agencies to function as “learning organizations,” thereby enhancing the success of community health efforts.

Another example of linkages with institutes of higher learning is the Council on Linkages Between Academia and Public Health Practice. Housed within the non-profit Public Health Foundation in Washington, D.C., the Council has a mission to “Improve public health practice and education by fostering, coordinating, and monitoring links between academia and the public health and healthcare community, developing and advancing innovative strategies to build and strengthen public health infrastructure, and creating a process for continuing public health education throughout one’s career.”

Research for new insights and innovative solutions to health problems can be accomplished many different ways. One way is via economic analyses to assess the “cost benefit” or the “cost effectiveness” of a program.

A cost-benefit evaluation assesses only one program, and focuses on the cost-to-outcome ratio, with the “outcome” having a dollar amount attached to it.  Example:  For a program that invests in prevention, the amount spent per client on prevention would be compared to the amount saved in averted health care costs per client (e.g., “For every $2 that we spend on diabetes management education, we save $4 in hospitalization costs.”).

A cost-effectiveness analysis can be used with one or multiple programs with the same objectives, to relate the cost of a program approach to specific measures of a program’s objectives.  Those measures may or may not have a monetary value attached to them (e.g., an outcome measure for an education program may be standardized test scores).

What is public health?

___Public health is the part of the civic infrastructure that keeps communities safe and healthy.

___The current generally accepted mission of public health is: “Promote physical and mental health, and prevent disease, injury, and disability.”

Who are public health professionals?

___Nurses

___Physicians

___Laboratory technicians

___Educators

___Nutritionists

___Social workers

___Biostatisticians

___Epidemiologists

___Economists

___Lawyers

___Community-based or “grassroots” workers might include concerned parents, grandparents, or civic leaders who volunteer their time.

What are the Ten Essential Public Health Services?

___The Ten Essential Public Health Services fall into three categories that define thecore functions of public health:

• Assessment
• Policy Development
• Assurance                                                                                                

Assessment:

___1. Monitor health status to identify community health problems.

___2. Diagnose and investigate health problems and health hazards in the community.

Policy Development:

___3. Inform, educate, and empower people about health issues.

___4. Mobilize community partnerships to identify and solve health problems.

___5. Develop policies and plans that support individual and community health efforts.

Assurance:

___6. Enforce laws and regulations that protect health and ensure safety.

___7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

___8. Assure a competent public health and personal health care workforce.

___9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

___10. Research for new insights and innovative solutions to health problems.

How do you use the Ten Essential Public Health Services in Community Practice?

1.  Monitor health status to identify community problems.

___This service comprises the ongoing, systematic collection, analysis, and interpretation of health related data, including:

• Identification of threats to health and assessment of health service needs;
• Timely collection, analysis, and publication of information on access, utilization, costs, and outcomes of personal health services;
• Attention to the vital statistics and health status of specific groups that are at higher risk than the total population; and
• Collaboration to manage integrated information systems with private providers and health benefit plans.

___To monitor community health status, you can use federal, state, and community-level information, such as:

• Census data
• Centers for Disease Control (CDC) data, including the National Vital Statistics System, the Behavioral Risk Factor Surveillance System, the National Health Interview Survey, and the Cancer Registries.
• State-level “report cards” on maternal and child health and other areas, as well as reports and statistics from the state public health agency.
• School health reports.
• Community surveys.
• Information about community-level indicators, such as drunk driving arrests, fett of store shelf space devoted to healthy products, and heart-related emergency room visits.

2.  Diagnose and investigate health hazards in the community.

___This service encompasses public health activities such as:

• Epidemiologic identification of emerging health threats;
• Public health laboratory capability using modern technology to conduct rapid screening and high volume testing;
• Active infectious disease epidemiology programs; and
• Technical capacity for epidemiologic investigation of disease outbreaks and patterns of chronic disease and injury.

3.  Inform, educate, and empower people about  health issues.

___Social marketing and targeted media public communication (e.g., Toll-free information lines).

___Providing accessible health information resources at community levels (e.g., free, mobile health screening initiatives).

___Active collaboration with personal health care providers to reinforce health promotion messages and programs.

___Joint health education programs with schools, churches, and worksites (e.g., stress reduction seminars; parenting support groups for enhancing mental health; and health fairs).

4.  Mobilize community partnerships to identify and solve health problems.

___Convene and facilitate community groups and associations, including those not typically considered to be health-related, to undertake defined preventive, screening, rehabilitation, and support programs.

___Build multi-sector community coalitions in order to draw upon the full range of potential human and material resources in the cause of community health.

5.  Develop policies and plans that support individual and community health efforts.

___Leadership development at all levels of public health.

___Systematic community-level and state-level planning for health improvement in all jurisdictions.

___Development and tracking of measurable health objectives as a part of continuous quality improvement strategies.

___Joint evaluation with the medical health care system to define consistent policy regarding prevention and treatment services.

___Development of codes, regulations, and legislation to guide the practice of public health.

6.  Enforce laws and regulations that protect health and ensure safety.

___Full enforcement of sanitary codes, especially in the food industry.

___Full protection of drinking water supplies.

___Enforcement of clean air standards.

___Timely follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings.

___Monitoring quality of medical services (e.g., laboratory, nursing homes, and home health care).

___Timely review of new drug, biologic, and medical device application.

___Advocacy for needed new health and safety laws and regulations.

7.  Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

___Effective entry for socially disadvantaged people into a coordinated system of clinical care.

___Culturally and linguistically appropriate materials and staff to assure linkage to services for special population groups.

___Ongoing “care management.”

___Transportation services.

___Targeted health information to high risk population groups.

___Technical assistance for effective worksite health promotion/disease prevention programs.

___Outreach and support to populations in need of government services.

8.  Assure a competent public health and personal care workforce.

___Education and training for personnel to meet the needs for public and personal health service.

___Efficient processes for licensure of professionals and certification of facilities, with regular verification and inspection follow-up.

___Adoption of continuous quality improvement and life-long learning within all licensure and certification programs.

___Active partnerships with professional training programs to assure community-relevant learning experiences for all students.

___Continuing education in management and leadership development programs for those charged with administrative / executive roles.

9.  Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

___Evaluation helps public health professionals continually refine or revise program approaches in future years of funding.

___Evaluation data provide information about the relative costs and effort for tasks so activity and budget adjustments can be made.

___To ensure useful results that lead to more effective services, it is necessary to conduct ongoing evaluations of health programs based on analysis of health status and service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs.

10.  Research for new insights and innovative solutions to health problems.

___Link with appropriate institutes of higher learning and research.

___Mount timely epidemiologic (e.g., outbreak investigations) and economic analyses (e.g., cost-benefit studies).

___Conduct needed health services research (e.g., survey design; conducting interviews and facilitating focus groups; conducting clinical trials; and accessing and using public records).

___Engage in collaborative research with other programs, and publicize your results.

___Seek funding for both individual and collaborative research into health problems.

___Publicize research results so others can use and build on them.

A PowerPoint presentation summarizing the major points in the section.

In Chapter 2, we’ve looked at a variety of different models for building healthy communities, including one -- asset development -- that focused on building the advantages that young people need in order to develop into healthy, successful adults. That model approaches adolescent health and growth from a positive angle, assuming that if you can provide youth with the proper support and opportunities, development will proceed in the right direction.

But there are negative as well as positive influences at work in families, schools, and communities. If no one in an adolescent’s family has graduated from high school, that adolescent may see quitting school at 16 as normal and desirable. Young people may find it harder to avoid drug use if drugs are readily available in school and on the street. If the community fosters a culture of violence, youth are likely to be caught up in that culture.

In this section, we’ll look at a model that acknowledges both the positive (protective) and negative (risk) factors that work on adolescents, with the goal of enhancing the former and reducing the latter.  The model has a narrower focus than some we’ve profiled, but its purpose is the same – to enhance the healthy development of youth, and thus to create a healthier community.

Like most other models, Communities That Care takes a community-wide perspective, and calls for broad community participation. Similarly to PRECEDE/PROCEED, it identifies problems and resources, devises solutions aimed directly at the identified problem, and integrates evaluation into the implementation of the solution.

Communities That Care resembles the Search Institute’s asset development model in its emphasis on youth and the protective and risk factors affecting them. Where asset development looks at the overall development of children and adolescents, however, Communities That Care, as we shall see, focuses specifically on problem behaviors and their prevention or reversal.

What is Communities That Care?

Communities That Care (CTC) is based on the Social Development Strategy formulated by J. David Hawkins and Richard Catalano at the University of Washington. Rather than a program, CTC is an “operating system” that provides the structure, but not the content, of a community effort to address youth issues.  It focuses on risk and protective factors, which are approached through a community-wide process that involves training at each step.

CTC is a copyrighted, structured process. The Channing-Bete Corporation charges a fee for administering a comprehensive community effort that includes training, materials, and help with assessment, planning, and the choice, implementation, and evaluation of specific interventions designed to address risk and protective factors for youth.

CTC is specifically aimed at addressing five problem behaviors among youth:

• Substance use
• Delinquency
• Teen pregnancy
• School dropout
• Violence

Risk factors

Risk factors are those elements in the environment or the inner makeup of people that make them more susceptible to particular behaviors or conditions. Research has identified 19 risk factors associated with one or more of the problem  behaviors identified above.  An assumption behind the CTC model, which it shares with the other models described in this chapter, is that such elements as risk and protective factors span all areas of community life.  With that assumption in mind, the 19 risk factors are divided into four groups related, respectively, to community, family, school, and individual/peer contexts.

Community risk factors. These have to do with both conditions within the community and its attitudes and structure.

• Availability of drugs. The availability of drugs is, not surprisingly, a significant risk factor for both drug use and violence. Availability is such an important factor that the drug use rate was found to be higher even in communities where drugs were perceived to be readily available, but actually were not.
• Availability of firearms.Statistics show that the more available firearms are in a community, the higher the violent crime rates tend to be, and, conversely, fewer firearms in a community is correlated with lower violent crime rates.
• Community laws and norms favorable to drug use, firearms, and crime. High taxes on alcohol and cigarettes, as well as bans on their use in various circumstances, can control their use and send a message about the community’s attitude toward them.

Lack of clarity in laws and practices can also raise problems for youth. If alcohol is customarily served at community festivals, if the drinking age isn’t enforced, or if drinking to excess among both adults and adolescents isn’t seen as a problem, the chances are that young adolescents won’t see any reason for avoiding these behaviors.

• Media portrayals of violence. There is evidence that young people who watch large amounts of media violence become numb to its impact and are more likely to behave violently themselves.
• Transitions and mobility. Transitions (from one school to another, for example, or from middle to high school) are always difficult for adolescents. Unusual community transitions (integration of socioeconomic groups through school busing, for instance, or widespread job losses), may compound the problem for teens. Transitions and/or a high level of transience – families moving frequently – can put kids at risk for substance use, delinquency, and school drop-out.
• Low neighborhood attachment and community disorganization. When people feel that they have little control over their lives, the results are all too often low community participation and voting levels, lack of community surveillance of public areas, vandalism, and decay of the physical and social structure of the neighborhood. These conditions can lead adolescents into substance use, violence, and delinquency.
•  Extreme economic deprivation. Poverty puts youth at higher risk for all problem behaviors.

Family. As might be expected, a child’s family’s attitudes and conditions have a huge effect on his present and future behavior. All five problem behaviors are subject to family-related risk factors.

• Family history of problem behavior. If their father spent time in jail, if their mother was only 15 when her first child was born, if a parent dropped out of high school, if someone in the family regularly drinks large amounts of alcohol, if physical violence is a family norm, then adolescents in the family risk repeating the same behavior, and engaging in other problem behaviors as well.
• Family management problems. Family management comprises the methods and procedures parents use to regulate relationships and raise their children. Some family management problems are obvious: no controls on children’s activity and whereabouts, or child abuse used as discipline.  Other less visible, but equally harmful, problems include lack of clear expectations for behavior and character, inconsistent demands, and unclear definitions of the boundaries between parents and children. All of these act as risk factors for all five problem behaviors.
• Family conflict. Whether the conflict is between parents, between parents and children, among siblings or step-siblings, or among other members of the household, a high level of conflict figures into adolescent susceptibility to all problem behaviors.
• Parental attitudes toward, or involvement in, substance use, crime, and violence. If parents approve of or accept these behaviors, or engage in them themselves, their children are much more likely to be involved in them as well.  This is especially true when parents involve the children directly in their own problem behaviors – heroin addicts taking their children along on drug buys, for instance (a situation the author has encountered often), or parents sending their children to buy cigarettes for them.

School. School represents not just a place to learn reading or algebra. It is a social center, and a miniature of society as a whole.The identity an adolescent assumes or that influences her in school is the identity that she and others expect she will assume as an adult.  School-related risk factors affect all the problem behaviors.

•  Early and persistent antisocial behavior. A child who’s a terror in kindergarten, but learns to stay out of trouble in school most of the time, is probably doing fine. If the antisocial behavior is still present at 12, he’s at serious risk.
• Academic failure in elementary school. In addition to being a source of frustration for both child and teacher, academic failure is self-perpetuating – the child can’t understand the material, and as a result, she pays little attention, misses even more, and falls further and further behind. Academic failure also distances the child from education as a tool for life, making it seem irrelevant and “not for me.” Finally, it encourages a self-image fueled in equal parts by anger and despair: “slow,” not very competent at anything related to the intellect, an outsider, etc. All of this leads the child away from the mainstream and toward the subcultures of problem behaviors.

In some cases, the subculture of a whole group of children may see academic success as suspect or wrong. Among some Black urban teens, for instance, doing well in school is viewed as trying to be white. Some working class cultures have looked down on academic success as class betrayal. If a child heeds these voices of culture, he’s limiting his adolescent options, and laying himself open for problem behaviors.

• Lack of commitment to school. This may be a result of academic difficulty, or simply of a lack of interest in school, and a feeling that school, or education in general, are unimportant.

Individual/peer. This last set of risk factors concerns personal characteristics and attitudes that are either inherent in the individual, or are influenced by close peer relationships – or, in some cases, both.

•  Alienation and rebelliousness.The Regional Preventive Center of the Flint Hills (Kansas) describes alienated and rebellious youth as those who “feel they are not part of society, are not bound by rules, don’t believe in trying to be successful or responsible, or who take an active rebellious stance toward society.”
• Friends who engage in problem behaviors. Because of the importance of peer approval to adolescents, friends’ attitudes and actions can be a powerful factor in teens’ behavior.  This risk factor is one of the most consistent predictors of the presence of problem behaviors.  In other words, your mother was right – you shouldn’t be hanging around with those bums.
• Favorable attitudes toward the problem behavior. If a youth’s friends – or parents, for that matter – binge drink, commit crimes, or drop out of school, she’s more likely to be positive about those behaviors.  Developing favorable attitudes toward problem behaviors obviously puts kids at greater risk of engaging in them.
• Early initiation of the problem behavior. The earlier you start drinking, for instance, the more of a “normal” behavior it becomes.  If you’ve been getting drunk for nearly half your life by the time you’re 17, you aren’t apt to see anything wrong with it.
• Constitutional factors. These are internal factors that may be either in-born (genetic, neurological, or biological) or environmental, but that are, in any case, very much a part of who an individual is.  These can include lack of impulse control, sensation-seeking, and low risk avoidance.

Protective factors

Just as there are risk factors that put adolescents in harm’s way, there are protective factors that tend to shield them from engaging in problem behaviors. These fall into three categories:

Individual characteristics.

• Gender. Conventional wisdom is right on this one – girls get into less trouble than boys do. Whether it’s testosterone or social conditioning, boys are at greater risk for all of the problem behaviors except teen pregnancy.
• Resilient temperament. Some children and adolescents simply seem to be better able to weather difficulties than others. They can experience numerous risk factors without losing their ability to cope reasonably with whatever comes up.
• Positive orientation. Children who are optimistic and cheerful, enjoy other people, and are themselves well-liked are at reduced risk for all the problem behaviors.
• Intelligence.Intelligence is a defense against delinquency and school drop-out, but not against substance use.

Everyone can cite examples of brilliant scientists or poets who were substance users. The real question is why others – often with similar pain in their lives – were not. Perhaps the necessary type of intelligence here is not intellect, but emotional intelligence – the ability to understand yourself and others, to be honest with yourself about your motivations, and to consider what you’re doing before you act.

Bonding. Many birds and other animals are programmed to recognize and bond with the first large creature they encounter after birth as their mother. Children and adolescents also bond – they establish strong connections to parents and other individuals and groups. When kids are bonded in this way, they tend to act in the ways expected by the individual or group they feel connected to, so as not to threaten the relationship.

CTC presents bonding as an unalloyed protective factor, but it is worth noting that these bonds are not always to individuals or groups that will prevent problem behaviors. If teens bond to a violent gang, that connection isn’t likely to act as a protective factor. Protective bonds are those where the relationship is with an individual or group that holds pro-social values that oppose the problem behaviors.

These might include:

• Parents and families
• Other significant adults – relatives, neighbors, counselors and mentors, etc.
• Teachers
• Peer groups
• School
• Organizations – Scouts, church groups, social clubs, workplaces, etc.
• Sports teams
• Community – service groups, cultural organizations, etc.

Healthy beliefs and clear standards. Significant adults and groups create a community environment that communicates a positive value system, and lets teens know what’s expected of them

Families, other adults, schools, and the community at large should all clearly state and practice values that oppose problem behaviors.  In addition to holding positive beliefs, families, schools, and the community should all have plainly stated high expectations and standards for children’s and adolescents’ behavior and achievement.

In other words, adults in the community should both preach and practice an admirable value system, and expect youth to do the same.

The ideal here – the one that CTC hopes to create in communities if it doesn’t already exist – is one where the community speaks with one voice about values and standards. In practice, that’s a difficult goal to achieve. However, if significant adults – parents, teachers, and coaches particularly – clearly communicate reasonable value systems as well as the standards that adolescents are expected to meet, most adolescents will get the message.

How protective factors work to counter high-risk environments: the Social Development Strategy

Hawkins and Catalano’s Social Development Strategy explains how protective factors operate.

Individual characteristics provide a foundation for healthy behavior. Gender, resilient temperament, positive orientation, and intelligence don’t, by themselves, necessarily lead kids in the right direction.  The possession of one or more of them does, however, give an adolescent a starting place from which she can move in that direction.  Having access to a piano doesn’t assure that you’ll learn to play, but it affords you the opportunity.  Without that access, you surely won’t learn.

While individual characteristics can act as protective factors, the lack of any of these individual protective traits doesn’t mean that a youth is doomed. Other protective factors can be reinforced to compensate, or, in some cases, the missing protective traits can be developed. Attitudes, and even personality, can change with positive changes in circumstances, or with appropriate counseling or psychotherapy. Even intelligence can be increased with the proper stimulation and circumstances.

• To develop or enhance individual characteristics, children and adolescents should be given a chance to contribute to their families, schools, and communities.  In order to contribute and reap the protective benefits, kids need three things:
  • Skills. These include both the social skills to work with others and the specific competencies (basic skills, reasoning, specialized knowledge, and/or physical abilities) that will make their contributions valuable.
  • The opportunity to contribute. Kids need to be given responsibilities that fit their age and abilities, and come with appropriately high expectations.  They should have the chance to make a significant contribution, not just a token.

Depending on the child’s age and ability, contributions can vary from simple household chores to running a youth organization or serving on a community board. The range can include such activities as in-school tutoring of younger children or school-based peer mediation; responsibilities in social clubs, Scouts, or faith-based groups; membership in a band or orchestra; or taking care of younger siblings.

• Recognition for their contribution. Like anyone else, kids need to know that their work is valued, and that someone noticed that they did a good job.  Recognition also helps cement their feeling as though they are part of the group, whether it’s a family, a school, an organization, or a group whose only other member is a caring adult.

Contribution leads to bonding. Providing real help to an individual, group, organization, or the community helps youth to identify with that entity and its ideals and values.  That identification makes adolescents less likely to engage in problem behaviors, both for fear of alienating the individual or group they’re attached to and because their image of themselves includes acting in ways consistent with the values of the bonded individual or group.

For a bonded child or adolescent, the provision of healthy beliefs and clear standards furnish the structure and corrective feedback needed for positive development.Adolescents get clear messages about the goals they should be striving for, and are held accountable for reaching those goals by adults and groups significant in their lives.

Ultimately, this progression leads to healthy behavior.The work of protective factors is demonstrated in the following diagram illustrating the Social Development Strategy:

Why would you want (or not want) to adopt the Communities That Care approach?

As with all the models discussed in this chapter, there are both advantages and disadvantages to using CTC. Many of the advantages can also be viewed as disadvantages, depending upon your point of view.  The advantages listed below largely mirror CTC’s own claims for effectiveness, while the disadvantages present, in many cases, an alternative way of looking at those claims.

Advantages

• CTC is grounded in theory and practice.The ideas underlying CTC – the concepts of risk and protective factors, for instance, and the studies that indicate their influence –come from prevention theory.  CTC’s list of “best practices” includes methods and programs that have been cited as effective, and can be reproduced in other settings.
• CTC is inclusive and participatory.The conceptualization and planning process involves people from all sectors of the community in discussion and decision-making.  A community board oversees the implementation and evaluation of the program.

There are real advantages to being inclusive – involving people from all sectors of the community, including youth and others directly affected by any intervention – and participatory – engaging everyone, not just leaders, in decision-making. First, it taps a broad range of ideas and knowledge, particularly about the history and character of the community and its youth. Second, it assures that all decisions are carefully discussed, and that nothing is hastily adopted. Perhaps most important, it means that, because everyone in the community has been represented, the final plan and implementation will be “owned” by the community. Since the plan came from the people, rather than being imposed on them by someone else, they’re likely to support it, and work to make it successful.

• CTC takes a community perspective. Adopting an outlook similar to that of the other models reviewed in this chapter, CTC looks at the prevention of problem behaviors and the healthy development of youth as a community-wide responsibility that demands a community-wide effort.  Whether the community in question is a rural village or a city as large as Seattle,Washington (which, led by the school system, has adopted the model), CTC assumes that only by engaging the whole community can a prevention program be truly effective.
• CTC involves training at every step. Rather than simply presenting a model or helping with assessment, CTC provides training and assistance at each point in the process.  Such crucial phases as community assessment and strategic planning are thus undertaken by groups that have the background to proceed competently.
• CTC provides a menu of best practices to choose from. Instead of having to engage in lengthy research or plan their own interventions from scratch, CTC participants choose the interventions most appropriate to their community from a list of “best practice” methods and programs that have been proven effective. Furthermore, CTC encourages communities to choose multiple approaches, aimed at a range of the risk factor areas.

“Best practices” are those whose effectiveness is documented in studies by funders (often government agencies) or academics (who publish the results in journals and other publications).

• CTC is adapted to its own needs by each community. Rather than employing a “cookie-cutter” approach, CTC encourages communities to mix and match best practices to build a prevention program that speaks specifically to local needs and character.  Because training and a community assessment are part of the system, each community builds the knowledge and skills to analyze its needs and make wise choices.
• CTC includes evaluation and adjustment as an integral part of any effort. No program or method, best practice or not, is perfect for every community, and no implementation of a program or method is perfect, either. Regular evaluation and readjustment of programs goes a long way toward assuring effectiveness.
• CTC seems to work for most problem behaviors. Communities, by their own reports, seem to have good results in reducing the incidence of problem behaviors, with the exception of substance use.

Disadvantages

• The CTC approach is only inclusive and participatory for certain people. While it claims to involve the whole community, the formal CTC approach is actually top-down, starting with a small number of “key community leaders.”  These leaders who may or may not be representative of the whole community in terms of race, socioeconomic class, or interests – then “invite” other participants “from all sectors” to make up a community board of 30.  The reality is that they’ll usually invite people they know, who are apt to be much like them and may not represent the true diversity of the community..

Especially in a large community, it takes research to know whom to include, and 30 may be too small a number to be truly representative of all sectors. Furthermore, some sectors – youth themselves, for instance, or single parents receiving public assistance – are unlikely to be included unless specifically targeted by the process.  And if the “key community leaders” see themselves as leading the process, its participatory nature can go out the window.

• CTC allows the choice of only a finite number of approaches. CTC’s claim of allowing communities the freedom to devise their own solutions is only partially accurate. Communities can create combinations of interventions that speak to their needs, but only from a limited pool of choices.

The fact that CTC offers a menu of best practices is a double-edged sword. On the one hand, it presents a community with a number of programs and interventions that have worked in other places, and the security of set curricula for implementing them. On the other, it can limit the possibilities for creativity and the use of local wisdom that might arise if there were more freedom of choice and the chance for the community to craft its own program.

• Choosing from among best practices may encourage communities merely to follow directions, rather than throwing heart and soul into the effort. Though it simplifies the process, an intervention that’s laid out for the community, rather than built from the ground up, may lead people to believe that if they implement it “right,” they’ll automatically get results.  If the results aren’t forthcoming, the community may be tempted to try harder to hone its implementation, rather than carefully analyzing the situation.
• CTC is narrowly focused. CTC focuses specifically on youth, and more specifically on the five problem behaviors – substance use, delinquency, teen pregnancy, school dropout, and violence.  This emphasis has both positive and negative aspects. On the one hand, it means not trying to do too many things at once, and setting manageable goals.  On the other, it implies taking a small-picture view of community health and development, and not necessarily planning for the long term or for the whole community.

If the ultimate goals are as narrow as reducing one or more of the problem behaviors, they can give the impression that reaching those goals “fixes” the problem and the community. If the goal is the end of the process, there’s no community commitment to long-term social change. And long-term social change is usually needed to fully solve community problems.

• CTC is, to a certain extent, based on assumptions. While the theory behind it and the best practices have been subject to a fair amount of research, the program has only been shown to be effective in the short- to mid-term range. Long-term data have not yet been collected.
• CTC has a service to sell.  In most cases, CTC is sold as a package that includes literature, training, and support. While there are some obvious advantages to this, it also means that there can be less flexibility in the model than might be desirable, and that the provider benefits from selling all parts of the package, whether they’re the most appropriate or effective possibilities for the community or not.  The fact that this is a commercial venture doesn’t make conflict of interest inevitable, but it raises the possibility of it.

Some of these disadvantages are serious, but none are insurmountable if you adapt the program to your community’s own needs. You may define “key community leaders” a bit more broadly, for instance, although you might want to include at least some of those that meet CTC’s criteria in an initial group. You can include teens, parents, and a cross section of people from the community as well, so that the initiative for the effort is community-wide, rather than top-down. You may be creative with programming ideas, or use some of the best practice programs and devise others of your own. No model is sacrosanct, and no model works equally well in all communities.

Who should be involved in Communities That Care?

As we’ve just discussed, CTC should be as broad-based as possible.  Community leaders – elected officials, respected business figures, etc. – are important, but you need all the stakeholders if you expect the whole community to buy into the effort.

Stakeholders include all who have a vested interest in an initiative: supporters, beneficiaries, planners, implementers, etc. Some possibilities include:

• People directly affected by the problem behaviors.They can bring to the discussion experience and a deep understanding of the behaviors and their effects.
  • Youth themselves, especially those who’ve been there – former gang members, people in recovery from substance use disorders, teen parents, dropouts. They can offer not only the insight of personal knowledge, but also credibility with other youth.They speak from experience, not from an adult position of moral rectitude.
  • Families, significant others, and friends of those involved in the problem behaviors. Their experience is often just as intense as, and more painful than, that of the adolescents themselves.
  • Victims of delinquency or youth violence.
• People affected indirectly by the problem behaviors. This group might comprise people with a number of different interests.
  • Teachers, counselors, coaches, and other school staff.
  • Those who work in non-school organizations that serve youth – caseworkers, street workers, gang liaisons, mentors, coaches, youth group leaders, etc.
  • Those who deal with the consequences of youths’ actions – police, medical professionals and other health workers, judges, probation officers.
  • Merchants and others who believe that their businesses or property values are reduced by teens loitering and/or getting drunk or high outside, or by streets made unsafe by youth violence.
• Community leaders and decision-makers.There are really two kinds of community leaders here: official and unofficial.
  • Official leaders. These are largely present and former elected and appointed officials.
  • Unofficial leaders. This is a larger group, made up of opinion leaders, well-known business, institutional, and civic figures, community activists, spokespersons for particular groups (underrepresented language groups, labor unions or tradespeople, neighborhoods), clergy, and ordinary citizens whom others respect and listen to.
• Those with a community interest. These are people who may not be directly involved or affected, but care about kids and the community.
  • Parents and others who want the best possible environment and support for youth.
  • Business people, community developers, etc., who want to be able to present the community as a desirable place to settle, raise children, or start a business.
  •  Community volunteers and other concerned citizens.
• The media. Involving representatives of the media from the beginning – as individuals and parents, rather than just in their professional capacities – is the best way to assure that the community gets the information it needs about CTC and its activities in your community.

How do you employ the Communities That Care approach?

In 2000, Hawkins and Catalano went into partnership with Channing-Bete Company of South Deerfield, MA, to market a trademarked “Communities That Careâ” package to communities. The package includes an overall strategy, training of community participants at several junctures, help with choosing and implementing effective interventions, evaluation tools, and technical assistance throughout the process.

To implement a formal CTC program, you have to make arrangements with Channing-Bete. Visit the CTC section of their website.

The description of the phases of prevention below outlines the CTC process (i.e., describes what would happen if you hired Channing-Bete to help your community run a CTC program. There is, understandably, a lack of detail here, since the CTC folks couldn’t sell their program if they gave all the details away for free.

According to CTC, an effective community prevention process has seven phases, the first two of which are preliminary, and may or may not be necessary in a given community:

Awareness.

The first step in the process is to assess community readiness to address adolescent problem behaviors. Citizens from all sectors have to be aware that adolescents are engaging in problem behaviors in the community, and to see it as an important issue. Only when the community reaches that point is it ready for the next phase.

Education.

 Once people understand that there are problem behaviors to be addressed, they need information about them, to better understand them and to see why addressing them is important.  Community education presents citizens with what they need to know to begin to approach the issue – what the problem behaviors are, their nature and effects, evidence that some or all of them are a problem in the community, etc.

These two phases reflect the first two stages of readiness for change recognized by social marketers. Community Tool Box Understanding Social Marketing: Encouraging Adoption and Use of Valued Products and Practices, describes the “continuum of understanding” that accompanies behavior change:

• Knowledge about the problem.
• Belief that the problem is important.
• Desire to change.
• Belief that change is possible.
• Action.
• Maintenance of action.

The awareness and education phases of the CTC process address the first two stages on this continuum, and, ideally, lead to the third. The latter three stages are dealt with as part of the presentation, adoption, and implementation of CTC as a community effort.

An important aspect of the theory behind the continuum is that a person’s level of understanding of a problem is crucial in persuading her to change. You have to approach her at her current stage and try, with arguments or information that address that current stage of understanding, to move her to the next. Thus, it’s important, before starting an initiative like CTC or any of the others modeled in this chapter, to take the pulse of community understanding of the issues you want to address. No matter how good your process or your proposed intervention, if the community hasn’t gotten to the point where it’s ready to support the effort, it will probably fail. You have to do the groundwork of bringing the community to that point (ideally, through the community’s own participation) before you can start to take action.

Community mobilization.

Once the community sees and understands the problem and the need for correction and prevention, community mobilization begins with the recruitment of a small number of  “key community leaders.”  These are the decision makers and opinion leaders whose support is needed for things to happen in the community – top elected officials, business and labor leaders, heads of institutions and agencies, the Superintendent of Schools, etc.

This core group receives an orientation to CTC and commits to the process.  They then invite 30 people from all sectors of the community to form a community board to oversee the CTC process. The community board, in turn, receives a two-day orientation and training about the theory behind CTC and how the process should work.

As discussed briefly above, this part of the process leaves something to be desired if you want a diverse group that sees itself as owning the process from the beginning. The Orlando Healthy Community initiative started with a self-selected group of key community leaders – the mayor, the heads of two hospitals, bankers, several present and former Junior League officers, etc. Their attempt at assembling a community board to oversee their effort was mediated by a facilitator. When the group drafted an “inclusive” list of people to invite as participants, the facilitator pointed out to them that virtually everyone on it was white, aged 35-65, and middle class.

To the group’s credit, they went back to square one, researched the community, made contact with many people they’d never met, and ultimately came up with a truly inclusive list...of 160, almost all of whom signed on. The number of community board participants again raises the other issue addressed in the previous discussion of inclusiveness and participation: whether 30 is a large enough number for a truly representative board.

In a small, relatively homogeneous community or a neighborhood, 30 might be fine. But in even a moderate-sized city, there might be more than 30 racial and ethnic groups, each of which might need to be represented. In addition, there might be powerful reasons to include representation by geography, age, and class, as well as by people from specific organizations and professions. And all of these are over and above the original key community leaders, others who need to be included for political reasons, and people from the other various community subgroups (business, large institutions, public employees, the schools, academia, community volunteers, etc.).

The community board, once trained by a CTC facilitator, holds public meetings to introduce CTC to the community, and to involve the community in developing a shared vision to guide the planning and implementation process.

Community assessment.

The community assessment phase of CTC revolves not only around pinpointing weaknesses and needs, but also around identifying strengths and resources already present in the community. The community board employs a number of strategies to examine the nature of community needs:

• Youth survey. A survey given to youth in the schools is part of the CTC package. It is meant to identify risk and protective factors, and to help the community board understand where and what the prevention needs are.
• Census and accompanying GIS (Geographic Information Systems) data. Examining these and comparing them with those from the previous census can highlight trends, changes, and possible problems or new assets in the community. GIS maps can also show concentrations of particular racial or racial and ethnic groups, underrepresented language groups, socioeconomic groups, employment patterns, and other information that might be useful.
• Archival records. The records of the school system, the police, the newspapers, and various government agencies can yield valuable information about what’s been done in the past, what the problems have been over time, whether there have been previous efforts and whether they have been successful, and much more.
• Direct contact with youth and other citizens. Through focus groups, community forums, individual interviews and conversations, and informal meetings with groups, the community board can obtain direct information from those who experience the problem behaviors and risk and protective factors and their effects every day.

Using these avenues, the board determines the nature of risk and protective factors in the community, and chooses two to five risk factors to focus on. Any action on these risk factors will be specific to the need in the particular community – that is, geared to areas and populations where the survey and other data show that the need for reducing risk and enhancing protection is greatest.

The board then receives a one-day training in identifying community strengths and resources, which it uses to find resources to support the CTC effort:

• Money, in the form of local funders or other sources.
• Expertise, from academics versed in theory, or from community groups or individuals experienced in working with youth.
• People – often both paid and volunteer – to provide the front-line and support tasks to make the effort work.
• Avenues to reach youth – schools, libraries, media outlets, sports facilities, street outreach, direct contact with parents, etc.

Prevention plan development.

Here, the community decides where to put its efforts, develops goals and ways of measuring them, and chooses from among a number of proven programs that address its issues.  This phase begins with community planning training, then launches into a strategic planning process.

The community board looks carefully at the risk and protective factors it has chosen to address in the last phase, and at the geographic, social, or demographic groups that show the greatest need.  Using this information, the board determines clear outcomes for protection enhancement, risk reduction, and behavior change.  It sets timelines and assigns accountability for carrying out a plan.

The next step is a two-day “effective prevention strategies” workshop that introduces the board to proven practices, and helps it select one or more appropriate to the community and its planning goals.  Rather than concentrating in one area, the board is urged to select strategies that address family, school, and community factors.

Program implementation.

The board creates an implementation task force, composed of members of the board itself, those who will actually run or work in the program, beneficiaries of the program, and other community members. CTC provides guidance and help in setting up the implementation, replicating the chosen programs, etc.

With CTC, as with any model, the keys to good implementation are thorough and inclusive planning, a carefully structured implementation process (i.e., everyone knows what comes when and who is responsible for doing what), and good communication among all parties to make sure that the process works the way it’s designed to. If these elements are present, the chances are that implementation of the plan will go smoothly.

That doesn’t guarantee that it will be effective, however. Effectiveness depends on whether you’ve chosen an intervention that properly addresses the issues at hand, and on how well the people doing the direct work of implementation do their jobs, relate to the population being served, and work together.

Outcomes evaluation.

The program is evaluated against the outcome and accountability criteria developed earlier. CTC provides evaluation instruments and assists with the process.  The evaluation is meant to show the board where the intervention has been successful and where it hasn’t, and thus to provide them with the information they need to adjust the program where necessary.

Evaluation and adjustment is an integral part of the process, and should continue throughout the life of the effort. An initiative doesn’t end when the community sees positive results. If the results are indeed positive, then the program should continue in order to maintain them.  If results are less positive than you hoped, then you have to keep adjusting the process and the content of the intervention until you get the results you’re aiming for.

Even if results are overwhelmingly positive, it’s not time to rest on your laurels.  As soon as you turn your back, your positive changes can disappear.  You have to maintain your effort indefinitely – by continuing to evaluate, adapt, and implement interventions, and to identify and address needs – to create a better, healthier future for youth and your community.

In Summary

Communities That Careâ (CTC) is a trademarked process that grew out of the work of J. David Hawkins and Richard Catalano at the University of Washington.  Based on prevention science, their Social Development Strategy looks at the ways in which risk and protective factors push adolescents away from and toward healthy development.

CTC focuses on five problem behaviors: substance use, delinquency, teen pregnancy, school drop-out, and violence.  It aims to reduce the 19 research-identified risk factors – divided into individual/peer, family, school, and community categories – that may encourage these behaviors, and to strengthen the three protective factors – individual characteristics, bonding, and healthy beliefs and clear standards – that deflect adolescents from them.

Advantages of the process include:

• CTC is grounded in theory and practice.
• CTC is inclusive and participatory.
• CTC takes a community perspective.
• CTC involves training at every step.
• CTC provides a menu of best practices to choose from.
• CTC is adapted to the needs of each community.
• CTC includes evaluation and adjustment as an integral part of any effort.
• CTC seems to work for most problem behaviors.

Along with these advantages, CTC also has a number of potential drawbacks:

• The CTC approach is only inclusive and participatory for certain people.
• CTC allows the choice of only a finite number of approaches.
• Choosing from among best practices may encourage communities merely to follow directions, rather than throwing heart and soul into the effort.
• CTC is narrowly focused on youth and specific behaviors.
• CTC is, to a certain extent, based on assumptions.
• CTC has a service to sell.

Because broad-based participation is necessary for a successful effort, CTC should involve all stakeholders and all sectors of the community. This includes those directly affected by the problem behaviors and the proposed intervention, those indirectly affected; those who deal with the consequences of the behavior; concerned citizens; and members of the media.

CTC is presented to a community as a package that includes an overall structure, several trainings, literature, survey and evaluation instruments, guidance throughout, and technical assistance. The process starts with analysis of whether the community is aware of the issues, and ready to support action on them. If not, it needs to be brought to that point.  Next, the community needs to be educated about the problem behaviors – their characteristics, their severity, their frequency in the community, who is at risk, etc. Then the process starts in earnest.

First, a small number of key community leaders is recruited, receives an orientation, and agrees to sponsor the effort. They in turn recruit 30 people from a variety of community sectors to constitute a community board. The board, after training, presents CTC to the community, and generates, with community input, a shared vision.

After more training, the board engages in community assessment to identify the important risk factors and the populations most in need, as well as the resources available to fund and support the program. A planning process, also accompanied by training, arrives at a strategy, and interventions are chosen – ideally in all the crucial areas of family, school, and community factors – from among a number of best practices that have been shown to be effective and replicable.

An implementation task force, which includes those who’ll do the work of the intervention, then takes over to oversee the implementation of the effort. They set timelines, determine accountability and outcomes, and design the actual work.  Regular evaluation is an integral part of the process, and is meant to point out successes, which need to be continued, and problems, which need to be corrected.  The intervention should be constantly adjusted and improved based on this evaluation.

Finally, the process and the interventions need to be maintained in order for gains to continue, and not to fade away from neglect.

What is Communities That Care?

___Your community focuses on one or more of the five youth problem behaviors:

• Substance use
• Delinquency
• Teen pregnancy
• School drop-out
• Violence

___You attend to all four domains in which risk factors occur:

• Individual/peer
• Family
• School
• Community

___You encourage the three protective factors:

• Individual characteristics
• Bonding
• Healthy beliefs and clear standards

Why would you want (and not want) to adopt the Communities That Care approach?

You use CTC because

___CTC is grounded in theory and practice.

___CTC is inclusive and participatory.

___CTC takes a community perspective.

___CTC involves training at every step.

___CTC provides a menu of best practices to choose from.

___CTC is adapted to the needs of each community.

___CTC includes evaluation and adjustment as an integral part of any effort.

___CTC seems to work for most problem behaviors.

You see disadvantages to CTC in that:

___The CTC approach is only inclusive and participatory for certain people.

___CTC allows the choice of only a finite number of approaches.

___Choosing from among best practices may encourage communities merely to follow directions, rather than throwing heart and soul into the effort.

___CTC is narrowly focused on youth and specific behaviors.

___CTC is, to a certain extent, based on assumptions.

___CTC has a service to sell.

Who should be involved in Communities That Care?

You strive to involve:

___Those most directly affected by the problem behavior(s).

___Those indirectly affected by the problem behavior(s).

___Those who deal with the consequences of the problem behaviors in the community.

___Concerned citizens.

___The media.

How do you employ the Communities That Care approach?

___You gauge the awareness of the community.

___You provide community education about the problem behaviors.

___You mobilize the community, starting with key leaders (or a more inclusive group) and a community board.

___You conduct an assessment of community needs and resources.

___You create a strategic plan for the initiative, choosing from among best practices in the areas of family, school, and community.

___You implement your plan.

___You evaluate the process and outcomes of your intervention, and adjust it accordingly.

___You maintain your gains, and continue your efforts over time.

A PowerPoint presentation summarizing the major points in the section.

 

Often, community members are expected to respond immediately to new projects and community change without adequate time to adjust to new ideas of the knowledge to fully understand them. This section is about how to understand and measure exactly how ready a community is to address a particular issue, and how to use that knowledge to stimulate community change.

What is community readiness?

Community readiness is the degree to which a community is ready to take action on an issue. That readiness can range from none at all (the community has never even heard of the issue in question – think of AIDS in 1982) to already having successful programs in place and making headway. Community readiness has some specific characteristics that are important for community builders to understand:

• Community readiness is issue-specific. A community can be more than ready to address one issue, while being at the very earliest stages of readiness in relation to another. It’s measurable. It’s measurable across multiple dimensions. Not only can you get an accurate assessment of community readiness, you can accurately measure where the community is on various elements of readiness. (We’ll discuss the dimensions of community readiness in the next part of this section.)
• Community readiness can vary across dimensions. A community may be more ready to address an issue in some ways than in others. It may know a great deal about the issue and realize it’s a problem, for instance, but be unable to conceive of implementing a particular solution.
• Community readiness can vary across different segments of the community. Some groups – those directly affected by the issue, for example – may be far more ready to deal with it than others. However, as we’ll see, there are some ways to help move communities toward higher levels of readiness.
• Understanding community readiness is essential knowledge for addressing an issue. You can easily doom an effort by trying to push a community into something it’s not ready for. People will only support what they see as reasonable, logical, and doable. You may be proposing something that’s all of those, but if the community’s perception is otherwise, the effort is unlikely to be successful.

An understanding of community readiness allows you to tailor an intervention or strategy to what the community is willing to accept and support. By taking small steps forward – by setting goals that necessitate a stretch for people, but not so great a stretch as to be beyond their current ability and understanding of the issue – you can make steady progress.

What is the community readiness model?

The Tri-Ethnic Center for Prevention Research at Colorado State University has developed a model that identifies dimensions and levels of community readiness. The model also comprises an instrument for determining community readiness that can be easily used and scored by community members. We’ll include the instrument and instructions for scoring it in the “How to” part of this section.

Dimensions of community readiness

Dimensions of readiness are key factors that influence your community’s preparedness to take action on an issue.  Six dimensions identified by the model are:

• Community efforts.To what extent are there existing efforts, programs, and policies that address the issue?
• Community knowledge of the efforts. To what extent do community members know about existing local efforts and their effectiveness? Are the efforts accessible to all segments of the community?
• Leadership.To what extent are appointed leaders and influential community members supportive of the issue?
• Community Climate. What is the prevailing attitude of the community toward the issue?  Is it one of helplessness or one of responsibility and empowerment?
• Community knowledge about the issue. To what extent do community members know about the causes of the problem, consequences, and how it impacts your community?
• Resources related to the issue. To what extent are local resources – people, time, money, space, etc. – available to support efforts?

Your community’s status with respect to each of the dimensions forms the basis of the overall level of community readiness. Remember that readiness can vary – sometimes widely – across dimensions, so that, for example, levels of community efforts and resources may be very different. The levels of readiness describe just how prepared your community is to tackle the issue in question.  The community’s level for the issue you’re concerned with doesn’t necessarily correspond to its level on other issues (remember that community readiness is issue-specific). 

Community readiness can be described by nine different levels:

• No awareness. The issue is not generally recognized by the community or leaders as a problem.
• Denial/ resistance. At least some community members recognize that it is a concern, but there is little recognition that it might be occurring locally.
• Vague awareness. Most feel that there is a local concern, but there is no immediate motivation to do anything about it.
• Preplanning. There is clear recognition that something must be done, and there may even be a group addressing it. However, efforts are not focused or detailed.
• Preparation. Active leaders begin planning in earnest. The community offers modest support of their efforts.
• Initiation. Enough information is available to justify efforts. Activities are underway.
• Stabilization. Activities are supported by administrators or community decision-makers. Staff are trained and experienced.
• Confirmation/ expansion. Efforts are in place. Community members feel comfortable using services, and they support expansions. Local data are regularly obtained.
• High level of community ownership. Detailed and sophisticated knowledge exists about prevalence, causes, and consequences. Effective evaluation guides new directions. The model is applied to other issues.

Once you know your community’s level of readiness, you can plan your effort to start at that level and move the community to the next, and to continue to move the community, one level at a time.

Why use the community readiness model?

• It conserves valuable resources (time, money, people) by guiding the selection of strategies that are most likely to be successful. Rather than spinning your wheels trying to get the community to do something it’s not ready for, you – and the community – can get up to speed quickly by starting in the right place.
• It is an efficient, inexpensive, and easy-to-use tool. It doesn’t take professional expertise to administer or score, it’s free, and it works.
• It promotes community recognition and ownership of the issue. Because it can be used by community members, and because it recognizes the needs and assumptions of the community, the model makes it easier for community members to see the issue and understand its effects.
• Because of strong community ownership, it helps to assure that strategies are culturally congruent and sustainable.
• It encourages the use of local experts and resources instead of reliance on outside experts and resources. Those local experts may not be “experts” in the professional sense, but rather community members who understand what’s going on and know the community.
• The process of community change can be complex and challenging, but the model breaks down the process into a series of manageable steps. Moving from no readiness to the highest level is a long step.  Moving from the lowest level to the next one up is manageable and easy to understand.
• It creates a community vision for healthy change. The levels of readiness mirror the levels of community competency, and describe, to some extent, how a healthy community handles issues.

When should you use the community readiness model?

The nature of the model makes it useful in virtually any situation where an issue needs to be addressed, but there are some times when it can be particularly useful.

• In the course of an ongoing effort. If your effort is successful, the community will be moving forward, not only in dealing with the issue, but in readiness.  In order to make sure that it continues to work on tasks and goals that most members can accept and accomplish – and to move forward – it’s important to monitor readiness, and adjust your strategy accordingly.
• Each time you tackle a new issue. Because community readiness is issue-specific, it’s important to know where the community falls on each issue you address.  Successful work on one issue may leave the community better prepared and more willing to address others, or it may leave community members complacent, and feeling that there’s not much more to be done.  In either case, a campaign will have to respond to where the community is currently.
• When several different communities, or different segments of the community, are involved. As we’ve discussed, groups within the community may be in very different places on the readiness scale. You may need a unique strategy for each in order to mount a successful effort.
• When you’re planning an effort that involves a participatory process. What level of participation can you expect to begin with?  Where do you have to start in order to have a reasonable possibility of success? Applying the model will help to answer these and similar questions.
• When you’re engaged in a community or neighborhood planning effort. Many such efforts start with the assumption that everyone is at the same readiness level, but provide very little encouragement to move. A close look at where the community or neighborhood is actually starting from might both speed up the process and broaden involvement and subsequent satisfaction with the results.

Who should be involved in using the community readiness model?

In any use of the model, there are really two groups of people whose involvement is crucial: those who should apply and administer the model and assessment, and those who should be surveyed when the assessment is conducted.

• Who should consider using the model and/or administering the assessment?
  • Policymakers and planners. These are the folks who usually have the most power to get things done, but often fail to think about such factors as community readiness when they devise what seem like solutions to community problems. Community activists. Many activists and organizers recognize the importance of community readiness – it’s a cornerstone of the organizing philosophy of Saul Alinsky, the grandfather of community organizing in America – but without an assessment, community activists may have only intuition to determine where a community is starting from. Health and human service organizations. These organizations are often the initiators of community efforts toward change or toward addressing issues such as hunger, homelessness, AIDS, and substance use. Knowing where to start such efforts is essential to their success. Coalitions. Understanding community readiness in relation to their issue can help coalitions plan and organize to address it.
  • Anyone else interested in community or social change. Simply understanding the concept may prove valuable in any community work that citizens engage in.
• Who should be surveyed when the model is being applied? To some extent, the answer to this question depends on the nature of the issue. If it concerns youth, for instance (youth violence, pregnancies among adolescents), youth should be among those consulted. Likewise for other groups – seniors living alone, Latinos, people with particular medical conditions, etc. Some general possibilities, with the character of the community in mind:
  • Schools/Universities
  • Municipal/county/tribal government
  • Law enforcement
  • Health & medical professions
  • Social services
  • Mental health & treatment services
  • Clergy or spiritual community
  • Community at large
  • Youth
  • People on limited fixed incomes (Social Security, disability, etc.)

How do you use the community readiness model?

The model relies on the Community Readiness Assessment.

The Community Readiness Assessment

The instrument itself is an interview that takes 30-60 minutes. Composed of 36 questions, it is broken down into sections, each of which addresses one (or in the case of dimensions A and B, two) of the dimensions of readiness. Questions in bold are required for scoring. Others may be eliminated or revised as needed (see the box on revision below).

Community Readiness Assessment Interview Questions

A. Community efforts (programs, activities, policies, etc.)

B. Community knowledge of efforts.

• Using a scale from 1-10, how much of a concern is this issue in your community (with 1 being “not at all” and 10 being “a very great concern”)? Please explain. (Note to interviewers: this figure between one and ten is NOT figured into your scoring of this dimension in any way – it is only to provide a reference point.)
• Please describe the efforts that are available in your community to address this issue. (A)
• How long have these efforts been going on in your community? (A)
• Using a scale from 1-10, how aware are people in your community of these efforts (with 1 being "no awareness" and 10 being "very aware")? Please explain. (Note: this figure between one and ten is NOT figured into your scoring of this dimension in any way – it is only to provide a reference point.) (B)
• What does the community know about these efforts or activities? (B)
• What are the strengths of these efforts? (B)
• What are the weaknesses of these efforts? (B)
• Who do these programs serve? (Prompt: For example, individuals of a certain age group, ethnicity, etc.) (A)
• Would there be any segments of the community for which these efforts/services may appear inaccessible? (Prompt: For example, individuals of a certain age group, ethnicity, income level, geographic region, etc.) (A)
• Is there a need to expand these efforts/services? If not, why not? (A)
• Is there any planning for efforts/services going on in your community surrounding this issue?  If yes, please explain. (A)
• What formal or informal policies, practices and laws related to this issue are in place in your community, and for how long? (Prompt: An example of “formal” would be established policies of schools, police, or courts. An example of “informal” would be similar to the police not responding to calls from a particular part of town, etc.) (A)
• Are there segments of the community for which these policies, practices and laws may not apply? (Prompt: For example, due to socioeconomic status, ethnicity, age, etc.) (A)
• Is there a need to expand these policies, practices and laws? If so, are there plans to expand them? Please explain. (A)
• How does the community view these policies, practices and laws? (A)

C. Leadership.

• Who are the "leaders" specific to this issue in your community?
• Using a scale from 1 to 10, how much of a concern is this issue to the leadership in your community (with 1 being “not at all” and 10 being “of great concern”)? Please explain.(Note to interviewers: this figure between one and ten is not figured into your scoring of this dimension in any way – it is only to provide a reference point.)
• How are these leaders involved in efforts regarding this issue? Please explain. (For example: Are they involved in a committee, task force, etc.? How often do they meet?)
• Would the leadership support additional efforts? Please explain.

D. Community climate.

• Describe the community.
• Are there ever any circumstances in which members of your community might think that this issue should be tolerated? Please explain.
• How does the community support the efforts to address this issue?
• What are the primary obstacles to efforts addressing this issue in your community?
• Based on the answers that you have provided so far, what do you think is the overall feeling among community members regarding this issue?

E. Knowledge about the issue.

• How knowledgeable are community members about this issue? Please explain. (Prompt: For example, dynamics, signs, symptoms, local statistics, effects on family and friends, etc.)
• What type of information is available in your community regarding this issue?
• What local data are available on this issue in your community?
• How do people obtain this information in your community?

F. Resources for prevention efforts (time, money, people, space, etc.)

• To whom would an individual affected by this issue turn to first for help in your community? Why?
• On a scale from 1 to 10, what is the level of expertise and training among those working on this issue (with 1 being “very low” and 10 being “very high”)? Please explain. (Note to interviewers: this figure between one and ten is not figured into your scoring of this dimension in any way – it is only to provide a reference point.)
• Do efforts that address this issue have a broad base of volunteers?
• What is the community’s and/or local business’ attitude about supporting efforts to address this issue, with people volunteering time, making financial donations, and/or providing space?
• How are current efforts funded? Please explain.
• Are you aware of any proposals or action plans that have been submitted for funding that address this issue in your community? If yes, please explain.
• Do you know if there is any evaluation of efforts that are in place to address this issue? If yes, on a scale of 1 to 10, how sophisticated is the evaluation effort (with 1 being “not at all” and 10 being “very sophisticated?”)? (Note to interviewers: this figure between one and ten is not figured into your scoring of this dimension in any way – it is only to provide a reference point.)
• Are the evaluation results being used to make changes in programs, activities, or policies or to start new ones?

There are two questions to be answered here:

• How do you administer and score the Community Readiness Assessment?
• How do you use community readiness information? We’ll look at each of these questions separately. How do you administer and score the Community Readiness Assessment?
  • Choose and train interviewers. You’ll probably do best with people who are good interviewers or who are members of the community and are trusted by those they’ll be interviewing. The ideal is to find interviewers who fit both criteria, if possible. These folks don’t have to be experts or professionals, but they should be comfortable with others, be able to think on their feet, and have a good understanding of how to put people at ease and get information from them. In addition, even if they’re trained in interviewing skills, interviewers should be familiar with the community readiness model, so they understand the kinds of answers to probe for.
  • Choose and train scorers. Since the scoring of the assessment is quite specific, scorers need both to be trained to score it correctly (see the details on the scoring procedure and training of scorers below), and to have a good understanding of the community readiness model in general
• Revise the assessment tool, if necessary, to reflect the issue you’re concerned with. You may need to alter or eliminate some questions in order to get important information about your specific issue.

Community Readiness: A Handbook for Successful Change has this to say about revision:

Read through the questions...and apply as needed depending on your issue. The questions we provide here are generic and you may need to tailor the questions to your issue. When applying questions, keep the following in mind: The questions are closely tied to the scoring process, so applying them must be done carefully so that the core meaning of the question is retained. In most cases, you can substitute your issue for “this issue.”

For example, if your issue is domestic violence, Question 2 would be revised to read “What efforts are present in your community to address domestic violence?”

However, if a question is clearly irrelevant to your issue, you may need to drop the question unless it is in bold print. Those questions in bold print are essential for scoring. You may also want to add other questions that are more specific to your issue. If you want to add questions, add them to the end to avoid confusion when scoring.

Have two people apply the questions to your topic independently and then meet to arrive at consensus on the revision. You will note that Dimensions A & B are combined. This is to improve the “flow” of the questions. We have also found the information to score these Dimensions seems to be related and it is beneficial to read items from both Dimensions A & B to get a comprehensive score for each Dimension.If translating questions from English into another language, ask a person who is very familiar with the language and culture to translate. Then, have the translated version “back-translated” into English by another person to ensure that the original content of the questions was captured.

Pilot test your revised questions to make sure they are easy to understand and that they elicit the necessary information for scoring each dimension.

• Select four to ten people to interview. They should be people who know the community well, and they should be chosen to reflect the perceptions of a number of segments of the community, particularly of those directly or indirectly affected by the issue.
• Contact the people you have identified and see if they would be willing to discuss the issue. Each interview should take 30-60 minutes.
• Conduct your interviews. Avoid discussion with interviewees, but ask for clarification when needed and use prompts as designated.  Record or write responses as they are given. Try not to add your own interpretation or to second guess what the interviewee meant.
• Score the interviews. Determine dimension and overall readiness scores.

Scoring the instrument

Scoring is an easy step-by-step process that gives you the readiness stages for each of the six dimensions. The following provides the process for scoring.

(You’ll find a scoring worksheet and anchored rating scales in Tool #1 below.)

Ideally, two people should participate in the scoring process in order to ensure valid results on this type of qualitative data. Here are step-by-step instructions:

• Working independently, both scorers should read through each interview in its entirety before scoring any of the dimensions in order to get a general feeling and impression from the interview. Although questions are arranged in the interview to pertain to specific dimensions, other interview sections may have some responses that will help provide richer information and insights that may be helpful in scoring other dimensions.
• Again, working independently, the scorers should read the anchored rating scale for the dimension being scored. Always start with the first anchored rating statement. Go through each dimension separately and highlight or underline statements that refer to the anchored rating statements. If the community exceeds the first statement, proceed to the next statement. In order to receive a score at a certain stage, all previous levels must have been met up to and including the statement which the scorer believes best reflects what isstated in the interview. In other words, a community cannot be at stage 7 and not have achieved what is reflected in the statements for stages 1 through 6.
• On the scoring sheet, each scorer puts his or her independent scores in the table labeled INDIVIDUAL SCORES using the scores for each dimension of each of the interviews. The table provides spaces for up to six key respondent interviews.
• When the independent scoring is complete, the two scorers then meet to discuss the scores. The goal is to reach consensus on the scores by discussing items or statements that might have been missed by one scorer and which may affect the combined or final score assigned. Remember: Different people can have slightly different impressions, and it is important to seek explanation for the decisions made. Once consensus is reached, fill in the table labeled COMBINED SCORES on one of the scoring sheets. Add across each row to yield a total for each dimension.
• To find the CALCULATED SCORES for each dimension, take the total for that dimension and divide it by the number of interviews. For example: If two scorers have the following combined scores for their interviews:

Interviews #1 #2 #3 #4 #5 #6 TOTAL

Dimension A  3.5  5.0  4.25  4.75  5.5  3.75  26.75

TOTAL Dimension A 26.75 ÷ # of interviews 6 = 4.46

Repeat for all dimensions, and then total the scores.

• To find the overall stage of readiness OVERALL STAGE OF READINESS, take the total of all calculated scores and divide by the number of dimensions (6). For example:
  • Dimension A: 4.46
  • Dimension B: 5.67
  • Dimension C: 2.54 Dimension
  • D: 3.29 Dimension
  • E: 6.43 Dimension F: 4.07

                                                           26.46  26.46 ÷ 6 = 4.41

• The result will be the overall stage of readiness of the community.

The scores correspond with the numbered stages and are “rounded down” rather than up, so a score between a 1.0 and a 1.99 would be the first stage, a score of 2.0 to 2.99 would be the second and so forth. In the above example, the average 4.41 represents the fourth stage or Preplanning.

Finally, under comments, write down any impressions about the community, any unique outcomes, and any qualifying statements that may relate to the score of your community.

How do you use community readiness information? With the information you’ve gained about dimensions and overall readiness, you’re now ready to develop strategies that will be appropriate for your community.The ideal here is to do this through a participatory planning process, perhaps involving some or all of the people you interviewed, as well as others representing various sectors of the community or various groups affected by the issue. The first thing to do is look at the distribution of scores across the dimensions.  Are they all about the same? Are some lower than others?

To move ahead, readiness on all dimensions must be at about the same level.

If you have one or more dimensions with lower scores than the others, focus your efforts on strategies that will increase the community’s readiness on that dimension or those dimensions first. Make certain the intensity level of the intervention or strategy is consistent with, or lower than, the stage score for that dimension.

To be successful, any effort toward making change within a community must begin with strategies appropriate to that community’s stage of readiness.

Goals and General Strategies Appropriate for Each Stage

• No Awareness. Here, your goal is to raise awareness that the issue exists.
  • Make one-on-one contacts with community leaders/members.
  • Visit existing and established small groups to inform them of the issue.
  • Make one-on-one phone calls to friends and potential supporters.
  • Place items in the media that explain or call attention to the issue.
• Denial / Resistance. To address this level, you have to raise awareness that the problem or issue exists in this community.
  • Continue one-on-one visits and encourage those you’ve talked with to assist.
  • Discuss descriptive local incidents related to the issue.
  • Approach and engage local educational/health outreach programs to assist in the effort with flyers, posters, or brochures.
  • Begin to point out media articles that describe local critical incidents.
  • Place your own items in the media about the issue’s local effects.
  • Prepare and submit articles for church bulletins, local newsletters, club newsletters, etc.
  • Present information to local related community groups.
• Vague Awareness. Now that people recognize the problem, they have to be aware that the community can do something about it.
  • Get on the agendas and present information at local community events and to unrelated community groups.
  • Post flyers, posters, and billboards.
  • Begin to initiate your own events (potlucks, etc.) and use those opportunities to present information on the issue.
  • Conduct informal local surveys and interviews with community people by phone or door-to-door.
  • Publish newspaper editorials and articles with general information and local implications.
• Preplanning. At this level, people are ready to start thinking about how to address the issue.
  • Introduce information about the issue through presentations and media.
  • Visit and invest community leaders in the cause.
  • Review existing efforts in the community (curriculum, programs, activities, etc.) to determine who the target populations are and consider the degree of success of the efforts.
  • Conduct local focus groups to discuss issues and develop strategies.
  • Increase media exposure through radio and television public service announcements.
• Preparation. Here, the goal is information-gathering to lay the groundwork for planning community strategies to deal with the issue.
  • Conduct school drug and alcohol surveys.
  • Conduct community surveys.
  • Sponsor a community picnic to kick off the effort.
  • Conduct public forums to develop strategies from the grassroots level.
  • Utilize key leaders and influential people to speak to groups and participate in local radio and television shows.
  • Plan how to evaluate the success of your efforts.
• Initiation. As a more serious community effort gets under way, you’ll need to provide community-specific information to support existing programs and initiatives.
  • Conduct in-service training on community readiness for professionals and paraprofessionals.
  • Plan publicity efforts associated with start-up of activity or efforts.
  • Attend meetings to provide updates on progress of the effort.
  • Conduct consumer interviews to identify service gaps, improve existing services and identify key places to post information.
  • Begin searches for additional resources and potential funding.
  • Begin some basic evaluation efforts.
• Stabilization. Now that efforts and programs are in place, it’s necessary to stabilize them so as to maintain the overall community effort.
  • Plan community events to maintain support for the issue.
  • Conduct training for community professionals.
  • Conduct training for community members.Introduce your program evaluation through training and newspaper articles.
  • Conduct quarterly meetings to review progress, modify strategies.
  • Hold recognition events for local supporters or volunteers.
  • Prepare and submit newspaper articles detailing progress and future plans.
  • Begin networking among service providers and community systems.
• Confirmation / Expansion. Once services are stabilized, the task is to expand and enhance them.
  • Formalize the networking with qualified service agreements.
  • Prepare a community risk assessment profile.
  • Publish a localized program services directory.
  • Maintain a comprehensive database available to the public.
  • Develop a local speaker’s bureau.Initiate policy change through support of local city officials.
  • Conduct media outreach on specific data trends related to the issue.
  • Utilize evaluation data to modify efforts.
• High Level of Community Ownership. Once the community reaches the highest level, the trick is to maintain the momentum and continue growth. You’re not done – the effort has to be sustained. At this level, community members have ownership of the efforts and will invest themselves in maintaining the efforts.
  • Maintain local business community support and solicit financial support from them.
  • Diversify funding resources.
  • Continue more advanced training of professionals and paraprofessionals.
  • Continue re-assessment of issue and progress made.
  • Utilize external evaluation and use feedback for program modification.
  • Track outcome data for use with future grant requests.
  • Continue progress reports for benefit of community leaders and local sponsorship. 

In Summary

Understanding community readiness – how ready a community is to address a particular issue – is an important tool for anyone concerned with health and community development. A community can’t be convinced to approach an issue until it realizes that the issue exists, and furthermore, that it affects the community. A community can’t be forced into action it is not ready for, or that goes against what most of its members believe.

The Tri-Ethnic Center’s community readiness model analyzes community readiness in a way that makes it possible to pinpoint a community’s level of readiness. Community builders can then use that readiness information to devise strategies for addressing the issue at hand that the community will support, and that will at the same time help the community reach the next level of readiness.

The community readiness model provides an accessible and relatively fast way of assessing a community’s level of readiness on a given issue. Its assessment tool can be used and scored by community members with a minimum of training, allowing the community both to save the funds often spent on outside experts and to take responsibility for solving its own problems, using its own expertise and assets. With that responsibility comes a sense of ownership and pride that, along with steady progress up the readiness ladder, is likely to make community efforts successful.

Community readiness can be described by nine different levels:

1. No Awareness. The issue is not generally recognized by the community or leaders as a problem (or it may truly not be an issue).

• Assessing Community Needs and Resources                           
• Assessing Community Needs & Resources
• Developing a Plan for Identifying Local Needs and Resources
• Understanding and Describing the Community
• Collecting Information About the Problem
• Analyzing Community Problems

2. Denial/Resistance. At least some community members recognize that it is a concern, but there is little recognition that it might be occurring locally

• Analyzing Problems and Goals
• Analyzing Community Problems and Solutions
• Defining and Analyzing the Problem
• Analyzing Root Causes of Problems: The "But Why?" Technique
• Responding to Counterattacks
• How to Respond to Opposition Tactics
• Getting Issues on Public Agenda
• Communicating Information about Community Health and Development Issues

3. Vague Awareness. Most feel that there is a local concern, but there is no immediate motivation to do anything about it.

• Increasing Participation and Membership
• Encouraging Involvement in Community Work
• Developing a Plan for Increasing Participation in Community Action
• Promoting Participation Among Diverse Groups
• Involving Key Influentials in the Initiative
• Involving People Most Affected by the Problem
• Recruiting and Training Volunteers
• Developing a Plan for Involving Volunteers
• Core Functions in Leadership
• Building and Sustaining Commitment
• Deciding Where to Start
• Identifying Targets and Agents of Change: who Can Benefit and Who Can Help

4. Preplanning. There is clear recognition that something must be done, and there may even be a group addressing it. However, efforts are not focused or detailed

• Developing a Framework or Model of Change
• Developing a Strategic Plan
• Proclaiming Your Dream: Developing Vision and Mission Statements
• Creating Objectives
• Developing Successful Strategies: Planning to Win
• Analyzing Community Problems and Solutions
• Generating and Choosing Solutions
• Choosing and Adapting Community Interventions
• Understanding Risk and Protective Factors: Their Use in Selecting Potential Targets and Promising Strategies for Interventions
• Introduction to Evaluation
• A Framework for Program Evaluation: A Gateway for Tools
• Choosing Evaluators
• Developing an Evaluation Plan
• Some Methods for Evaluating Comprehensive Community Initiatives
• Behavioral Surveys
• Gathering and Using Community-Level Indicators

5. Preparation. Active leaders begin planning in earnest. The community offers modest support of their efforts.

• Developing Strategic and Action Plans
• Analyzing Problems and Goals
• Developing a Framework or Model of Change
• Developing an Intervention
• Our Model for Community Change and Improvement
• Our Model of Practice: Building Capacity for Community and System Change
• Getting Issues on Public Agenda
• Gaining Public Support for Addressing Community Health and Development Issues
• Choosing Strategies to Promote Community Health and Development
• Strategies for Community Change and Improvement: An Overview
• Encouraging Involvement in Community Work
• Involving Key Influentials in the Initiative
• Developing a Strategic Plan
• Creating Objectives
• Developing Successful Strategies: Planning to Win
• Developing an Action Plan
• Identifying Action Steps in Bringing About Community and System Change
• Deciding Where to Start
• Designing Community Interventions

6. Initiation.  Enough information is available to justify efforts. Activities are underway.

• Increasing Participation and Membership
• Enhancing Cultural Competence
• Advocating for Change
• Influencing Policy Development Toolkit: Implementing a Social Marketing Effort
• Our Model for Community Change and Improvement
• Some Lessons Learned on Community Organization and Change
• Choosing Strategies to Promote Community Health and Development
• Systems Advocacy and Community Organizing
• Coalition Building I: Starting a Coalition
• Developing a Strategic Plan
• Developing an Action Plan
• Developing an Organizational Structure for the Initiative
• Creating and Gathering a Group to Guide Your Initiative
• Hiring & Training Key Staff of Community Organizations
• Developing a Plan for Staff Hiring and Training
• Developing Training Programs for Staff
• Recruiting & Training Volunteers
• Developing a Plan for Involving Volunteers
• Recruiting Volunteers
• Developing Training Programs for Volunteers
• Providing Training and Technical Assistance
• Designing a Training Session
• Orienting Ideas in Leadership
• Developing a Plan for Building Leadership
• Core Functions in Leadership
• Learning How to be a Community Leader
• Discovering and Creating Possibilities
• Understanding People’s Needs
• Building and Sustaining Commitment
• Influencing People
• Building and Sustaining Relationships
• Becoming an Effective Manager
• Developing a Management Plan
• Analyzing Community Problems and Solutions
• Putting Your Solution into Practice
• Working Together for Racial Justice and Inclusion
• Building Relationships with People from Different Cultures
• Principles of Advocacy
• Recognizing Allies
• Encouraging Involvement of Potential Opponents as well as Allies
• Getting Grants and Financial Resources
• Developing a Plan for Financial Sustainability
• Social Marketing of Successful Components of the Initiative
• Conducting a Social Marketing Campaign
• Promoting Awareness and Interest Through Communication

7. Stabilization.  Activities are supported by administrators or community decision-makers. Staff are trained and experienced.

• Increasing Participation and Membership Toolkit: Enhancing Cultural Competence
• Influencing Policy Development Toolkit: Evaluating the InitiativeChapter12
• Providing Training and Technical Assistance
• Delivering a Training Session
• Conducting a Workshop
• Providing Information and Enhancing Skills
• Training for Conflict Resolution
• Establishing Youth Organizations
• Developing a Speaker's Bureau
• Enhancing Support, Incentives, and Resources
• Creating and Facilitating Peer Support Groups
• Improving Services
• Promoting Coordination, Cooperative Agreements, and Collaborative Agreements Among Agencies
• Developing Multisector Collaborations
• Developing and Increasing Access to Health and Community Services
• Changing Policies
• Changing Policies: An Overview
• Using Tax Incentives to Support Community Health and Development
• Changing Policies to Increase Funding for Community Health and Development Initiatives
• Changing the Physical and Social Environment
• Promoting Neighborhood Action
• Working Together for Racial Justice and Inclusion
• Learning to be an Ally for People from Diverse Groups and Backgrounds
• Creating Opportunities for Members of Groups to Identify Their Similarities, Differences, and Assets
• Building Culturally Competent Organizations
• Transforming Conflicts in Diverse Communities
• Working with the Media
• Creating News Stories the Media Wants
• Changing the Media's Perspective on Community Issues
• Responding to Counterattacks
• Overview of Opposition Tactics: Recognizing the Ten D's
• How to Respond to Opposition Tactics

8. Confirmation/Expansion. Efforts are in place. Community members feel comfortable using services, and they support expansions. Local data are regularly obtained.

• Evaluating the Initiative
• Applying for Grants
• Improving Organizational Management and Development
• Sustaining the Work or Initiative
• Getting Issues on Public Agenda
• Talking About Risk and Protective Factors Related to Community Issues
• Introduction to Evaluation
• A Framework for Program Evaluation: A Gateway for Tools
• Choosing Evaluators
• Developing an Evaluation Plan
• Some Methods for Evaluating Comprehensive Community Initiatives
• Measuring Success: Evaluating Comprehensive Community Health Initiatives
• Rating Member Satisfaction
• Constituent Survey of Outcomes: Ratings of Importance
• Reaching Your Goals: The Goal Attainment Report
• Conducting Interviews with Key Participants to Analyze Critical Events
• Gathering and Using Community-Level Indicators
• Using Evaluation to Understand and Improve the Initiative
• Providing Feedback to Improve the Initiative
• Communicating Information to Funders for Support and Accountability

9. High Level of Community Ownership

Detailed and sophisticated knowledge exists about prevalence, causes, and consequences. Effective evaluation guides new directions. The model is applied to other issues.

• Sustaining the Work or Initiative
• Improving Organizational Management and Development
• Applying for Grants
• Developing a Strategic Plan
• Developing Successful Strategies: Planning to Win
• Maintaining Quality Performance
• Achieving and Maintaining Quality Performance
• Obtaining and Using Feedback from Participants
• Rewarding Accomplishments
• Arranging Celebrations
• Providing Incentives for Staff and Volunteers
• Getting Grants and Financial Resources
• Developing a Plan for Financial Sustainability
• Creating a Business Plan
• Applying for a Grant: The General Approach
• Writing a Grant
• Managing Finances
• Planning and Writing an Annual Budget
• Investing in Community Resources
• Establishing Micro-grant Programs
• Planning for Long-Term Institutionalization
• Planning for the Institutionalization of an Initiative
• Strategies for Sustaining the Initiative

What is community readiness?

___Community readiness is the degree to which a community is ready to take action on an issue.

Community readiness is:

___Issue-specific.

___Measurable.

___Measurable across multiple dimensions.

___Variable across dimensions.

___Variable across different segments of the community.

___Able to be increased successfully.

___Is essential knowledge for addressing an issue.

What is the community readiness model?

___The community readiness model has six dimensions and nine levels.

Dimensions of community readiness:

___Community efforts.

___Community knowledge of the efforts.

___Leadership.

___Community climate.

___Community knowledge about the issue.

___Resources related to the issue.

Levels of community readiness:

___No awareness.

___Denial/Resistance.

___Vague awareness.

___Pre-planning.

___Preparation.

___Initiation.

___Stabilization.

___Confirmation/Expansion.

___High level of community ownership.

Why use the community readiness model?

___It conserves valuable resources (time, money, people) by guiding the selection of strategies that are most likely to be successful.

___It is an efficient, inexpensive, and easy-to-use tool.

___It promotes community recognition and ownership of the issue.

___Because of strong community ownership, it helps to assure that strategies are culturally congruent and sustainable.

___It encourages the use of local experts and resources instead of reliance on outside experts and resources.

___The process of community change can be complex and challenging, but the model breaks down the process into a series of manageable steps.

___It creates a community vision for healthy change

When should you use the community readiness model?

___In the course of an ongoing effort.

___Each time you tackle a new issue.

___When several different communities, or different segments of the community, are involved.

___When you’re planning an effort that involves a participatory process.

___When you’re engaged in a community or neighborhood planning effort.

Who should be involved in using the community readiness model?

___Who should consider using the model and/or administering the assessment?

• Policymakers and planners.
• Community activists.
• Health and human service organizations.
• Coalitions.
• Anyone else interested in community or social change.

___Who should be surveyed when the model is being applied?

• Schools/Universities
• Municipal/county/tribal government
• Law enforcement
• Health & medical professions
• Social services
• Mental health & treatment services
• Clergy or spiritual community
• Community at large
• Youth
• People on fixed incomes

How do you use the community readiness model?

Administering and scoring the community readiness assessment:

___Choose and train interviewers.

___Choose and train scorers.

___Revise the assessment tool, if necessary, to reflect the issue you’re concerned with.

___Select four to ten people to interview.

___Contact the people you have identified and see if they would be willing to discuss the issue.

___Conduct your interviews.

___Score the interviews.

Using community readiness information:

___Initiate a participatory planning process, if possible.

___To move ahead, readiness on all dimensions must be at about the same level.

___Begin with strategies appropriate to the community’s stage of readiness.

___Stick to it – the job’s never really done.

Example #1 - Preventing Suicide in Native Alaskan Communities

After hearing about the model at a conference, a Native Alaskan woman came to the Center seeking help. In her village of 600 people, there had been 18 suicides in the previous six months. She requested that the team go to her community and help them to use the Community Readiness Model. Because of the urgency of the situation, and with the financial support of the Colorado Injury Control Research Center at Colorado State University, Tri-Ethnic Center staff members traveled to the remote village. The staff were expecting no more than 15-20 people from the village to attend, but were very moved when they were greeted by almost 100 Native people, young and old, from six different villages. Many people had overcome great challenges to come to the meeting. Between villages, there are no roads, and the only way in is by flying in small airplanes or by barging down the river if it isn’t frozen. Once visitors arrive, there are no hotels, so visitors must find a family that is willing to take them in. Despite these difficulties, people found a way to be there.

Initially, community members spoke of their grief and helplessness in the face of the pain of their losses. The model was presented, and participants divided into village groups. The members of each group used the model to assess their village’s stage of readiness and to identify their strengths and resources. An outsider might think that these small villages had very little in the way of resources (no clinics, shelters, etc.). But the village groups recognized many resources – human resources to cultural resources. They later talked about how grateful they were to rediscover those strengths because they had forgotten them in their grief, or because they hadn’t really recognized them as strengths.

Community members offered their time, their creativity, and their knowledge of the culture. The youth formed their own group to develop strategies to offer support to friends in school. Elders lined the outer walls of the community center. Most couldn’t hear what was going on and some were blind, yet they stayed from eight in the morning until eleven at night to offer their support. At the conclusion, the groups from each village summarized the strategies they had developed. Finally, the entire group formed a circle and again, using the model, worked together to brainstorm an action plan to maintain inter-village communication and support.

They indicated that for the first time in a long time, the communities felt hope and empowerment. A woman from the state office who had attended the gathering was so impressed by the efforts that she offered each of the six villages $2,000 to begin working on their strategies. Another woman donated her 80 acres of allotment land for a treatment center. The group was so motivated that they were able to move from a lower to a higher stage of readiness in only two days. The villages continue to work toward their goals, and their strategies have been remarkably successful. From having experienced 18 suicides in a six-month period before the training, they did not lose a single person to suicide in the three years following the training and the suicide rate has continued to be very low.

Example #2 - Tai Chi in the Parks

This section was developed by combining portions of participatory evaluation materials provided by the Area of Sustainable Development and Environmental Health of the Pan American Health Organization.

Background

The “Tai Chi in the Parks” initiative was implemented in the 1990s as a public health strategy in the municipality of Miraflores in Lima, Peru. Today, the “Tai Chi in the Parks” Association is responsible for the maintenance, improvement and advancement of the initiative along with Tai Chi Clubs and more than 20,000 elderly people who practice Tai Chi in the municipality.

The mission of the “Tai Chi in the Parks” program was to transform Miraflores into the municipality with the healthiest and most active elderly population in Peru, thereby, promoting healthy aging of the population.

The initiative’s main objectives were to:

• Incorporate the practice of Tai Chi and its philosophy as a daily, voluntary and accessible habit in the life of Miraflores’ elderly population.
• Achieve physical, psychological, social and spiritual development of Miraflores’ elderly population through the practice of Tai Chi.

To reach its objectives, the program aimed to achieve the following goals:

•  Increase the number of elders practicing Tai Chi up to 25,000.
• Multiply the effects of the initiative in other parks and share the experience with other municipalities.
• Maintain support by the Ministry of Health and the Peruvian Sports Institute.
• Secure financing to expand the program to Lima’s underserved communities.
• Disseminate program results among health workers to improve collaboration in the construction of a primary care system for the elderly based on health promotion.

Activities of the Tai Chi in the Parks initiative include:

• Tai Chi classes offered weekdays in various parks in Miraflores.
• Support the formation of Tai Chi clubs, which are informal Tai Chi groups, and the development of a “Tai Chi in the Parks” network.
• Organize gatherings such as the “Tai Chi Convention” organized by the Peruvian Sports Institute.
• Promote community activities such as festivals, Tai Chi championships, conferences, etc., jointly organized by the Miraflores municipality and the Peruvian Sports Institute.
• Train community elderly to become Tai Chi instructors and therefore increase human resources necessary to expand the program.
• Hold capacity-building workshops with other municipalities to share the experience.
• Prepare and publish promotional material.

Preparation

After years of implementing the Tai Chi in the Parks Initiative, partners decided it was time to engage in a participatory evaluation process. An Evaluation Subcommittee was formed with 15 members that represented the following sectors and institutions

• Tai Chi in the Parks Association
• Tai Chi in the Parks Network
• Peruvian Federation of Kung Fu
• Peruvian Sports Institute
• Miraflores’ Health Department
• Local universities
• Mayor’s office
• Miraflores’ Elderly Program
• Ministry of Health and Ministry of Women and Social Development
• NGO EsSalud
• Tai Chi Clubs formed by elderly who practice Tai Chi
• PAHO/WHO
• Network of groups working on elderly health in Miraflores

By engaging in the preparation process, the group was able to identify potential problems for their joint work, as well as facilitating factors.

Potential barriers included:

•     Different interests and agendas from each of the institutions and sectors represented.
•     Lack of coordination of sectors and activities
•     Lack of public policies geared toward the elderly

Among the factors facilitating the group’s work, the following were identified:

•     Existence of a “House of the Elderly” that belongs to the municipality and that offered its premises for the meetings of the group.
•     The presence of representatives from the program’s users.
•     Commitment to community participation by local authorities.
•     Presence of Tai Chi instructors that enjoyed great acceptability by the community.

Defining Evaluation Questions in Miraflores

The main interest of the Evaluation Subcommittee was to understand what influence the initiative had on the wellbeing of Miraflores’ elderly population.  This interest was based on the fact that the Tai Chi in the Parks Program had a positive unexpected outcome: it had become one of the most popular physical exercise and social interaction programs in the municipality and, as a result, it had been implemented in another 15 municipalities through the Peruvian Sports Institute. After discussion, the Evaluation Subcommittee came up with the following evaluation questions:

•  What has been the contribution of each stakeholder sector
•   What factors have facilitated or hindered the participation of each sector (i.e. competing interests; creation of Tai Chi clubs managed by program users, etc.)?
•   What is the impact of the Tai Chi in the Parks program on:
•   Promoting social integration of the elderly?
•   Improving the health of the elderly population?

Evaluation Questions selected in Miraflores

The Miraflores’ Evaluation Subcommittee decided to focus its efforts on answering the following evaluation questions:

What is the impact of the Tai Chi in the Parks program on:

•     Promoting social integration of the elderly?
•     Improving the health of the elderly population?

Documenting Information

To document health improvements among those participating in the Tai Chi in the Parks program, the Evaluation Subcommittee will use various sources of information.  For example, it will interview participants (participants are the source of this information) and review program attendance sheets (sheets are the source of information).

• Qualitative information helps to understand the meaning of an initiative and its effects from the community’s standpoint (i.e. the community feels that the initiative is improving its quality of life).
• Qualitative information can provide rich descriptions about activities, context and behaviors and are usually collected by reviewing documents, observations, and interviews.
• It can also be expressed in numbers or quantified.  For example, interview responses can be added up to report how many people responded in a certain way, for example, how many participants reported feeling healthier after enrolling in the Tai Chi program.
• Similarly, an observer can report how many people out of a group engaged in a particular behavior, for example, how many people who were present at the Tai Chi classes actually performed the exercises as opposed to just observing his or her classmates doing the exercises.
• Quantitative information is measured and expressed with amounts or quantities (i.e. attendance records of elderly participating in Tai Chi classes, number of participants who were trained to be Tai Chi instructors, etc.)

Interpret Results

The Evaluation Subcommittee wanted to know if the elderly population of Miraflores had been empowered through participation in the Tai Chi in the Parks Program. In order to find out, they interviewed program participants, their family members, Tai Chi instructors, and members of the municipality’s Elderly Program.  They also observed the Tai Chi classes and meetings of the Miraflores Elderly Program.

The results showed that:

• A large number of elderly people, who had a low level of physical activity before the program, reported they are now exercising and are physically active.
• Many are actively involved in Tai Chi clubs and are in training to become Tai Chi instructors themselves.
• Family members report the elderly are more assertive and less dependent on them to care for their daily needs.
• Some program participants have joined committees that implement programs for the elderly in Miraflores.
• However, even though they are physically present at the meetings of the Miraflores Elderly Program they rarely participate or express their opinions.

Questions Asked Based on Results

• What do these results mean?
• How can the Evaluation Subcommittee interpret this data?
• What do these results say about goal of ‘empowering elderly people’ through the practice of Tai Chi?

Defining Audiences

The Evaluation Subcommittee decided that the results demonstrating the benefits of the Tai Chi in the Parks Program should be disseminated to various groups in order to encourage more elderly to join the Program and bring new partners into the process.  Audiences included the elderly, with a focus on men and low-income groups; their family members, neighbourhood networks and associations; Tai Chi instructors; health professionals; municipal staff; NGOs and funders.

Defining key messages to target audiences

One of the target audiences for the evaluation results was the elderly population of Miraflores. The goal of sharing the evaluation results with this group was to promote the idea of Tai Chi as a health promotion strategy and to encourage more people to participate in the program, particularly men and those with low-income.

Some of the key messages developed for this communication strategy included:

• Tai Chi is the exercise most practiced by Lima’s elderly population.
• The practice of Tai Chi can help you better manage your blood pressure, prevent depression and improve your health in general.
• (for men) Tai Chi is closely related to martial arts and is a very popular sport among Asian men.
• (for low-income populations) Tai Chi can be practiced by everyone since it does not require special equipment and it does not cost anything.

The results of the evaluation were presented, and the focus was put on the evaluation committee collaboration: what it achieved, how it worked, what were the constraints and the possibilities of such strategy, etc.

Action Based on Evaluation Results

Evaluation question:  What is the impact of the Tai Chi in the Parks Program in improving the health of Miraflores’ elderly population?

Information collected: The information collected shows that the practice of Tai Chi could improve health:  participants showed lower blood pressure and decreased levels of depression after one year of practice.  However, the majority of the participants were women from mid to high income levels.

Interpretation: The initiative was successful in improving health in the elderly population, however it reached more women and those in the mid to higher-income sections of the population.

Recommendation: Expand the initiative but review efforts to encourage men and low-income people to join the program. Action:

• Schedule a meeting of the evaluation committee and organizations working in low-income areas of the municipality to discuss how to better promote the initiative.
• Incorporate Kung Fu and other martial arts demonstrations into presentations given by the Tai Chi clubs to encourage more men to join the program.
• Prepare and distribute a report to health centers, NGOs and institutions working on issues related to elderly health.

Tool 1: IPFS Tri-Ethnic Community Readiness Assessment Process

The Tri-Ethnic Community Readiness Assessment (.docx), developed by the Van Buren County Safe Coalition, is a meticulously structured process designed to evaluate a community's preparedness to tackle specific issues, particularly underage and binge drinking among youth. The primary objective is to align interventions with the community's current level of readiness, ensuring their effectiveness.

This assessment utilizes survey interviews conducted with at least six individuals, each representing diverse community sectors such as education, law enforcement, healthcare, clergy, and youth. This comprehensive approach guarantees that a variety of perspectives are taken into account.

The survey comprises questions that span six dimensions: Knowledge of the Issue, Community Efforts, Community Knowledge of Efforts, Leadership, Community Climate, and Resources for Prevention. The scores from the interviews and dimensions are averaged to ascertain the community's overall readiness stage, which ranges from 1 (No Awareness) to 9 (High Level of Community Ownership).

A PowerPoint presentation summarizing the major points in the section.

Nearly every community – large or small, urban, suburban, or rural – must cope, to some extent, with the substance use disorder of alcohol, tobacco, and other drugs. Most communities try to combat this problem, and some are reasonably successful. Others find themselves doing everything they can think of, and barely staying even, or – worse – losing ground.

The difference is sometimes in the way they approach the problem.Those that are most successful often try to prevent the problem from starting. They focus on the community as a whole, and try to devise ways to help the community members who are experiencing increased risk – typically youth – to avoid the behaviors or situations that would put them in harm’s way. Although they don’t ignore law enforcement, medical treatment, policy decisions, public education, or other actions necessary to address the problem as it already exists, these successful communities try to reduce substance use permanently by taking a long-term perspective.

Most of the models we’ve described in this chapter look to both the present – addressing a current issue – and the future. In this section, we examine another that does the same – the Strategic Prevention Framework developed by CSAP, the Center for Substance Abuse Prevention, part of the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services.

What is the Strategic Prevention Framework?

The Strategic Prevention Framework (SPF) outlines a process that an organization, initiative, community, or state can follow in order to prevent and reduce the substance use disorder of alcohol, tobacco, and drugs.

This framework can also be applied to other community issues, such as violence, health-related problems (obesity, heart health, diabetes, HIV), homelessness, or racial tensions and discrimination. By the same token, while SPF focuses primarily on youth, there is no reason that the model can’t be adapted to any population group.

The framework addresses both risk and protective factors. Risk factors are those elements within an individual or her environment that make her more susceptible to particular negative behaviors or conditions. Protective factors are the opposite – those elements within an individual or his environment that make him less susceptible to those negative behaviors or conditions.

Risk and protective factors vary, depending on the issues they relate to. Some examples of risk factors for alcohol use disorder, for instance, include:

• The availability of alcohol in the community (number of liquor stores, willingness of adults to buy alcohol for teens).
• Community norms that tolerate and expect alcohol use among youth and adults.

Acceptance of alcohol use disorder may include such elements as the acceptance of binge drinking on weekends as a “stress reliever;” parties where large quantities of alcohol is consumed as a norm; and alcohol availability at public events – festivals, concerts, etc. This kind of tolerance is not confined to low-income or working-class communities. In many upper-class communities, at least until 20 or so years ago, large amounts of alcohol were consumed at dinners, weddings, etc., with the assumption that guests – many of them underage, and most at least slightly drunk – would then drive themselves home.

• Poverty and lack of economic opportunity for young people.
• A family history of alcohol use disorder.
• An early start – preteen or young teen – in alcohol use.

Some examples of protective factors for the same behavior:

• Close family ties.
• Good communication between children and parents.
• Peer support for avoiding alcohol use disorder.
• Being female.
• Consistent community and family values that oppose alcohol use disorder.

The Strategic Protection Framework addresses risk and protective factors with a five-phase process. 

The Community Tool Box has hundreds of how-to resources that can be used to help implement the Strategic Prevention Framework in your community. Some links to related toolkits are provided beneath each of the SPF phases below. 

Assessment

To begin, a working group is assembled that includes representatives of all stakeholders (those who will be affected, directly or indirectly, by the prevention effort) to survey the community and decide on the most pressing issue that can be successfully addressed with the resources available. Assessment consists of three elements:

• Identifying and understanding the population’s needs.
• Determining necessary resources and their availability.
• Assessing community readiness.

Related Toolkits:

2. Assessing Community Needs and Resources

3. Analyzing Problems and Goals

Capacity development

Developing the community’s capacity to engage in a prevention effort involves mobilizing the human, organizational, and financial resources necessary, and then providing the appropriate training and technical assistance so that the community has the knowledge and skills to plan and do the work.

Related Toolkits:

1. Creating and Maintaining Partnerships

6. Building Leadership

8. Increasing Participation and Membership

15. Improving Organizational Management a Development

Planning

In this phase, a diverse group of stakeholders creates a plan with goals, objectives, and action strategies aimed at meeting the needs of the community. In the course of planning, the group adopts a logic model or framework for action; chooses from among a number of possible evidence-based “best practices;” and determines the costs and other resources that will be needed to implement the plan successfully.

Related Toolkits:

4. Developing a Framework or Model of Change

5. Developing Strategic and Action Plans

Implementation

The plan is carried out.

Related Toolkits:

7. Developing an Intervention

10. Advocating for Change

11. Influencing Policy Development

13. Implementing a Social Marketing Effort

Evaluation

Although listed as the last phase, this actually goes on throughout the process. The program is evaluated in terms of process (Did you actually carry out what you planned to do in the way and time period you planned?), impact (Did your program have the intended effect on the targeted risk and protective factors?), and outcome (Did the program achieve its overall community-change goals?). The results of the evaluation are then used to adjust the program to make it more effective, and the cycle begins again.

Related Toolkits:

12. Evaluating the Initiative

Sustainability and Cultural Competence. 

At the heart of the model.

Related Toolkits:

16. Sustaining the Work or Initiative

14. Writing a Grant Application for Funding

9. Enhancing Cultural Competence

Why use the Strategic Prevention Framework?

Given that there are a large number of models available, what are the advantages of using SPF?

• SPF is inclusive and participatory. The framework involves the representation of all stakeholders in the process from the very beginning, including the group the effort is aimed at. This leads to community ownership of the prevention program, which in turn leads to community participation and support, both major factors in its potential for success.
• SPF emphasizes the role of the community in prevention. A cornerstone of the framework’s philosophical base is that prevention only works when the whole community supports it, and when the real needs of the community are taken into account. This agrees with the WHO/Healthy Communities conception that health is a community issue, regardless of who is affected by a particular condition, and that successful health promotion efforts must take a community perspective.
• SPF is open-ended, and encourages communities to find their own solutions. SPF doesn’t advocate a set program to approach prevention, only a general process. It provides a broad range of proven options to choose from, and encourages communities to develop their own variations where appropriate, thus empowering them to solve their own problems and develop their own assets for the future.
• SPF aims to create long-term social change by focusing on risk and protective factors that can be influenced by short- or medium-term prevention efforts. The emphasis on risk and protective factors both makes prevention manageable and makes it seem more manageable. The fact that it doesn’t seem overwhelming makes communities more likely to keep at it and be successful.
• SPF provides communities with proven, evidence-based models to choose from. Rather than prescribe a particular program, SPF provides resources to help communities find best practices that suit their own needs.
• SPF has associated technical assistance and links to other practitioners and programs. Through its website, CSAP links communities and prevention programs to a great number of online resources from a variety of sources. In particular, we refer you to the Community Tool Box supports for Strategic Prevention Framework founding in Tool #1 of this section. Other resources include the CSAP Prevention Platform, a set of program development, implementation, and evaluation tools, the CSAP and SAMSHA websites and other best practices.
• SPF’s focus on risk and protective factors can improve the long-term well-being of the community. Over and above their influence on the issue at hand, most risk and protective factors are general as well. Such protective factors for youth, for instance, as parent-child communication, attachment to the community, self-respect, and high expectations are likely to lead not only to a reduction in dangerous and self-destructive behavior, but to young people themselves developing into better parents and citizens, and becoming role models for the next generation.

There is a fine line between prevention of a negative condition (e.g., substance use) and promotion of a positive one (e.g., a healthy lifestyle.) A well-run prevention program that focuses on eliminating risk factors and strengthening protective factors can turn into a promotion program that encourages citizens to take positive steps to make their lives as healthy and fulfilling as possible.

Potential disadvantages to using SPF

• Limited resources. It should be noted that, while CSAP makes grants to states and communities, those grants are relatively few. States distribute much of their funding to communities, but grants are competitive, and it may be difficult, particularly for communities with few resources, to obtain the funds that might increase those resources. Those who are interested in implementing SPF on their own can expect a certain amount of technical assistance and guidance from the CSAP and SAMHSA websites, but little else. For those that lack resources, this may not be enough to make it possible to use the framework.

SAMHSA/CSAP awards grants to states under the SIG (State Initiative Grant) program; to community coalitions under the Drug Free Communities Support Program; and to community organizations to prevent the spread of methamphetamine use. In addition, SAMHSA awards grants to a variety of organizations, institutions, and agencies for the prevention and treatment of substance use for those with HIV/AIDS. While the total amount of these grants is relatively large, the number of recipients is still quite small, and most are large organizations and institutions. States may distribute their SIG’s to smaller organizations in communities, but the amount of money available is still relatively modest, and not all states have these grants.

• Insistence on the faithful implementation of evidence-based programs. While it certainly makes sense to use proven practices, rather than trying to reinvent the wheel, it is also important to understand that even the best programs don’t necessarily work everywhere, and that all parts of a given program may not be appropriate in a particular situation. An insistence on following program implementation guidelines exactly can ignore the knowledge of the community that may be a local organization’s greatest asset.
• A large administrative load. Reporting requirements on CSAP and SAMHSA grants are considerable, and cover every aspect of the development, implementation, and evaluation of the prevention effort. For many small community-based organizations with limited staff, this requirement may make it impossible to compete for grants.

These disadvantages largely apply to those who seek CSAP grants to implement SPF, either through state funds, or directly from CSAP. For those who simply want to use the framework, CSAP does provide access to a large amount of information, and can make it possible to put together an effective prevention program using local resources. In that case, having to contend with the potential problems raised by points 2 and 3 is not an issue.

When should you use the Strategic Prevention Framework?

Prevention, in the ideal, means just that. The best time to start a prevention program is before there’s a serious problem. In fact, with its emphasis on risk and protective factors, particularly for youth, the framework could act as prevention for nearly any undesirable issue, as well as promotion of healthy behaviors and environments. In that respect, it’s similar to asset development.

The reality in most communities, however, is that given the problems that already exist, most issues don’t get addressed until they reach crisis proportions, or at least become cemented in the public consciousness. Thus, the best time to embark on a strategic prevention initiative may be when the community is ready to turn its attention in that direction.

You can often hurry this process along by assessing where the community is at, and beginning a campaign to raise that readiness to the next step, or whatever step is necessary for the community to get on board with a prevention plan. The first part of a prevention initiative may in fact be an effort to increase community readiness. You may not begin to devise and implement a prevention program for a while, but the readiness development is all part of the same effort.

With that said, there are times when SPF might be particularly appropriate and possible:

• When resources are available. Some of those resources may come from CSAP, in the form of grants and technical assistance. Others may come from the community itself, and consist of people with successful prevention experience, local sponsorship for prevention efforts, funding from community foundations or municipal agencies, media support, etc.
• When a community problem has entered the public consciousness, but before it has reached crisis stage. The ideal time to begin a prevention effort is before the problem has become so large that prevention may take a back seat to dealing with its immediate effects, but after people have become aware that it could get considerably worse without some intervention. It’s a good time to persuade the community that a prevention program can help to create a future where the issue at hand simply isn’t an issue at all.
• When a community problem has reached the crisis stage. In this situation, prevention, as implied above, may be harder to sell. If prevention isn’t part of the solution, however, the problem will persist. It’s important to convince the community that a prevention effort is vital to its long-term health.
• When there’s public focus on a population experiencing increased risk, particularly youth. The best way to reduce the risk for any population, and particularly for youth, who are still unformed in many ways, is to keep them from embarking on high-risk behavior. Working with young children and their families, for instance, can have its effects not only when those children become adolescents, but – more profoundly – when they become parents themselves. If the public understands that, prevention can become the mode of choice when addressing a population’s risk and protective factors.
• When there’s a community economic development effort under way, and people are looking at the community’s quality of life. Because SPF has the potential to influence substance use over the long term, it’s an ideal way to approach quality-of-life issues. An ongoing, successful prevention program is a community asset that can be used to attract businesses and their employees to a community.
• When a grassroots movement for community improvement has arisen, and is looking for a way to address community issues. Many groups of this sort are concerned with long-term social change. A prevention effort can be an ideal vehicle to address such change, because it can deal with both the current situation and the next generation. An ongoing substance use prevention program can affect what happens next year, but can have even more serious effects on what happens in 20 years.

Who should use the Strategic Prevention Framework?

As with many of the “Who...?” questions in the Community Tool Box, this one not only has more than one answer, but is, in reality, more than one question.

• Who might implement SPF? The multiple answers here stem both from the way CSAP grants are made and from the fact that SPF is intended to be inclusive and participatory.

CSAP awards several kinds of grants that focus on or include prevention, as mentioned earlier:

• State Incentive Grants (SIGs), which go to states to fund statewide assessments and to be distributed among communities for state-monitored local prevention programs.
• Drug Free Community Support Program grants, which go directly to local community coalitions.
• Grants to state and local organizations, institutions, and agencies to address methamphetamine use.
• Grants to state and local organizations, institutions, and agencies to address substance use among those with HIV/AIDS.

The first answer, then, is that SPF should be implemented by those who administer these grants at the state and local levels. They might be state and local health and human service officials, coalition coordinators, human service providers, universities, hospital and clinic administrators, etc. But, because of the nature of the grants, these folks are only the beginning. They are required to involve all stakeholders from the beginning, and that implies a much broader range of people.

If you take a community perspective on prevention, then stakeholders comprise all sectors of the community, and should be represented in planning, implementing, and evaluating the framework. These include:

• Members of the population(s) experiencing increased risk.
• Medical professionals, particularly those who work directly with populations experiencing increased risk.
• Human service workers.
• Alcohol- and drug-treatment professionals, as well as researchers in the field.
• Law enforcement officials.
• Educators.
• Elected and appointed public officials and policy makers at the appropriate level.
• Parents.
• Youth.
• Older Adults.
• The business community.
• Interested community members.

All or most of these groups would probably be part of the Epidemiological Working Group mandated under the various grants, but should also be part of any SPF effort. As stated constantly in the Community Tool Box, we believe that, in most cases, participatory planning and implementation of programs leads to efforts that both meet real community needs and assure community support.

In addition, there are those who might run SPF programs that aren’t funded by CSAP, but that simply use the framework to structure their work. They are likely to be community-based health or human service organizations, community coalitions, local health departments, or similar groups that engage in prevention efforts either to respond to community needs or as part of a larger local initiative.

• Whom should SPF efforts serve? This question asks both how those efforts should be aimed and who the targets should be. CSAP identifies three kinds of programs: universal, selective, and indicated. Universal programs are geared toward a whole community or part of a community, even though everyone they reach is not necessarily at risk for substance use. Selective programs are intended to reach populations experiencing increased risk: particular populations, neighborhoods, age groups, or cultures. Indicated programs serve referred individuals who have been identified as at high risk for substance use.

A typical universal program might involve community education efforts through the media, schools, and organizations. It might try to explain the effects of alcohol and various other drugs, conduct prevention classes in middle or elementary school, identify risk and protective factors, let people know where they can get more information, and generally raise community consciousness and concern about the issue. It might be aimed at a neighborhood, at the community as a whole, or even at a whole county or state. Who would be served in this case would be everyone the program could reach, in the hope of establishing community norms that work toward prevention, and alerting the community to existing risk factors.

Populations at risk that might be the subjects of a selective program vary from one community to another. Some of the most common:

• Youth, particularly those of middle- and high-school age. This is often the population at highest risk for substance use, for a number of reasons. Adolescents are risk-takers by nature; they tend not to think carefully about the consequences of their actions; and most will do almost anything when encouraged by peers. Adolescence, or just before, is also the typical age for people to start using alcohol, tobacco, and other drugs. If they can be persuaded not to start at all, or to delay until they’re mature enough to understand what they’re doing and what the results might be, the chances of their using and abusing these substances are greatly reduced.

This is not to imply that all adolescents who use alcohol or drugs will become people with substance use disorders. In the U.S., large numbers of adolescents drink – often to excess – and somewhat smaller, but still significant, numbers smoke marijuana. Only a small percentage of these become dependent on these or other substances. That doesn’t change the number of non-dependent teens killed or injured in alcohol- and drug-related motor vehicle or other accidents, or the amount of emotional and property damage they may cause or suffer while under the influence. If all a prevention program does is to convince young people to think for a second before they act, it will have performed an enormous community service.

• Pregnant women. Current medical practice warns pregnant women not to drink at all during pregnancy. Excessive drinking during pregnancy can lead to fetal alcohol syndrome, which produces babies with a number of serious developmental problems, almost always including brain damage and abnormal facial features, and often including growth problems and developmental disabilities. Smoking during pregnancy can be responsible for low birth weight and other problems for the baby, over and above its effects on the mother herself. Although the effects have not been as carefully studied as those of alcohol and tobacco, drug use – particularly of heroin and amphetamines – appears to pose dangers to fetal development as well. An effective prevention program can eliminate a lifetime of difficulty for both mother and child.
• Older Adults. Older people who live alone, far from family and often isolated, may be at risk for alcohol use disorder. As metabolisms change with age, older adults may react differently to medications. They may be overmedicated, or their medications may interact with one another or with alcohol to produce apparent dementia or other symptoms. The amount of alcohol they once drank without problems may now be too much. Worst of all, these issues are seldom raised by health professionals, social workers, and others who work with older people, and may go unrecognized. Prevention programs can raise and address them, and lead to a longer and more productive and satisfying later life.
• People experiencing homelessness. Many people who are homeless struggle with substance use disorders of various kinds. Their substance use is often one of the reasons that they are homeless, and contributes to their difficulty in changing their status. Substance use disorders in people experiencing homelessness population is also often tied to physical and mental health issues leading to the misuse of various medications prescribed for physical and psychological conditions, or self-medication with alcohol or narcotics to dull the emotional or physical pain of mental or physical illness.

Indicated programs focus not on probabilities (populations likely to be at risk, for example), but on specific individuals who are known to be already involved in substance use. Depending on the program, these individuals could be identified and referred by school personnel, parents, the court system, law enforcement, social workers, therapists, or others who have contact with them. In such cases, it would be not only the participants, but those who referred them who are the users of SPF.

How do you use the Strategic Prevention Framework?

As described above, the SPF has five phases. We’ll examine those in more detail here to see how they guide the use of the framework.

SAMHSA/CSAP provides information, instruction, and technical support. There you can find a template for planning your effort; information on such topics as risk and protective factors; and links taking you to lists and descriptions of evidence-based programs and to numerous other helpful sites, including the Community Tool Box.

Phase 1: Assessment. In the assessment phase, you determine community needs and resources, and identify existing risk and protective factors.

• Form an epidemiological workgroup. This group will do the work of assessment. Since the prevention effort takes a community perspective, the workgroup should involve all sectors of the community. Those represented should include:
  • Law Enforcement
  • Education
  • Youth
  • Criminal Justice
  • Civic Organizations
  • Parents
  • Faith-Based Organizations
  • Elderly
  • Business
  • Human Service Providers
  • Health Care
  • Military
  • Colleges and Universities
  • Ethnic Groups
  • Government Agencies
  • Elected and Appointed Officials
  • Child Care Providers

One of the ironies of a prevention effort is that those most affected and damaged by the issue – people with substance use disorders – are those least likely to want to be involved. Perhaps the best way around this, in addition to recruiting workgroup members from the population(s) experiencing increased risk, is to include those recovering from alcohol and drug dependency. They understand the substance use culture from the inside, while being clear on the need to prevent people from joining that culture.

• Assess community needs and assets. The ideal here is to conduct a full community assessment. If the sponsor of the assessment is the municipality (the Mayor’s office, for example), a large institution or organization (a university or a large-city United Way), or a state agency, it will probably have the resources to do that. If it’s a small, community-based organization, or a coalition of such organizations, it may well have to rely on volunteers and on inexpensive techniques, and to focus more narrowly, unless members of the workgroup are able to provide financial and other resources.

In general, some of the questions you might try to answer through a community assessment include:

• How great are the substance use disorders of alcohol, tobacco, and/or other drugs in the community?
• What substances seem to be most available? Most used?
• What are the trends in community substance use and availability?
• Which populations are experiencing increased risk?
• Where (geographically) is the problem most serious?
• Are some substances particularly favored by particular populations, and others by others? Is the same true for geographic areas?
• How early do most users of particular substances begin their use?
• What kinds of prevention efforts and treatment services already exist? How successful are they? How many people can they serve?
• What substances or aspects of substance use pose the biggest problem for the community?

A community assessment of substance use can be conducted using some or all of a number of methods. In general, the more methods of collecting information you use, the better picture you’ll get of the issue in your community. Some basic ways of finding out about community needs and resources:

• Surveys. These may be conducted in person, by phone, by mail, or by e-mail. They can be given to groups or individuals, at random or by selection (population, geographic area, age, etc.) If they’re well-conducted, they can cover various topics, and yield a broad range of answers.
• Interviews. Interviews may be individual or group, structured, semi-structured, or unstructured. They may be conducted in person (usually considered more reliable) or by phone (which may make a larger number possible.)
• Focus groups. A focus group is a specific kind of guided discussion intended to get information on a particular topic from a group. It can be used effectively for assessment, but requires a trained facilitator to draw out the participants and keep them on the topic.

In surveys, and particularly in talking to community members, there may be some people you specifically want to reach. These might be:

• Community leaders – those people from various walks of life whom others look to for leadership and guidance. They may hold leadership official leadership positions in government or institutions, be respected for their professional status or social leadership, or they may simply be known as people of integrity and wisdom.
• The population of interest, or the one experiencing increased risk. Generally, these are the same, although they may not be. You might focus on youth, for instance, even though the worst problems are among adults, in the hope of curbing substance use in the future.
• Those who deal with the population of interest – health and human service workers, teachers, police, youth outreach workers, etc.
• Those affiliated with the population of interest. Parents, extended families, AA and AlAnon groups.
• Policy makers. Legislators and others who determine laws and regulations regarding substance use, as well as those opinion leaders in the community who help to determine attitudes toward it.
• People who’ve done research on the issue in the community. These may be academics, or may be health and human service providers.

• Observation. There are different ways that observation might be used in this kind of community assessment. It could mean walking the streets and noting conditions, watching to see whether young people approach adults to buy alcohol for them outside of liquor stores, noting obvious crack houses, or simply watching interactions in various neighborhoods and parks. Participant observation could mean riding or walking a beat with a police officer, getting to know drug dealers or runners, or actually making a buy. The range really depends on what you’re looking for, and what you and others involved in the assessment are capable of.
• Public records. Much of your work may have been done for you by various federal, state, and local agencies. In the U.S., the Census, conducted in full every ten years, is a treasure trove of demographic and other information. Local agencies, the National Institutes of Health (of which CSAP is a part), the Department of Health and Human Services, state youth service departments – all may have collected information on substance use in your community that’s just waiting for you to look up.
• Assess community readiness. Community readiness is the degree to which a community is ready to take action on an issue. Once you understand your community’s level of readiness, you can plan your effort to start at that level and move the community to the next, and to continue to move the community, a level at a time.

Understanding where the community is and starting from there is incredibly important. People simply won’t do what they’re not ready to. Until community members are aware of the problem and believe it is important, it’s unlikely that you’ll get much of the support needed for a successful prevention effort. Your first tasks in that case may be to get the community to that point, and to involve it in planning. Once community members understand the concept of prevention and see the need for it locally, it’s more than likely they’ll support and participate in your effort.

Tools that identify the dimensions and levels of community readiness have been developed. An instrument for determining community readiness that can be easily applied and scored by community members can be found in Community Readiness, and related Community Tool Box sections that support improving readiness.

• Determine the most pressing need that a prevention effort can influence. There may be many possible areas where prevention is needed – among teens, among older adults, among people experiencing poverty, etc. The questions are where your effort can have an impact, and what you have the resources to do. The substance use problem among a particular population may be more than you have the ability to take on at the beginning. You may want to focus on a more manageable population, or a different issue – alcohol use as opposed to crack, for example – that you can be successful with, and thereby build your capacity to take on something more formidable.

Phase 2: Capacity.

Not only does the community have to be ready to take on a prevention effort, but it has to have the capacity to do so. This includes awareness and knowledge of community substance use disorders; an understanding of how to create, implement, and maintain a prevention program; other community resources that can serve (are serving) to address the issue; widespread community support and participation; and the will to sustain the effort for the long term.

This doesn’t mean that everyone in the community has to understand, support, and be willing to participate in a prevention program, although this may be an ideal. Rather, it implies that there has to be a critical mass of support and knowledge in order to run an effective program.

To build community capacity:

• Start with your core group. The group that conducted the community assessment and others that have been interested in the prevention effort from the beginning constitute a core group. Many or most of them may be willing to remain active in continuing to plan and implement the program. Even if they’re not, they may help to recruit others to participate in the next phases.
• Choose or develop a logic model or theory of practice to guide your effort. A logic model will expand the SPF framework to help you map out exactly how you’ll approach.
• Use what you know about the community’s level of readiness to publicize the issue and encourage participation. Depending on what people in the community are aware of, you may want to draw attention to the issue of substance use, and emphasize its existence and nature in the community. Using the stories of community members recovering from substance use, especially if they’re willing to tell those stories themselves, is a powerful way to emphasize the need for prevention. It’s important to enlist and work with the media here as well.

If the community is already well aware of the problem – you may be able to concentrate on gathering support and volunteers to start planning your program. You may want to form a community advisory board or similar group to represent the effort.

• Expand the network of community members interested in preventing substance use. As the community grows more knowledgeable about substance use, it should be easier to recruit people to help with the prevention effort. You can reach community members through the media, through brochures and bulletin board messages in appropriate places, and – most effectively – through personal contact.

Seek out individuals for either their skills or their enthusiasm, and ask them to do things they’re good at and/or find interesting. You may be able to find volunteers who are experienced in curriculum development, public relations, youth work, filmmaking, and other areas that might benefit the effort. People whose only apparent skill is a willingness to help can network, provide logistical support (stuffing envelopes, scheduling meetings, making phone calls), and help to recruit still others, as well as developing leadership capacity over the long term.

Phase 3: Planning.

The planning phase is at least as important as any other for two reasons: first, it plays out the participatory nature of the effort, thereby gaining both a variety of thinking and community buy-in, if it’s done well; and second, it creates the structure, organization, and content of the actual prevention program, by which that program will rise or fall. As a result, it’s important to go about planning carefully. More time spent on this phase can mean less trouble and greater success over the long run.

• Assemble a planning team. This team might be the same as the assessment team, might include some members of the assessment team and some others, or might be entirely different. It might include members of – or be – the advisory board, if you have one. Whatever the overlap or lack of overlap, team members should represent all sectors of the community. The team’s composition should be as diverse and inclusive as possible, crossing racial, ethnic, class age, gender, and other dividing lines, so that everyone in the community feels that her point of view can be heard.
• Train the planning team. If the planning team is truly inclusive, at least some members of it may never have had experience in meetings or in group problem-solving, let alone in planning a community intervention. Most may have relatively little knowledge about substance use or its prevention, beyond understanding that it’s a local problem that they wish to address. The more training you can provide, the better job the team is likely to do. Some areas where training might be useful include:
  • Generating ground rules for meetings. Respecting everyone, making clear that everyone’s opinions are equally valued, drawing in those whose thoughts haven’t been heard, dealing with ideas rather than personalities, listening carefully to everyone without interruption, keeping an open mind, being willing to compromise, not allowing anyone to dominate, reaching consensus, etc.
  • Problem-solving. Methods of approaching problems in a group, including such techniques as brainstorming, small-group discussions, and role plays.
  • Substance use in the community. This might mean information on the effects and health implications of various widely-abused substances, which substances present the greatest problems, which populations are experiencing increased risk, etc. The results of the community assessment, as well as statistics from various sources, can provide team members with a profile of community substance use, and some ideas about which directions to move in.
  • Risk and protective factors. What they are, how they work, how they can be used in the context of a prevention program, and some examples.
  • Consideration of resources. Many team members might not have thought about figuring the cost of a prevention program into their plans, or that program resources include not only funding, but also volunteer time, community knowledge about the issue, community and media support, local expertise (from professionals, organizations, and institutions), and the willingness of local officials and the community to change bylaws and policy to favor prevention.
  • Evidence-based programs. What constitutes an evidence-based program, how to sort out those that can be reproduced from those that are specific to the situations in which they operate, and how to tinker with such programs to make them more appropriate for a particular community.
• Analyze local risk and protective factors. CSAP recommends hiring a consultant – The KU Center for Community Health and Development or a similar organization – to work with the community on this step, but the reality is that many organizations or communities won’t have the resources for that. Help may be available from a local college or university, or from one or more local organizations or individuals. At least some risk and protective factors may also have been identified in the course of the community assessment, and in evaluating community readiness.

Some organizations place risk factors for adolescent substance use (and other undesirable behaviors as well) in four categories: community, family, school, and individual/peer. CSAP (see Tool # 2) adds a societal domain to these four, encompassing the roles of the national media, the Internet, and the wider culture in forming community and adolescent attitudes and behavior.

Protective factors for CTC reside in individual characteristics, in bonding (with family, particularly, but also with mentors and other significant adults), and in the healthy beliefs and clear standards imposed on adolescents by families and the community.

Developmental assets (similar to protective factors) for children and adolescents can also be divided into external and internal.

External assets are further divided into four categories:

• Support. People significant to the adolescent encourage, help, and respect her.
• Empowerment. The adolescent has the opportunity to exercise responsibility, and to feel in control of important parts of his own life.
• Boundaries and expectations. The adolescent is expected to adhere to clear rules and meet high standards.
• Constructive use of time. The adolescent has opportunities to engage in meaningful and productive activity.

Internal assets are also divided into four categories:

• Commitment to learning. The adolescent understands the value of learning and education, and can apply herself in school and other areas of learning.
• Positive values. The adolescent has developed and internalized a positive value system.
• Social competencies. The adolescent possesses the personal and interpersonal skills to conduct his own life and to engage in positive relationships with others.
• Positive identity. The adolescent sees herself in a positive light, and has good self-esteem.

The goal here is to understand how these factors operate in your community – which are important and which less so, which are most likely to influence substance use among populations at risk.

• Choose the factors you’ll concentrate on. You should select a manageable number of factors – you can’t address everything at once: that will almost undoubtedly doom you to failure by overextending your capabilities and resources and diluting your efforts in any one direction. You should also select factors that you can truly influence, and in a reasonable period of time.

Trying to limit the availability of drugs, for instance, is not just a matter of changing enforcement and/or attitudes in your community. Drugs may be equally available in the next community or neighborhood, or through sources other than those you crack down on. Furthermore, the new sources may be more dangerous to users than the old, both in terms of the drugs they offer and in their potential for violence. You might be able to rid your own neighborhood or community of drugs, but that doesn’t mean you’ve eliminated, or even reduced, their availability.

• Research and choose an evidence-based approach that can be used with the risk and protective factors you’ve settled on. Evidence-based programs are those that have been formally studied using carefully-structured research designs, and have been found to be effective in preventing substance use with the populations they served. Some may have been tested and found to work in different circumstances and with different groups; others may be specific to a given population or situation – a program targeting rural older adults, for instance, or one aimed at urban teens.

Programs you find may also take different forms. We’ve already discussed universal (aimed at the whole community), selective (aimed at a particular populations experiencing increased risk), and indicated (aimed at identified at-risk or substance-involved individuals) programs.  Another way to look at programs is as either individual or environmental.

Individual programs are aimed at helping individuals to develop the knowledge, attitudes, and skills they need to change their undesirable behavior, or to maintain healthy behaviors. Some examples here might be school courses on the chemical and biological effects of alcohol and/or various drugs; parenting programs; smoking cessation groups; and various 12-step and similar programs.

Environmental programs seek to alter the environment to make it easier for people to change or maintain their behavior. These might include policy change (particularly as it relates to regulation of substances and enforcement of laws and regulations regarding substance use disorders); media and other efforts to educate the community about the dangers of substance use (Surgeon General’s warnings on cigarette packs, anti-drunk-driving campaigns); and attempts to change community attitudes and norms.

Effective prevention strategies often include both individual and environmental elements.

CSAP encourages communities to find programs that work specifically for them. At the same time, for programs it funds directly or indirectly, it requires that, once they choose an evidence-based model to implement, they copy that model exactly. There are obvious reasons for this: once a model has been proven to work, it makes a certain amount of sense to try to reproduce it perfectly, since any change in it might affect its success. If the program you’ve chosen speaks directly to your community and your population, there is no real reason not to implement it just as its creators did.

In some cases, however – because communities and populations often differ in subtle and not-so-subtle ways – even the program that comes closest to addressing your situation may have elements that are unlikely to work in your community, or lack elements that would improve its effectiveness. In these cases, it’s important to acknowledge your experience and understanding of the community and its history.

If you’re funded by CSAP, you might try to negotiate appropriate changes in the implementation of the evidence-based model you’ve selected. If you’re not funded by CSAP, but are simply using SPF as a framework for a community prevention program, you can make your own adjustments as you plan your program. You can borrow some strategies from another evidence-based program that you’ve examined, for example, or devise some strategies of your own to add on to the program you’ve chosen.

It makes sense to start with an evidence-based program. Reinventing the wheel is unnecessary, especially if you already know that the wheel works quite well. Improving the wheel is not impossible, however, and if you have the opportunity and the ideas to do so, you might come up with a prevention program that works faster or more smoothly, and that avoids the particular potholes presented by the peculiarities of your community.

• Create an overall plan for the effort. Strategy includes not just what the program itself will look like, but a number of other elements as well. These include:
  • Vision and mission statements for the effort.
  • How you’ll gather the resources you need. How much funding will you need and where will it come from? How will you recruit staff and/or community volunteers?
  • The timeline and implementation process for the effort. What will you do by when?  Who will take responsibility for what?
  • What results you hope to see in both the short and long terms.
  • How you’ll evaluate the effort.

Your plan should be detailed enough that it could still be followed even if everyone involved in the planning suddenly decided to retire to a tropical island and left no forwarding address.

• Present the plan to the community and gather support. The assumption here is that a prevention effort, to be successful, must be aimed at and involve the whole community. The greater the community ownership of the plan, the more likely it is that the plan will be carried out across the board.

Phase 4: Implementation.

Now it’s time to put your prevention program into practice. This phase isn’t easy, but it will be a lot easier if you’ve done a good job planning and have the support of the community. Paying attention at the beginning of and throughout the implementation phase to some specific aspects of it will also make the task easier.

• Hire staff and/or recruit volunteers. Whether your program uses paid staff or volunteers – or a combination of both – it’s important to find the right people to work in it.
• Stick to your plan for the implementation process. While timelines can often be affected by external factors – how long it takes to hire staff, a contractor’s work on space, etc. – the implementation of your plan will go much more smoothly if you stick to the process you’ve outlined. It’s often easy to skip steps or to ignore the plan, but those almost always lose you time, cost you extra money, or simply make getting the program off the ground much more difficult. You’ve made a plan for a reason – you’ll generally do better by following it.

The same is true for the methods, content, and structure of the program itself. You’ve chosen an evidence-based model because it has proven itself and because it seems to fit your community, your population, and the issues they’re dealing with. It makes sense to stay as close to the model as possible, at least for an initial period, to see if it works as well for you as it did for others that tried it.

• Continue to pay attention to resources. You may have obtained the resources you need for the moment, but that doesn’t mean you should relax. As we’ll see, your program, to maintain its success, will need to continue. Almost all funding is time-limited (often to a year, or even less), so the need for new or continuing sources never really ends. You don’t have to, and shouldn’t, spend every minute in pursuit of funds and other resources. You should, however, be aware of the program’s needs, take advantage of opportunities that arise, seek new and maintain good relations with current funding sources, and always be preparing documentation and other materials for funding and other requests. Just as the best treatment for substance use is to prevent it in the first place, the best remedy for a crisis over resources is to prevent it from arising.
• Keep the community informed. Through placing news articles and press releases, presentations to groups, maintaining a presence at community events, and other actions, you can broadcast the program’s successes and continue to generate community interest and support.

Phase 5: Evaluation.

Only by monitoring and evaluating your effort can you tell just how successful it is, and know what parts of it you need to change or strengthen. Evaluation should be ongoing throughout the life of the prevention program, and should cover at least three areas:

• Evaluate the process. Did you do what you set out to do? Did you meet timelines, reach the number of people and the population you planned to, provide the kinds of service or activities you intended in the way you intended? If not, why not? Were there barriers that you didn’t expect?
• Evaluate the impact of the program. Is the program having the desired effect on the risk and protective factors you’re aiming at? You may be doing exactly what you planned, but it may have little or no effect on your chosen risk and protective factors, or it may be having effects you didn’t count on. You’ll have to find another way to affect those factors, or determine whether you were simply not implementing the program properly.
• Evaluate the outcomes. Has the effort led to the desired outcomes – lower rates of drug and alcohol use, fewer drunken driving deaths, better services for older adults? Again, your program may be affecting the chosen risk and protective factors in the ways you anticipated, but that may not have led to the outcomes you were aiming at. In that case, you’ll have to decide whether you were addressing the wrong risk and protective factors (and which ones you should address), or whether there’s another way to reach your goals.

The results of your evaluation should be reassessed on a regular basis (typically once a year), and used to adjust your program to respond to changing community needs or to change or improve areas of it that aren’t working as well as they could. That’s the whole point of evaluation – to make your program better. Finding ways to make the effort stronger isn’t an admission of failure, but rather a way of keeping your work dynamic.  No program is perfect – there are always some actions you can take to improve it.  Programs that never change generally go downhill over the long run: change revitalizes staff and participants, and leaves room for experimentation that leads to new discoveries.

When you make major changes, tell the community about them, and ask for help if you need it. Adjustments may require more volunteers, more funding, a different method of reaching people, or some other change that the community can assist with. The opportunity to provide real aid leads to community ownership and support of the program.

The Community Tool Box considers evaluation such a valuable part of any intervention or initiative that it devotes four chapters – 36 through 39 – to it. You can find information about almost any aspect of evaluation in the more than 30 sections that comprise these chapters.

SAMHSA/CSAP doesn’t include a sixth phase of the prevention process, but we’ll suggest one here. It will be familiar to regular users of the Tool Box: keep at it indefinitely. You’re actually attempting to create long-term social change, and that takes time. You may see the changes you desire, but that doesn’t mean they’re permanent, or part of the community culture...or that they’ll remain part of that culture without being nurtured. Changes have to be maintained, and that means continuing at least some of the major elements of your prevention program for as long as substance use remains a problem in society.

In Summary

CSAP’s Strategic Prevention Framework is intended as a structure for substance use prevention programs, although, because of its generality, it could easily be used for other prevention programs as well. The components of its process – assessment, capacity building, planning, implementation, and evaluation – are similar to those of the other logic models and frameworks described in this chapter.

The Strategic Prevention Framework, like several of the Other Models for Promoting Community Health and Development. focuses on risk and protective factors. Risk factors are those elements in the individual, family, peer group, or society that make it easier or more likely for someone to fall into substance use. Protective factors, on the other hand, are those elements in the individual or his environment that make it easier or more likely for him to avoid substance use.The assumption is that if you can reduce or weaken risk factors and strengthen protective factors in a population or community, its members are less likely to experience substance use problems.

CSAP provides funding for prevention both through states and directly to organizations.  More important for the majority of prevention programs not funded by CSAP grants, the agency also provides web-based tools and information to help with each phase of development and implementation. CSAP’s website also provides links to evidence-based programs that can be used in the implementation phase with at least some degree of confidence that they’ll work.

What is the Strategic Prevention Framework?

___The Strategic Prevention Framework (SPF) outlines a process that an organization, initiative, community, or state can follow in order to prevent and reduce the use and abuse of alcohol, tobacco, and drugs.

___SPF concentrates on eliminating risk factors and strengthening protective factors.

___Risk factors are those elements within an individual or her environment that make her more susceptible to particular negative behaviors or conditions.

___Protective factors are the opposite – those elements within an individual or his environment that make him less susceptible to those negative behaviors or conditions.

___SPF has five phases:

• Assessment
• Capacity
• Planning
• Implementation
• Evaluation

Why use the Strategic Prevention Framework?

___SPF is inclusive and participatory.

___SPF emphasizes the role of the community in prevention.

___SPF is open-ended, and encourages communities to find their own solutions.

___SPF aims to create long-term social change by focusing on risk and protective factors that can be influenced by short- or medium-term prevention efforts.

___SPF provides communities with proven, evidence-based models to choose from.

___SPF provides technical assistance and links to other practitioners and programs.

___SPF’s focus on risk and protective factors can improve the long-term well-being of the community.

Possible Disadvantages to Using SPF

___Limited resources.

___Insistence on the faithful implementation of evidence-based programs.

___Administrative load.

When should you use the Strategic Prevention Framework?

___Before there’s a serious problem.

___When resources are available.

___When a community problem has entered the public consciousness, but before it has reached crisis stage.

___When a community problem has reached the crisis stage.

___When there’s public focus on an at-risk population, particularly youth.

___When there’s a community economic development effort underway and people are looking at the community’s quality of life.

___When a grassroots movement for community improvement has arisen, and is looking for a way to address community issues.

Who should use the Strategic Prevention Framework?

___Members of the population(s) most at risk.

___Medical professionals, particularly those who work directly with at-risk populations.

___Human service workers.

___Alcohol- and drug-treatment professionals, as well as researchers in the field.

___Law enforcement officials.

___Educators.

___Elected and appointed public officials and policy makers at the appropriate level.

___Parents.

___Youth.

___Elders.

___The business community.

___Interested community members.

How do you use the Strategic Prevention Framework?

Phase 1: Assessment

___Form an epidemiological workgroup.

___Assess community needs and assets.

___Assess community readiness.

___Determine the most pressing need that a prevention effort can influence.

Phase 2: Capacity. 

___Start with your core group.

___Choose or develop a logic model or theory of practice to guide your effort.

___Use what you know about the community’s level of readiness to publicize the issue and encourage participation.

___Expand the network of community members interested in preventing substance use.

Phase 3: Planning.

___Assemble a planning team.

___Train the planning team.

___Analyze local risk and protective factors.

___Choose the factors you’ll concentrate on.

___Research and choose an evidence-based approach that can be used with the risk and protective factors you’ve settled on.

___Create an overall plan for the effort.

___Present the plan to the community and gather support.

Phase 4: Implementation.

___Hire staff and/or recruit volunteers.

___Stick to your plan for the implementation process.

___Continue to pay attention to resources.

___Keep the community informed.

Phase 5: Evaluation.

___Evaluate the process.

___Evaluate the impact of the program.

___Evaluate the outcomes.

___Use the evaluation results to adjust the program to be more effective.

___Keep at it indefinitely.

Tool #1: Supports for the Strategic Prevention Framework

Assessment

Toolkit 2: Assessing Community Needs and Resources

Toolkit 3: Analyzing Problems and Goals

Assessing Community Needs and Resources

Analyzing Community Problems and Solutions

An Introduction to the Problem-Solving Process 

Thinking Critically

Defining and Analyzing the Problem

Analying Root Causes of Problems: The "But Why?" Techinique

Information Gathering and Synthesis

Capacity Building

Toolkit 1: Creating and Maintaining Coalitions and Partnerships

Toolkit 6: Building Leadership

Toolkit 8: Increasing Participation and Membership

Toolkit 15: Improving Organizational Management and Development

Our Model of Practice: Building Capacity for Community and System Change

Using Internet-Based Tools to Promote Community Health and Development

Getting Issues on the Public Agenda, especially:

•  Communicating Information about Community Health and Development Issues      
•  Gaining Public Support for Addressing Community Health and Development Issues
•  Talking About Risk and Protective Factors Related to Community Issues

Choosing Strategies to Promote Community Health and Development

•  Coalition Building I: Starting a Coalition
•  Coalition Building II: Maintaining a Coalition

Communications to Promote Interest

Encouraging Involvement in Community Work, especially:

• Developing a Plan for Increasing Participation in Community Action
• Promoting Participation Among Diverse Groups
• Involving Key Influentials in the Initiative
• Involving People Most Affected by the Problem

Developing an Organizational Structure for the Initiative

Hiring and Training Key Staff of Community Organizations

Recruiting and Training Volunteers

Providing Training and Technical Assistance

Orienting Ideas in Leadership, especially:

• Developing a Plan for Building Leadership
• Styles of Leadership
• Developing a Community Leadership Corps: A Model for Service Learning
• Collaborative Leadership

Core Functions in Leadership

Becoming an Effective Manager

Group Facilitation and Problem Solving

Working Together for Racial Justice and Inclusion, especially:

• Building Relationships with People from Different Cultures
• Creating Opportunities for Members of Groups to Identify Their Similarities, Differences, and Assets
• Understanding Culture, Social Organization, and Leadership to Enhance Engagement
•  Building Inclusive Communities

Planning/Implementation

Toolkit 4: Developing a Framework or Model of Change

Toolkit 5: Developing Strategic and Action Plans

Toolkit 7: Developing an Intervention

Toolkit 8: Increasing Participation and Membership

Toolkit 10: Advocating for Change

Developing a Logic Model or Theory of Change

Developing a Strategic Plan

Generating and Choosing Solutions

Putting Your Solution into Practice

Deciding Where to Start

Choosing and Adapting Community Interventions, especially

• Criteria for Choosing Promising Practices and Community Interventions
• Understanding Risk and Protective Factors: Their Use in Selecting Potential Targets and Promising  Strategies for Interventions   
• Identifying Strategies and Tactics for Reducing Risks
• Adapting Community Interventions for Different Cultures and Communities

Providing Information and Enhancing Skills, especially:

•  Helping Parents Practice Prevention with Their Children and Teens
•  Establishing Youth Organizations

Enhancing Support, Incentives, and Resources, especially:

Youth Mentoring Programs

Modifying Access, Barriers, and Opportunities, especially:

Improving Services, especially:

• Overview of Tactics for Improving Services
• Establishing a Peer Education Program

Chapter 25: Changing Policies, especially:

• Changing Policies: An Overview
• Using Tax Incentives for Support Community Health and Development
• Supporting Local Ordinances to Modify Access to Unhealthy Products and Practices

Building Culturally Competent Organizations

Conducting a Direct Action Campaign

Media Advocacy

Responding to Counterattacks

Toolkit 12: Evaluating the Initiative

Our Evaluation Model: Evaluating Comprehensive Community Initiatives

Participatory Evaluation

Introduction to Evaluation

Some Operations in Evaluating Community Intervention

Some Methods for Evaluating Comprehensive Community Initiatives

Using Evaluation to Understand and Improve the Initiative

Maintaining Quality Performance

Rewarding Accomplishments

Sustainability and Cultural Competence

Toolkit 7: Developing an Intervention

Toolkit 9: Enhancing Cultural Competence

Toolkit 16: Sustaining the Work or Initiative

Promoting Participation Among Diverse Groups

Adapting Community Interventions for Different Cultures and Communities

Working Together for Racial Justice and Inclusion

Social Marketing of Successful Components of the Initiative

Planning for Long-Term Institutionalization

Tool #2: CSAP’s Principles of Substance Use Prevention

The principles are divided into six domains: Individual, Family, Peer, School, Community, and Society/Environmental.

Individual Domain

1. Build social and personal skills.

2. Design culturally-sensitive interventions.

3. Cite immediate consequences.

4. Combine information dissemination and media campaigns with other interventions.

5. Provide positive alternatives to help youth in high-risk environments develop personal and social skills in a natural and effective way.

6. Recognize that relationships exist between substance use and a variety of other adolescent health problems.

7. Incorporate problem identification and referral into prevention programs.

8. Provide transportation to prevention programs.

Family Domain

1. Target the entire family.

2. Help develop bonds among parents in programs; provide meals, transportation, and small gifts; sponsor family outings; and ensure cultural sensitivity.

3. Help minority families respond to cultural and racial issues.

4. Develop parenting skills.

5. Emphasize family bonding.

6. Offer sessions where parents and youth learn and practice skills.

7. Train parents to both listen and interact.

8. Train parents to use positive and consistent discipline techniques.

9. Promote new skills in family communication through interactive techniques.

10. Employ strategies to overcome parental resistance to family-based programs.

11. Improve parenting skills and child behavior with intensive support.

12. Improve family functioning through family therapy when indicated.

13. Explore alternative community sponsors and sites for schools.

14. Videotape training and education.

Peer Domain

1. Structure alternative activities and supervise alternative events.

2. Incorporate social and personal skills-building opportunities.

3. Design intensive alternative programs that include a variety of approaches and substantial time commitment.

4. Communicate peer norms against use of alcohol and illicit drugs.

5. Involve youth in the development of alternative programs.

6. Involve youth in peer-led interventions or interventions with peer-led components.

7. Counter the effects of deviant norms and behaviors by creating an environment for youth with behavior problems to interact with other nonproblematic youth.

School Domain

1. Avoid relying solely on knowledge-oriented interventions designed to supply information about negative consequences.

2. Correct misconceptions about the prevalence of use in conjunction with other education approaches.

3. Involve youth in peer-led interventions or interventions with peer-led components.

4. Give students opportunities to practice newly acquired skills through interactive approaches.

5. Help youth retain skills through booster sessions.

6. Involve parents in school-based approaches.

7. Communicate a commitment to substance use prevention in school policies.

Community Domain

1. Develop integrated, comprehensive prevention strategies rather than one-time community-based events.

2. Control the environment around schools and other areas where youth gather.

3. Provide structured time with adults through mentoring.

4. Increase positive attitudes through community service.

5. Achieve greater results with highly involved mentors.

6. Emphasize the costs to employers of workers’ substance use and abuse.

7. Communicate a clear company policy on substance use.

8. Include representatives from every organization that plays a role in fulfilling coalition objectives.

9. Retain active coalition members by providing meaningful rewards.

10. Define specific goals and assign specific responsibility for their achievement to subcommittees and task forces.

11. Ensure planning and clear understanding for coalition effectiveness.

12. Set outcome-based objectives.

13. Support a large number of prevention activities.

14. Organize at the neighborhood level.

15. Assess progress from an outcome-based perspective and make adjustments to the plan of action to meet goals.

16. Involve paid coalition staff as resource providers and facilitators rather than as direct community organizers.

Society/Environmental Domain

1. Develop community awareness and media efforts.

2. Use mass media appropriately.

3. Provide structured time with adults through mentoring.

4. Avoid the use of authority figures.

5. Broadcast messages frequently over an extended period of time.

6. Broadcast messages through multiple channels when the target audience is likely to be viewing or listening.

7. Disseminate information about the hazards of a product or industry that promotes it.

8. Promote replacement of more conspicuous labels.

9. Promote restrictions on tobacco use in public places and private workplaces.

10. Promote clean indoor air laws.

11. Combine beverage server training with law enforcement.

12. Combine beverage servers’ legal liability.

13. Increase the price of alcohol and tobacco through excise taxes.

14. Increase minimum purchase age for alcohol to 21.

15. Limit the location and density of retail alcohol outlets.

16. Employ neighborhood antidrug strategies.

17. Enforce minimum purchase age laws using undercover buying operations.

18. Use community groups to provide positive and negative feedback to merchants.

19. Employ more frequent enforcement operations.

20. Implement “use and lose” laws.

21. Enact deterrence laws and policies for impaired driving.

22. Enforce impaired-driving laws.

23. Combine sobriety checkpoints with positive passive breath sensors.

24. Revoke licenses for impaired driving.

25. Immobilize or impound the vehicles of those convicted of impaired driving.

26. Target underage drivers.

Example: Evidence-Based Environmental Strategies to Prevent Underage Drinking Using the Strategic Prevention Framework.

Preventing Underage Drinking: Using Getting To Outcomes™ with the SAMHSA Strategic Prevention Framework to Achieve Results describes 10 environmental strategies for reducing underage drinking that have the strongest evidence base. Each example includes a brief research summary and additional text that describes issues related to planning, implementing, and evaluating the strategy. The examples also include samples of tools, worksheets, or ordinances to facilitate the community’s work.The ten strategies are briefly described below.

• Responsible beverage service is a merchant education program designed to reduce sales to minors and intoxicated adults. It involves media advocacy to promote policy changes, manager training, and server/seller training.
• Alcohol compliance checks are thought to be most effective when they are frequent and well publicized, solicit community support, and involve penalties for the licensed establishment rather than just the server.
• Happy hour restrictions eliminate one of the environments most conducive to overconsumption of alcohol.
• Controls on alcohol outlet location and density reduce the accessibility of alcohol to young people by making it less prevalent in their immediate environment.
• Sobriety/traffic-safety checkpoints, which are very effective in reducing alcohol-related traffi c accidents, injuries, and deaths, are even more effective when combined with a vigorous public awareness campaign.
• Graduated drivers’ licensing laws, which entail clearly specified learner, intermediate, and full license phases, are effective in reducing crashes among teen drivers, but they need to be adequately enforced.
• Social-host liability laws state that adults providing alcohol to minors or those who are obviously intoxicated are legally liable if the person is killed or injured, or kills or injures another person.
• Keg registration is intended to prevent friends or relatives of legal drinking age from buying beer kegs for teen parties. Registration can be achieved in a number of ways, for example, permanent markings on each keg that identify where and when it was purchased or a requirement that keg delivery requests be made in person at the store.
• Restricting sales of alcohol at public events controls the availability of alcohol at gatherings such as concerts, street fairs, and sporting events.
• Increasing taxes on the sale of alcohol leads to reductions in the levels and frequency of drinking and, especially, heavy drinking among youth, as well as lower traffic accident fatality rates and reduced incidence of some types of crime. Several surveys indicate that most Americans support increased alcohol taxes.

For more in-depth information on these evidence-based environmental strategies to prevent underage drinking, please see the full manual Preventing Underage Drinking: Using Getting To Outcomes™ with the SAMHSA Strategic Prevention Framework to Achieve Results. Imm P, Chinman M, Wandersman A, Rosenbloom D, Guckenburg S, Leis R. (2007). Preventing Underage Drinking: Using Getting to Outcomes with the SAMHSA Strategic Prevention Framework to Achieve Results, RAND, TR-403-SAMHSA. Santa Monica, CA: RAND Corporation.

A PowerPoint presentation summarizing the major points in the section.

The Health Impact Assessment (HIA) is a tool that helps community leaders, legislators, and changemakers find out what health and safety impacts their proposed projects may have on area residents and community members. The HIA can be a valuable resource in anticipating the health effects of a projects, a long-term plan, or a new party. This section explores how to effectively conduct an HIA and use the results to improve community projects and planning.

What is a Health Impact Assessment?

A consensus of those at a meeting of the World Health organization (WHO) held in Gothenburg, Sweden in 1999 defines HIA as “a combination of procedures, methods, and tools by which a policy, program [a series of projects over time], or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within that population.” In simpler language, it’s a way of finding out whether and how a proposed action or policy will affect the health of people who are in some way exposed to it.

While there is obviously a difference between a single project and a series of projects, for the purposes of this section, we’ll lump the two together under the term “project.” We’ll consider a project as an activity that has clear physical consequences, as opposed to a policy, which may set guidelines for future action in any number of areas or sectors.

An HIA is intended not to determine, but to support decision-making. It helps decision-makers choose among options by predicting the health consequences of each option. Rather than having a set structure, HIAs are individually designed to match the needs and conditions of different locations and circumstances. They can be, and have been, used at the local, regional, national, and international levels, and have been applied to projects and policies in such sectors as agriculture, residential development, transportation, mining, industry, and recreation. HIAs can be helpful in making decisions in such areas as tax and foreign policy, employment strategies, and urban planning.

The actual practice of an HIA involves one or more practitioners – ideally both trained and experienced in conducting HIAs – studying the existing research on potential issues, and gathering background evidence from the people who are expert in the subject of the project or policy (agriculture, transportation, etc.), residents and other community members, officials from sectors involved, health professionals, etc.. In addition, the HIA practitioner might attend and/or conduct meetings among the various sectors, involve the community in meetings with developers or officials, and otherwise oversee the process, in order to collect as much information as possible about potential health effects and potential areas of health promotion associated with the proposed project or policy. Ultimately, the HIA practitioners prepare a report that should be presented to all involved, including the community. Decision-makers for the project or policy can then use the report – which includes recommendations for various options – to inform their decision.

An HIA may be commissioned by the government oversight agencies or policy makers concerned with the proposed project or policy; by the contractor(s) carrying out a project; by the local, regional, or national government; or by citizens or a citizen group, depending upon the circumstances. It generally carries the most weight when it has the authority of government behind it, regardless of who commissions it.

HIAs are generally conducted in one of three ways, depending on the time, resources, and personnel available.

• Desktop. As the name implies, this HIA is essentially a sit-down process, focusing mostly on existing research and on phone contact with some stakeholders. It would probably be carried out by one or two people, and might take two to six weeks.
• Rapid. A rapid HIA uses both existing research and rapid assessment techniques, thus including some fieldwork as well as literature research. Although it could be carried out by one or two researchers, it might also involve more, and might take about three months.
• Comprehensive. A comprehensive HIA seeks to ferret out as much evidence as possible, using an extensive search of the literature and other existing evidence, in-depth interviews and community surveys, some original research if appropriate, and a good deal of contact with experts and agencies from the sectors involved in the project or policy under study. This type of HIA can take 6 months or more, and can require a team to conduct it.

The ideal HIA is planned through a participatory process that involves all stakeholders, and is carried out with the help of cooperation among all parties involved. In practice, that can mean encouraging various agencies--government agencies particularly--to work together and share information. It can also mean changing the culture of professionals to accept and welcome community participation.

Also in the ideal, HIAs are prospective – i.e., they look forward. An HIA, to be most useful, should be conducted before a project or policy is implemented (even better, before it’s fully planned), so that any health impacts, whether positive or negative, can be factored into the final design. In reality, HIAs are sometimes concurrent – running as the project or policy is being implemented – or retrospective – after completion. Concurrent or retrospective HIAs are better than nothing, and can result in adjustments that address health impacts. It’s more difficult, however, to change something that’s already built or in force than to adapt the plans for it. Where possible, HIAs should be conducted well before projects or policies are implemented.

HIAs are guided by four basic values:

• Democracy. Wherever possible, all stakeholders affected by or taking part in a proposed action or policy should have a voice through an HIA and in its planning and development, and should understand its possible consequences.
• Equity. HIAs should assess health impacts on the whole population, treating all fairly and equitably, with particular attention paid to the needs of the most vulnerable populations (children, older adults, people with lower incomes, etc.).
• Sustainable development. Attention should be paid to both short and long-term impacts of a proposed action or policy, both obvious and not-so-obvious. That means that a major project or policy should be examined not only in light of current health impacts, but of possible impacts in the future as well.

We can look at this both as a health issue – Will the safeguards to health that we put in place today still be adequate in 10 or 20 or 100 years? – and as a larger societal issue related not only to individual health, but to the long-term health of the society. Do we develop an irrigation system that helps farmers now, but that will cause an aquifer to run dry in ten years? Do we build housing with construction techniques and materials that use renewable resources, allow it to stand indefinitely, and provide a healthy environment for inhabitants?

• Ethical use of evidence. Research in the course of an HIA should be objective, and should deal in the reality, rather than seek and use research results to confirm a position already held. That means including all the legitimate information you find, whether or not it supports your position for or against a particular part of the proposed action or policy.

The ethical use of evidence concerns not only ethics, but also the effectiveness of an HIA. In general, there are four levels of HIA effectiveness:

• Direct effectiveness: A project or policy is modified or cancelled as a result of an HIA.
• General effectiveness: An HIA is properly conducted and adequately considered, but doesn’t result in any changes in original decision – either because changes are not necessary, or because the evidence was complete and weighed carefully, and the final decision was that any potential health impact was less important to community, regional, or national well-being than the potential results of the original proposal.
• Opportunistic effectiveness: The HIA is used only to confirm or support the original proposal. This may result in evidence being slanted or suppressed, or in a legitimate HIA which is being conducted only for the wrong purposes.
• Ineffectiveness: An HIA is conducted but ignored, or is conducted so poorly that it’s no help at all.

In order for an HIA to fall into either of the first two categories – the categories of real effectiveness – all the evidence has to be considered and presented, so that it paints as nearly complete a picture as possible of the situation. Only then can decision-makers make a truly informed decision. An opportunistic result, on the other hand, is an example of the unethical use of evidence – not mentioning information that conflicts with decision-makers’ assumptions, or actually changing statistics or other information to conform to the decision that those in authority want to see.

It should be noted that, while we usually think of unethical behavior as being indulged in by people in power to confirm their status, or by those who stand to gain financially from it, it can also be a product of ideology. It’s probably less common, but it’s not impossible that health advocates might ignore data that would contradict their objections to a project. No one is immune to trying to make sure that his philosophy prevails.

Like most of the other models we discuss in this chapter, HIA looks at health from a community perspective. It considers the social, economic, and political, as well as the physical determinants of health when examining the potential health effects of a proposal.

The WHO includes in these:

• Biological factors (body type, other genetic factors).
• Individual lifestyle factors (smoking, exercise, diet).
• Social and community networks (family, friendship groups, clubs and associations, faith communities).
• Living and working conditions (education, work environment, water and sanitation, housing).
• General socioeconomic, cultural, and environmental conditions (income, physical environment, access to open space, status by gender or caste, etc.)

These factors may act alone, act in combination, or interact to determine the overall health and well-being of individuals, communities, and even whole nations.

This list of determinants matches up well with both the ten social determinants of health set out in “The Solid Facts,” a WHO publication by Richard Wilkinson and Michael Marmet, as well as with the nine necessary elements of a healthy community presented in the Ottawa Charter, a statement that emerged from a 1986 WHO conference in Ottawa, Canada.

From “The Solid Facts”:

• The social gradient (Equity: the extent of the difference in wealth and opportunity between those with the most and those with the least.)
• Stress
• Early life experience
• Social exclusion (the opposite of social connectedness)
• Work
• Unemployment
• Social support
• Addiction
• Food
• Transport

From the Ottawa Charter:

• Peace
• Shelter
• Education
• Food
• Income
• A stable ecosystem
• Sustainable resources
• Social justice
• Equity

The attention paid to social determinants greatly increases the breadth of what we might consider health impacts. While impacts on health are often seen in direct, medical terms – chemicals from an industrial plant or from farm run-off can poison water supplies, for example, causing specific types of cancer – they can also be indirect and far less visible.

Noise from increased traffic as a result of a faraway commercial development might disturb the sleep of residents in a community, and affect their immune systems...even though the development itself has no direct impact on their lives. Subsidies to industry or currency fluctuations on another continent might cause loss of income and severe stress to workers in a North American factory town, leading to substance use and a major public health problem.

That’s why an HIA can be so important. In the best case, it can directly prevent negative health consequences. Even where it can’t – a local project or policy can’t control the global economy – by predicting them, it can perhaps help to stave off their worst effects. At the very least, it can make policy makers and others in authority aware of the issue, and motivate them to consider ways to address it. For more information about Health Impact Assessment, see the National Research Council's report on Improving Health in the United States: The Role of Health Impact Assessment.

A note here: At this writing (2008), HIAs are still, on a world scale, not widely used.

The European Union has made a legal commitment to factoring in the health impacts of new projects, programs, and policies, but leaves it up to individual members – which, in turn, often leave it up to provinces or municipalities – to decide how this is to be done. The result is that there are places where stand-alone HIAs are regularly employed, others where HIAs are incorporated into environmental impact assessments (EIAs), and still others where there is precious little formal assessment at all.

The rest of the world is less committed to the HIA concept. HIAs have been used to some extent in Canada and Australia and in various parts of the developing world, but mostly in the context of projects that could have an obvious impact on health – water systems, dams, surface mining, and the like. In the U.S., the use of HIAs is still in its infancy, most often occurs within the confines of an environmental impact assessment, and may examine only obvious possible health problems (increase in asthma from increased traffic, for instance), rather than more subtle, long-term implications or the possibility of health promotion.

Why would you conduct a Health Impact Assessment?

HIAs, if done well, are painstaking and time-consuming. Why should you spend the time, money, and effort on them? There are a variety of answers to this question.

• HIAs make for better decisions. An HIA provides decision-makers with as much of the best available information about the project or policy they’re about to embark on as possible. That means fewer, if any, surprises in the course of the work, and a lot fewer mistakes to fix afterward.
• HIAs promote cross-sectoral cooperation. Government agencies and other institutions or organizations that represent particular sectors – health, agriculture, industry, education, transportation, housing, recreation, human services, etc. – seldom work together on planning and implementing projects, especially when those projects seem to be the province of only one of them. An HIA for a transportation project might bring together all or some combination of highway engineers, public health officials, environmental groups, citizens living near the current and proposed roads affected, water department officials, electricity providers, farmers with abutting property, landscape architects, trucking companies, and others to examine all aspects of the project. At least some of the intersectoral relationships developed are likely to carry over long after the HIA is finished, and have a positive effect on numerous other projects and policies as well.
• HIAs raise the profile of health and health issues, and make it more likely that they’ll be considered in all circumstances. By bringing health impacts to the attention of government officials, developers, industry, and the public, HIAs increase general knowledge and establish health as an important factor to be considered whether or not an HIA is required in a particular situation.
• HIA champions a participatory approach that values, includes, and empowers the community. This allows those affected by a project or policy to be consulted and listened to, or – even better – to participate in the planning and implementation of the HIA and, through it, of the policy or project itself. Such an approach increases the amount of knowledge and creativity brought to bear on solving problems and handling challenges, empowers and gives a voice to community members, increases community trust in the process, and encourages community support of the final result.
• HIAs bring the community together. By emphasizing the importance of health impacts on all segments of the community, and by involving all segments in the HIA process, HIAs can unite communities and establish relationships among people who might otherwise have little contact with one another.

Through the participatory process, an HIA can also bring together community leaders and activists with government agencies, developers, and others to work out differences and build personal ties that will lead to collaboration in the planning and implementation of other projects and policies.

• HIAs promote equity. One of the governing values of HIA concerns the promotion of equity and the particular consideration of health impacts on vulnerable populations. This promotes the fair treatment of everyone involved, with the needs of the most vulnerable addressed, and balanced against the needs of the general population. HIAs also give voice to community concerns, and thus promote equity in participation as well.
• HIAs promote healthy behaviors and practices.The point of an HIA is not only to understand and prevent the negative, but to stimulate the potential positive health impacts of a project or policy. A new housing development, for example, can not only be built without volatile organic compounds (VOCs) – chemicals often contained in glues and solvents used in construction that can cause health problems in many people – but can include walking and bike paths and other features that encourage exercise and promote heart health. Thus HIAs can promote health both by forestalling possible hazards and by advancing healthy practices.
• HIAs can be used in numerous and varied situations. HIAs can be, and are meant to be, adapted for use in individual local, regional, or national projects; long-term multi-project plans; and policy decisions that can cover anything from local economic development to national foreign policy. In addition, they can be designed individually for projects and policies in all sectors and in all different types of local, regional, or national circumstances. Because of the flexibility of the concept, HIAs can be a valuable tool for decision-making at any level.
• Prospective HIAs provide information before the fact, leaving time to make adjustments in plans. HIA is meant to be prospective, and to give information that can guide decisions about how to implement projects and policies. This can eliminate problems down the road, deal with complaints or concerns, stave off potential legal battles and other conflicts, and generally make things go more smoothly. Even when an HIA is concurrent or retrospective, it can make it possible to correct problems or add features that promote health.
• HIAs can promote sustainable development and environmental responsibility. Because sustainable development and concern for the environment are inextricably linked with the health of communities and populations (and are, in fact, specifically identified as determinants of health), HIA recommendations often link to them. Preservation of open space, alternative energy sources, environmental cleanup, non-toxic construction materials, curbs on pollution and noise, organic fertilizers and farming techniques – all of these may be elements of addressing health impacts, while addressing sustainability and environmental stewardship as well.
• HIA is adaptable to the needs of many different groups. Local, regional, and state governments can employ HIAs to ensure that any projects or policies they undertake have the desired results without any unexpected negative side effects to health. Contractors and developers can make decisions about construction and other large projects that will avoid future problems and satisfy government requirements. Communities and community organizations can make sure that the health of the community is a major consideration in decision-making about projects and policies that affect them. Advocates for people experiencing disadvantage or other vulnerable groups – children, people with disabilities, older adults – can see to it that the needs of those groups are carefully considered when decisions are made.
• HIA assists policy development. HIAs ensure that health is a concern when policies are considered, and that the potential health impacts of a policy are understood before it is implemented. This makes for better and more comprehensive policies, and helps to eliminate unintended consequences.
• HIA helps the EU and some other policy makers address policy making requirements. In places where local, regional, national, or international laws and regulations dictate what must be included or considered when policies are developed and implemented, HIAs can provide decision-makers with the information they need in order to meet the requirements.
• HIA recognizes that other factors besides health guide decisions. HIA can help decision-makers weigh all the factors that go into designing a project or developing policy. If there is a potential of adverse health effects for a very small number of people, versus a huge economic benefit for a very large number – many of whom may be lifted out of poverty – an HIA might serve to sway the decision away from making the health impact a priority...and that may be appropriate.
• HIA is a proactive process that improves positive outcomes and decreases negative outcomes. An HIA affords decision-makers the opportunity to actively take steps to improve the health and well-being of the population in the course of accomplishing necessary and desirable projects or developing policy that enhances the community, the region, or the nation. Decision-makers can create a win-win situation in which everyone reaps the benefits.

When should you conduct a Health Impact Assessment?

As we discussed earlier, the timing of an HIA can take place before the project or policy is implemented (prospective), during the implementation (concurrent), or after the project is complete or the policy has become established (retrospective.) While any of the three can be valuable, it seems clear that the ideal is a prospective HIA. Getting all the facts and information before you start a project or implement a policy makes it much more likely that you’ll get it right, and not have to clean up a mess later. Some proponents of HIA feel that concurrent or retrospective HIAs aren’t really HIAs at all, but are simply monitoring or evaluating the project or policy.

The best time, therefore, to initiate an HIA is during the planning process, well before activity is scheduled to begin or policy put in place. A later HIA, whether concurrent or retrospective, can be useful, and can lead to correcting mistakes that are being or were made in the course of the activity. It’s much harder, however, to change a project or revamp a policy once it’s under way or – worse – completed than it would be to change plans beforehand. Furthermore, by the time a concurrent or retrospective HIA identifies a potential negative health impact, there’s a good chance that there will already be community or other groups calling attention to and perhaps protesting it. Considering impacts before the fact not only makes addressing them easier, but also avoids unnecessary conflict and distrust.

Who should be involved in conducting a Health Impact Assessment?

There are actually two ways to answer to this question. The first is a discussion of who needs to be included in a participatory HIA process and how. The second is a consideration of who should actually lead the process and conduct the assessment – a large amount of work, as we shall see, is involved; some of it is technical, and all of it requires a variety of skills. We’ll look at the second of these in the how-to part of the section, and limit the discussion here to who should be included in the process.

A truly participatory process is one in which all stakeholders are represented, and in which their role is significant, rather than just symbolic. That means that they actually take part in the planning and monitoring of the HIA, as well as in helping to formulate recommendations.

Stakeholders include:

• Those who are directly affected by the proposed actions or policies. These folks might fall into several categories.
  • Members of the population at whom changes are aimed, where applicable.
  • Members of the population in closest physical proximity to proposed actions, and who will be directly affected by work to be done or other actions being carried out. Some examples are those living next to a proposed development site or irrigation project; those on a route between a major population center and an area to be developed; and those downwind or downstream of a proposed industrial development that could pollute their area, even if they’re relatively far away. (Heavy industry in the UK, Germany, and Poland is responsible for much of the acid rain in Norway, for example.)
  • Members of the most vulnerable populations that could be affected – children, older adults, people with disabilities, people from underrepresented language or other groups, groups with lower incomes.
  • Residents and officials of the communities or areas in which proposed projects or programs will take place (including neighborhood associations and the like.)
  • Residents and officials of communities that will be affected by the proposed actions or policies (e.g., communities subjected to heavier road traffic because of tourism development).
• Those who are involved in carrying out the proposed actions or policies. These are the people responsible for actually doing the work of a project or implementing the details of a policy. Some possibilities:
  • Private developers and construction firms.
  • Local, regional, and national government agencies and officials.
  • Planners.
  • Police, firefighters, health workers, and other public service providers
• Nonprofit and non-governmental organizations (NGOs) concerned with the issues and/or the populations affected. In many countries, particularly the U.S., these are often the groups that actually do the work of carrying out health and health-related policies, serving those with physical and mental health conditions, and addressing violence prevention, environmental issues, and various other community challenges. They often see themselves as representing vulnerable populations, and may understand the needs of those populations more clearly than the government agencies that oversee them or the policy makers that decide their fates. It makes sense to involve them both for this understanding and because they are themselves affected by projects and policies.
• Advocacy groups. Whether the subject of their advocacy is a cause or a population, these groups should be included in the HIA process from the beginning. If they’re included, they can be helpful in some of the same ways as NGOs. If they’re excluded, they’ll be (rightly) suspicious of the process, and can create problems for both the HIA and the project or policy it’s analyzing. With a seat at the table, they can work out any problems as they arise, and the process will go much more smoothly.
• The decision-makers themselves. These are the people – government agencies, developers, architects, planners, local officials – who actually control the design and implementation of projects or policies. It goes without saying that they should be represented in the HIA process. First of all, they know the particulars of budget, time limits, and other factors that make a given option feasible or impossible. Just as important, the weight of the decision sits on their shoulders. It’s to their advantage – and to the advantage of a good decision – that they understand the true character of the evidence and its implications.
• Government agencies that have responsibility for the issues and/or populations in question. It’s often up to agencies in the various sectors to carry out a project or policy. Not only should they be included for that reason, but because the better they understand the reasons for a project or policy being conducted in a certain way, the more likely they are to make that happen.
• Representatives of other sectors that are affected by the proposal. An agriculture project, for example, may directly or indirectly affect water supply, transportation, the environment, and employment, to name but a few of the possibilities. Including the agencies or departments responsible for these areas will furnish better and more nearly complete information, foster inter-sectoral cooperation and communication, and keep all relevant sectors in the loop.
• Health workers at local, national or international levels. These folks are the ones who are best situated to make judgments about health impacts and risks, and can add immeasurably to the usefulness of an HIA.
• Employers and unions. As the people who will be responsible for and do the actual physical labor of a project, these groups can predict the feasibility of various options, and are affected by the choices of decision-makers. They may also have internal rules or contract conditions that dictate what can and cannot be done in the course of a project.
• The commissioner(s) of the HIA – those who set it in motion (and pay for it, in many cases.) That could be a private developer – just as they often pay for environmental impact assessments as part of their permitting process – a municipality, the national government, an organization, etc.
• Those who actually conduct the HIA. It goes without saying that the people who conduct the HIA are involved in its planning and implementation. That’s their job.

How do you conduct a Health Impact Assessment?

An HIA has both political and practical aspects, and they can’t really be separated. The political aspects have to do with the motivation and support for conducting an HIA, as well as its financing. The practical has to do with the mechanics and logistics of gathering the appropriate participants, putting together and implementing a plan, and coming up with information and potential courses of action. We’ll examine both of these – the political first, because at least some of the political elements have to be in place for an HIA to happen at all.

Political aspects of conducting an HIA

• In order for HIA to become common, and particularly for it to be institutionalized, politicians and government agencies have to at least be willing to entertain some basic concepts:
  • That health is important enough to be integral to any project or policy that can have an impact on it.
  • That health is not an individual issue, but has to be viewed in a larger – community, regional, national, or international – context, depending on the scope of the project or policy proposed.
  • That health is more than the alleviation, elimination, or prevention of disease, injury, or medical conditions, but also includes the promotion, psychological implications, and other aspects of health.
  • That the social and other determinants of health are both real and crucially important to creating a healthy community and society.
  • That health transcends any one department or ministry – i.e., that more than public health agencies need to be involved in examining the health impacts of a project or policy, and that interdepartmental and inter-sectoral collaboration is necessary in order to fully understand the health impacts of projects or policies.
  • That they need the best, most accurate, most nearly complete information possible in order to make good decisions that take health impacts into account.
• HIAs won’t happen with any regularity or quality control unless they’re institutionalized by a legal basis of some sort – a law, an agency regulation, a clear policy, permit requirements, etc.. This legal basis has to set out clear standards for what an HIA needs to include and who should be involved, at whatever level it takes place. (A recent EU regulation, for example, requiring that any new project or relevant policy conduct an SEA – Strategic Environmental Assessment – specifies that population and health must be assessed alongside other factors.)
• HIAs have to be paid for. Written into the governing legislation or regulations should be some consistent mechanism for financing them, or they won’t get done. This might be government funding out of a specific budget item, or out of the budget of the appropriate department or ministry. (A specific budget item makes more sense, since it eliminates the possibility of departments or agencies arguing over whose responsibility it is to pay for an HIA in an area where both have some oversight.)

Another possible financing method, at least for projects that are initiated by private firms, is to have the developer, corporation, or contractor pay for the HIA as part of the permit process, as they do in the U.S. for EIAs (Environmental Impact Assessments). Some combination of public and private funding might also be an option, at least in some cases. Although there are situations where citizens, an advocacy group, or an NGO might commission an HIA in order to protect a population experiencing increased risk, funding, in general, should not have to depend on the people affected, but should be a government responsibility in some sense, as American EIAs are. (In that situation, the law specifies who pays for the EIA.)

• Government agencies have to collaborate for an HIA to be of high quality. It usually takes the department or ministry of health, the governing agency of the sector the project or policy is directly related to, and often several other related ones as well to look at all the aspects of the proposal and to tease out all the potential implications for health embedded in them. A commercial development, for instance, might involve the departments of health, environment (air quality, noise, open space preservation, etc.), transportation (traffic patterns, new or improved roads), employment (economic factors), agriculture (effects on nearby cropland), and housing (displacement by the development), among others.

Government bureaucracies are often used to being competitive and secretive, rather than open and collaborative. For HIAs to work well, they have to understand that working together actually benefits all of them and makes their jobs easier.

• Government has to be willing to involve, listen to (and heed) the concerns and advice of those who will be affected. Bureaucracies are often even more resistant to working with citizens than with other bureaucrats. The culture of government departments and agencies may need to change in order for that to happen. As with the necessity for collaboration among bureaucracies, bureaucrats need to see the advantages of public involvement (citizen buy-in, more trust in officials’ decisions, less aversion, reductions in post-project or -policy protests or lawsuits, etc.) before they’ll commit to it fully.

Practical aspects of conducting an HIA

There is no prescribed way to conduct an HIA. By definition, each is adapted to its context – the proposed policy’s location, sectors, and character, the amount of controversy it generates, the levels of government involved, etc. There is, however, a general, five-stage form to any HIA, and a set of logical, if not set-in-stone, guidelines that go with the stages that can help you conduct an HIA effectively.

The first step in the process is to choose assessors to conduct the HIA. The general, though not universal, consensus among HIA proponents is that people charged with this responsibility should be trained and/or experienced in HIA, regardless of what particular background – public health, social science research, public administration, or something else entirely – from which they come. Although not discussed widely, training probably should include a grounding in public health issues and in determinants of health, as well as in the broader perspective of health as a community (or wider) issue. Training should also encompass the mechanics of conducting an HIA – involving the community, including and conferring with all relevant agencies and organizations, generating options, etc., and perhaps some instruction/practice in reconciling opposing viewpoints, convincing sectors to work together, conflict resolution, and facilitation of discussion.

John Kemm, a leading HIA theorist and supporter, believes that training is less necessary than a general background in dealing with people and some ability to conduct research. He feels that HIA is so necessary that it’s more important to spread it widely as quickly as possible than to wait until a large number of people are expert at leading the process. Others feel that you’re setting yourself up for failure if you embark on the process without specific training and experience in conducting an HIA.

The author falls somewhere in between, as the next paragraph indicates. It seems reasonable to assume that a number of people have the skills – and personal characteristics – necessary to conduct a successful HIA as a result of the training and experience they already have. Training health impact assessors is certainly a good idea, but in a field as new as HIA, much of the expertise that’s needed will undoubtedly come through experience in any case. The best training may well be to understudy with someone who’s conducted successful HIAs in the past.

So who are the conductors of an HIA likely to be? Given the skills they need – the less training necessary, the more quickly they’ll be ready to undertake the task – they’d probably come out of one of the fields mentioned above, or perhaps others such as community psychology or the NGO world, where many of those skills are regularly needed and practiced. Other possible sources are universities, think tanks, and government. Wherever they come from, those who conduct HIAs should be able to relate to and communicate effectively and amicably with a broad range of people, be comfortable dealing with conflict and apparent contradictions, know how to navigate and negotiate government and other bureaucracies, understand research, and maintain their calm in the face of whatever comes their way.

There are political aspects to this choice as well. The most objective HIAs will obviously be conducted by people with no stake in the outcome and no connection to the agencies or other parties involved. Governments and other entities are often tempted, however, to have activities like HIAs conducted by people who are likely to favor their preferred course of action. There should be some guard against the employment of HIA practitioners who have particular biases, or who have obligations to those who commission the HIA. Both the need for the ethical use of evidence and the uselessness of an opportunistic HIA make the choice of practitioners an important one, and one that shouldn’t be dictated by politics.

HIA consists of five stages:

• Screening
• Scoping
• Assessment
• Reporting
• Evaluation

We’ll look at each of these separately, and lay out some general guidelines within each to provide both a broader understanding of the HIA process and a series of steps you might take to conduct that process.

• Screening. Each project or policy needs to be examined to determine whether an HIA is needed. There are at least two reasons why an HIA might not be needed. One is that the project or policy simply doesn’t have an impact on any area that affects health.

The second reason is that the project or policy already specifically takes health into account. This might be illustrated by a development that was designed to the LEED (Leadership in Energy and Environmental Design) gold standard – the highest rating from the U.S. Green Building Council – and used no toxic materials, in addition to setting aside several acres of its site for open space and recreation, creating bike and walking paths, and using a design that encouraged social interaction and group activity among residents.

Screening is the first – and sometimes the last – task in the conduct of an HIA. The identity of the screener can pose a problem. If you hire an individual or team to be the HIA assessor, he or they will have the knowledge and experience to judge whether an HIA would be valuable in a given circumstance. Unfortunately, he or they will also have a conflict of interest: if they decide an HIA is unnecessary, they’re out of a job. Leaving the task to the commissioner of the HIA can present a similar problem – HIAs are time-consuming, and involve dealing with the community and other sectors, neither of which the commissioner may be eager to do – as well as the danger that something important will be missed. A good option might be to hire someone with knowledge and expertise specifically to do the screening, and then to hire someone else to conduct the HIA if it’s needed.

• Scoping. Scoping is the actual planning of the HIA. In this stage, you initially identify ways in which the decision in question could potentially affect health (positively or negatively) – the people who might be affected, how impacts should be assessed, whose expert opinion you need to get the full picture, what resources are needed to conduct the HIA, what kinds of evidence should be gathered, etc. At the end of the scoping process, you should have a complete plan for how to conduct the assessment.

As we’ve discussed, there’s no one way to conduct an HIA. It depends on the individual circumstances of each situation and place. What follows is one logical way to structure a scoping process, but should not be taken as the only way.

• Using logic, prior knowledge, and the concerns of the community, make an educated guess about the possible health impacts of the proposed project or policy.
• Determine the sectors, populations, groups, and individuals that need to be consulted and/or drawn into the process.
• Assemble a team from among them to plan and do the groundwork for the HIA. This team should comprise representatives of as many stakeholders as possible, including those directly affected and those from or representing vulnerable populations.

The composition of this group may depend on time. If the timeline is short, it may not make sense to try to include the community on the planning team, although they do need to be consulted and kept informed. It is necessary to make sure that all relevant government agencies are included, or at least in the loop, both to avoid missing something important and to make sure that turf issues don’t interfere with the process.

An inclusive, participatory team is the ideal. Many HIA commissioners hire a consultant or a firm to conduct the HIA, and that individual or group may or may not make sure that all voices are heard. A short timeline makes it less probable that the process will actually be inclusive and participatory, but it should aim at those goals to the extent possible.

One point of using a team approach is that it gives everyone a chance to establish cross-sectoral personal relationships. These relationships not only make working together easier in the context of the HIA, but also improve relations among sectors for the future. HIAs, after all, aren’t the only processes that can benefit from various state agencies cooperating, or from collaboration between the government and the community.

• Become familiar with the current state of the project or policy, and with the decisions that can and/or must be made. Can any or all aspects of the project or policy be cancelled or changed, and if so, which ones? Are there other projects or policies dependent on this one, or vice versa, and what are they? What is the project or policy meant to accomplish? What are its benefits expected to be, and to whom? Does it affect any vulnerable populations or groups?
• Determine what evidence is needed. Different HIAs will need different types of evidence. Some may rely to a large extent on local first-hand accounts and interviews. Others may require monitoring of such things as water pollution or traffic flow. Still others may rely in part on epidemiological studies (broad-based examinations of health problems from many angles). Almost all will need some combination of evidence types. Types of evidence that might need to be sought out include:
• Existing evidence. Studies of the issue that are relevant to the current situation, studies of the population(s) and geographical area(s) to be affected, statistics, etc.. These may be available from the various agencies involved, or from consultants, or may need to be found in professional journals, in libraries, or on the Internet.

Proponents of HIA emphasize that it’s important to search both the existing literature – i.e., published research – and “gray literature,” evidence that’s been gathered but not published. This may be statistical data that’s been gathered for funders; physical evidence, such as soil samples, that’s been taken and kept for other purposes (checking on the best places to plant a particular crop); interviews done in the course of undergraduate courses; etc.. Often, studies and evaluations conducted internally by NGOs or government agencies fall into this category as well: they’re meant not for publication, but merely to guide the work of the organization or agency.

• Evidence that needs to be gathered. There are several types of evidence that can be useful here. One is conditions on the ground – the physical state of the geographic area, logistics (transportation, power, water, etc.), proximity to residences and frequented areas (schools, churches, parks, commercial districts), and the situation of the affected population. (Once again, agencies might be helpful here, as will experts in the field.) Another type of evidence lies in information from key informants and the community at large – community leaders or spokespersons, advocacy groups, people with an understanding of the area’s history, and people affected by the project or policy under scrutiny. A final type of evidence consists of studies or statistics that need to be conducted or gathered by the HIA, particularly on vulnerable populations. This work may be done by consultants or, where appropriate, by assessors or other members of the team.
• Assign responsibilities for all parts of the HIA. Everyone should understand clearly just what her role is – planning and oversight, accomplishing specific tasks, attending meetings, contacting or interviewing people, etc. – and the time frame it entails. The assessors are generally responsible for overseeing the whole process, in addition to whatever other specific tasks they take on, and making sure that team members fulfill their commitments and meet deadlines.
• Assessment. Up to this point, you’ve been planning. Now it’s time to perform the actual assessment – gather and study the evidence, and identify the nature, size, and targets of potential impacts under different options. The steps here aren’t really steps, in that most can be undertaken at the same time, if there are a number of people involved in the assessment.
  • Review existing evidence. This is largely a matter of tracking down and reading through studies and statistical reports, both published and unpublished. It might be assigned to one experienced researcher while others work on other tasks. (It may involve digging in university libraries and in the files of government agencies and departments – that’s where good relationships with people from many sectors come in handy.) The reviewer carries the responsibility to determine the reliability of studies and other existing evidence. Not every study is constructed or conducted well, and not all conclusions drawn are necessarily logical or accurate. It is the task of the reviewer to decide whether the study was constructed so that it would actually measure what it proposed to, and whether the researcher’s interpretation of the results bears up under scrutiny. If not, the evidence shouldn’t be used, or should be presented with the explanation that it’s suspect in some way.

Key steps in undertaking an objective and methodical review are:

• Using a standard approach to guide the process.
• Being systematic.
• Focusing on a specific question.
• Assessing the quality of the studies included in the review.
• Analyzing and combining findings.
• Presenting clear conclusions and recommendations

Following these steps will result in an unbiased consideration of findings, and will bolster one of the key values behind HIA: the ethical use of evidence.

• Familiarize yourself with the proposed project or policy. Visit worksites, natural areas, factories, mines, farmlands, roads, etc., that the proposed (or current, if that’s the case) project or policy affects and learn all you can about it. Obtain and study blueprints, maps, proposed routes, and the like. Get to know the neighborhood, region, etc., which the project or policy will affect, what the residents’ circumstances are, what the geographic and social boundaries of the project or policy are, what connections they have to other neighboring or farther-away geographic and social areas. Understand the intentions of the decision-makers – their assumptions about the costs and benefits of the project or policy, its intended effects, etc. Be clear on the differences between the proposed project or policy and what currently exists. Research all the relevant laws and regulations. Understand what, if anything, would have to change if the project or policy were implemented. Know what areas the proposed project or policy might affect in addition to the particular one it concerns.
• Learn what the range of options is. Some projects or policies may be open to cancellation, or to any changes that need to be made in them in order to address health impacts (we don’t need this road so badly that we’ll risk adverse health effects to build it.). Others may be modified only in certain ways (the road has to be built – the question is where to put it.). Still others may be severely limited in the changes they can absorb (the road has to go through here, but we want to soften the health effects of its construction and use on the local population.). If there are defined options – the road can go here, here, or here (Options 1, 2, or 3) – be aware of what they are, and of whether they are the only options possible, or whether others could be considered if they were practical.
• Conduct individual and group interviews, hold meetings, administer surveys, etc., to gather other evidence and obtain community input.

The community or population should be kept informed throughout the process. Whether or not there’s a participatory planning group, the community should know that HIA exists, who is involved, and who they represent. The HIA should be described to them at the beginning, and they should be kept current on its progress. This will help to keep citizens from feeling that the government or big business or the government-corporate conspiracy is simply doing whatever it wants under a cloak of secrecy, and will find and decide whatever it pleases (and will also keep it from doing just that.)

• Gather or compile statistics and other evidence currently unavailable which is necessary for a full picture of the situation. In some cases, when time and resources permit, that may involve conducting a study specifically for the HIA.
• Gather information available from the various agencies, NGOs, think tanks, businesses, institutions, and other groups whose responsibilities or concerns are directly or indirectly relevant to the HIA or the issue, sector, geographic area, or population potentially affected. Evidence here may include such things as SES (socio-economic status) data, health and demographic statistics, scientific information, etc.
• Assess the impacts of the proposed project or policy on the health of populations affected. This is, in some sense, the meat of the HIA. Once the evidence has been gathered and studied, it needs to be analyzed to understand possible health impacts. This can be a complex exercise, involving not only immediate effects on health in medical terms – air pollution that can cause or aggravate respiratory illnesses, for example – but also social determinants of health.

A development or policy that displaces people from a neighborhood and thereby disrupts families and social networks may have as much of an effect on their health as air pollution or the dumping of carcinogens. An industrial development may impact air pollution many hundreds of kilometers away, either through actual emissions, or in the form of increased truck traffic. It may also upset the economic balance of an area, throwing people on the financial edge into poverty, or lifting them out. The latter circumstance creates a dilemma, since it leaves the decision-makers weighing the positive health impact of economic security against the negative of increased medical risks.

But this is the purpose of an HIA. It isn’t meant to tell decision-makers what to do, but rather to give them the whole picture so they can make an informed decision. If that decision is difficult, and involves contradicting factors, it is even more important that they make it with their eyes open, and are able to explain the reasoning behind it.

It should be noted that HIAs can also serve to guide policy or projects outright in a positive direction. Karen Lock, in a BMJ online article (see Resources), cites a regional development plan that was designed around an HIA conducted to determine what kind of development would provide the strongest positive (and, one assumes, the weakest negative) impact on the health of the area’s population.

• Determine the impacts that come with different options. Again, this can be complex, and isn’t guaranteed to be 100% accurate. How accurate it is depends on the expertise and experience of those conducting the HIA, as well as how much they consult with others in related fields to make sure they know all they can about the possible consequences of various courses of action. It also depends on whether options are predetermined or whether they can be generated by the HIA team, based on the evidence.

There are some basic questions that you can ask to help think about options and their impacts. If a negative health impact comes with the plan of the project or policy as it exists, how could it be eliminated? Are alternatives practical? Are they affordable? Who will they benefit? Who will the plan benefit if it is left as it is? Is there an option that turns the negative into a positive? (Creating a pedestrian-only space in a development may both eliminate the threat of injury and illness to children playing outside, and create an area where people can create social bonds and exercise as well, thus promoting healthy practices.)

Asking these kinds of questions and weighing the answers should give you a base for providing options and making recommendations, the next stage in the process.

• Reporting and recommendations. Once the evidence has been analyzed and the assessment completed, the HIA team delivers a report to the commissioners of the process, the community, and the various agencies, organizations, and institutions involved. The report has two parts: The first describes the proposed project or policy, the HIA process, the evidence gathered, the conclusions drawn, and the options considered. The second consists of recommendations to minimize negative and enhance positive consequences for each option. Where it’s appropriate, recommendations should either present predetermined options in priority order or suggest other options (also prioritized) based on their analysis of the situation.

The recommendations should be generated based on the evidence. This means being non-political and objective, using all the relevant and reliable evidence, analyzing it scientifically where possible, and trying to understand and reconcile (or explain) conflicting conclusions where they exist. It also means weighing all the factors involved, not only health. While an HIA is meant to assess health impacts, one of the assumptions behind the process is that there may be several conflicting purposes – often all positive – and that in some cases, you can’t have your cake and eat it, too. The decision-makers may have tough choices, and the HIA process can help them.

The report should be framed so that everyone involved can understand it. If there are complex scientific, engineering, or other considerations, they should be included in the full report, but there should be a summary that’s understandable for the average person that explains the evidence and the conclusions drawn from it. It’s particularly important that those affected by the project or policy have a clear understanding of what was reviewed, what the conclusions and recommendations were, and to what extent their concerns were addressed. If they trust the process, they’ll be much more apt to support the final decision.

The report should be presented directly to decision-makers, and conclusions and recommendations explained at length and in person by those who conducted the HIA. It’s crucial that decision-makers understand the report completely, so they can use the information in it to best advantage.

The report should also be available to all stakeholders, and not just as a public record that they can find at the town hall or in the national archives. It should be easily accessible – sent to all affected households, if that’s a manageable number, for instance, and/or published in the newspaper or distributed to public libraries. It could also be sent to organizations that serve the affected population, or presented at public meetings. However it’s done, efforts should be made to ensure that the community knows that an HIA has been conducted, and what it’s found.

It’s also important that everyone – from decision-makers to the general public –understand that HIA is not a directive, but a tool to help decision-makers reason out the best course of action. They may choose not to take all or any HIA recommendations, but they should be able to explain why, and to defend their decisions with counterarguments.

• Evaluation of the HIA’s effectiveness. As we’ve discussed, HIAs can be directly effective (the HIA resulted in changes to the original project, plan, or policy); generally effective (the HIA was conducted and considered, but didn’t result in any changes); opportunistically effective (the HIA was used only to confirm or support the original proposal); or ineffective (the HIA was ignored, or so poorly conducted as to be useless.) The HIA process, its results and conclusions, its recommendations, and its effect on decision-makers all need to be considered in an evaluation, in order to understand whether it was effective, and why or why not.

The process can be evaluated along several lines. How well did it reflect HIA’s guiding values of democracy, equity, sustainability and ethical use of evidence? How participatory and inclusive was it, and how well did it do at convincing stakeholders to participate? How successful was it at encouraging inter-sector cooperation? How well were responsibilities divided (if there was more than one person involved in conducting the HIA)?

Did the conclusions consider all the evidence? Did they accurately reflect the information contained in that evidence? Did they take into account all the determinants of health involved? Did they consider the feelings, fears, and opinions of the people affected? Did they acknowledge and describe conflicting health concerns (air quality vs. financial security, for example)?

Did the recommendations follow from the conclusions? Were they reasonable, considering such factors as expense, bureaucracy, logistics, hardship to citizens, etc.? Were the impacts on vulnerable populations given serious consideration and priority?

Were recommendations followed? If not, why not? If so, how were they implemented (e.g., was there a law passed, were actions modified, different materials substituted, a different route chosen, etc.)? How helpful was the HIA to decision-makers from their point of view?

The outcomes of the project or policy might be considered as well, but would be more likely to fall under an evaluation of the project or policy itself. That evaluation would be ongoing, and, ideally, would involve revisiting and perhaps revising some of the original recommendations of the HIA, as well as providing feedback on the effectiveness of the HIA process.

Conditions, populations, and economic circumstances change, and health impacts may change with them. New information surfaces and some new health threats appear, while former ones disappear. When that happens, there should be adjustments that reflect the changes and work to continue to support healthy communities. HIAs, and paying continuing attention to their conclusions and recommendations, can help projects and policies to remain dynamic, and to respond to the real health needs of the community, region, or nation they’re meant to benefit.

In summary

Health Impact Assessment (HIA) is a process that attempts to understand and make recommendations about the possible health impacts of local, regional, national, and international projects, plans, and policies. It involves all the players – government agencies in several sectors, contractors and developers, local officials, civic institutions, people affected by the proposed action or policy, etc. – to at least some extent in the planning and carrying out of the HIA, and is meant to inform them of its results as well.

An HIA is not meant as a directive for what decision-makers should do, but rather as a tool to give them the best and most accurate information possible to work with. They aren’t bound to its recommendations, but can use them to weigh competing interests and goals, and to make decisions that seem to carry the most overall public benefit, and the least potential for conflict.

HIAs are guided by the values of democracy, equity, sustainability, and the ethical use of evidence. If these values are practiced, a well-conducted HIA that is carefully considered by decision-makers can result in not only a well-planned and well-executed project or effective and equitable policy, but in community buy-in and support, and in a project or policy that truly protects and enhances public health and contributes to the creation of a healthy society.