Health for All: Making Community Collaboration Work

Health for All Making Community Collaboration Work Health for All Making Community Collaboration Work Howard P. Gree...

Author: Howard Greenwald | William Beery

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Health for All Making Community Collaboration Work

Health for All Making Community Collaboration Work

Howard P. Greenwald and William L. Beery Health Administration Press, Chicago

Your board, staﬀ, or clients may also beneﬁt from this book’s insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424-9470. This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The statements and opinions contained in this book are strictly those of the author(s) and do not represent the oﬃcial positions of the American College of Healthcare Executives or of the Foundation of the American College of Healthcare Executives. Copyright © 2002 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher. 06

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Library of Congress Cataloging-in-Publication Data Greenwald, Howard P. Health for all, making community collaboration work / Howard P. Greenwald and William L. Beery. p. cm. Includes bibiographical references and index. isbn 1-56793-180-4 (alk. paper) 1. Community health services. 2. Medical cooperation. I. Beery, William, 1994- II. Title. ra445 .g744 2002 362.1'2—dc21 2002020502 The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ansi z39.48-1984. ™ Acquisitions editor: Marcy McKay; Project manager: Joyce Sherman; Text design: Matt Avery; Cover design: Anne Locascio Health Administration Press A division of the Foundation of the American College of Healthcare Executives 1 North Franklin Street, Suite 1700 Chicago, il 60606-3491 (312) 424-2800

To Romalee and Madeline

Table of Contents Foreword

ix

Preface

xi

Acknowledgments

xiii

Part I: Coll aboration Past and Present 1

The Promise of Collaboration

3

2

Health Systems and Community Health: Tradition and Innovation

23

3

Partnership Challenges

59

Part II: A Case Study: The Mutual Partnerships Coalition 4

An Ambitious Partnership: The Mutual Partnerships Coalition

79

5

A Case Study in Conﬂict

115

6

Project Outcomes

145

Part III: Lessons Learned

79

7

Assessing Accomplishments: Traditional and Nontraditional Approaches to Evaluation

167

8

Collaboration Intervention: Challenges and Triumphs

213

Appendix A: Resources to Help Implement Community Partnerships

227

vii

Appendix B: Other Resources for Community Collaboration

235

Appendix C: Key Foundations Involved with Community Collaboration

247

Appendix D: Further Reading for Chapter 2

251

About the Authors

255

Foreword

In Health for All: Making Collaboration Work, Howard Greenwald and William Beery have extended their past years of highly productive personal collaboration to delineate the social context, promises, and processes of community coalitions for health. Although health service institutions in the United States such as hospitals, health departments, and universities have long recognized the need for “outreach” to their communities and undertaken eﬀorts in that direction, something new has emerged in recent years. The health service institutions, in approaching communities, have begun to encounter more fully than previously—and sometimes partner with—two types of agencies. One consists of longestablished organizations such as churches and schools that are indicating considerable interest in what they can do for the public’s health as well as that of their own constituents. The other is composed of organizations, often informal at ﬁrst, that are arising in communities for a variety of social purposes, for example, to safeguard neighborhoods and combat crime, improve education, and serve seniors or children and families. Often these groups include activists who are passionate about social betterment and have a knack for leadership. This grass-roots movement seems to be advancing across the country, possibly in substitution for declining ix

conﬁdence in the traditional agencies presumed to attend to such matters. The book analyzes experience in developing collaboration between the “two sides,” major health services organizations on the one hand, and on the other, community groups and agencies that are interested, or can be interested, in health. Their coming together involves some shift in authority toward the community forces, often called “empowerment” by the traditional institutions. Greenwald and Beery describe in considerable detail this shift, which occurs in varying degrees. The spectrum ranges from the previous eﬀorts by the major health services organizations to community groups to genuine delegation of power and what the authors consider the ideal: citizen power. Their book focuses on what is highly important in this dynamic situation, namely, “how to” advance health. They draw on their own extensive experience in the movement and evaluation of similar work by others. Substantial attention is given to a case study of the Mutual Partnership Coalition in Seattle, Washington. This organization brought into play such diverse groups as an inner-city educational and cultural organization, the local housing authority, a senior services agency, a faith-based organization, and Group Health Cooperative of Puget Sound (the convener). The account deals with, among other issues, the challenge (not pretty) that a serious conﬂict within the organization posed. The authors also describe other episodes in the movement such as Project Immunization Virginia. Two particularly valuable aspects of the work are the explicit statement of lessons learned and the appendices that list the extensive resources available to help community coalitions for health, including foundations that are interested, and strategies for evaluation. Lester Breslow, M.D., M.P.H., Sc.D. Professor Emeritus, Health Services ucla School of Public Health

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Health for All

Preface

Health for All: Making Community Collaboration Work draws together and integrates hitherto scattered ideas and experiences associated with collaborative community interventions. Ubiquitous throughout the United States, the collaborative community intervention brings together diverse forces capable of determining the health of communities. The collaborative community intervention can be viewed as a social movement within the worlds of healthcare, public health, and health policy. It departs from tradition by integrating the interests and eﬀorts of powerful institutions, grass-roots groups, and private citizens. It also breaks new ground by focusing not on treatment of disease but on creating conditions within communities that can prevent illness and promote well-being for residents of every age and economic stratum. Hence, the book’s title: Health for All. The book is at the same time a conceptual and practical guide. It is both a celebration and a critique of the collaborative community intervention. It highlights the contribution community collaboration can make to health in the new century, and it provides concrete information about the factors that can keep this dream from becoming reality. Most important, this book provides practical lessons

xi

intended to promote fulﬁllment of the potential of collaborative community interventions. The chapters to follow oﬀer information of particular value to leaders and managers of healthcare organizations who have an interest in launching collaborative eﬀorts with the community. The basic concept of community collaboration is reviewed. This review emphasizes the importance of community collaboration as a means for mobilizing ideas, resources (material and political), and energies from highly diverse quarters. Only through collaboration, it is noted, can the ideal of community health be realized. Alerting leaders, managers, practitioners, and citizen-activists to the power that can be unleashed by coalitions is the book’s principal mission. However, a message presenting only the payoﬀs of community collaboration would be misleading. Everyone who contemplates a collaborative venture must be aware of the hurdles that can stand in the way of success. Thus, this book pays signiﬁcant attention to factors that can derail even the most conscientious and well-funded eﬀorts. The chapters include stories about programs initiated with insuﬃcient preparation, collaboratives beset with conﬂict, and expertly planned evaluation eﬀorts that resulted in negative ﬁndings. Many lessons are to be learned from these cases. Over all, the authors wish to convey encouragement: Collaborative interventions represent the best values in the American tradition, and community health reﬂects the most progressive contributions of the health sciences. We hope the book will inspire creativity and experimentation and endow such eﬀorts with the practical wisdom required for success. Howard P. Greenwald William L. Beery

xii

Health for All

Acknowledgments

The community health movement involves government agencies, foundations, private organizations providing healthcare, healthcare professionals, scientists, community activists, and many individual private citizens committed to making a diﬀerence. This book reﬂects the ideas and experiences of the full range of organizations and people who have initiated and participated in the movement. The formal acknowledgments that follow can express thanks to only a few of those who have inspired and supported us in writing this book and in founding and developing the movement itself. We ﬁrst acknowledge Group Health Cooperative of Puget Sound, Washington. “Group Health,” as folks in the Paciﬁc Northwest know it, occupies a venerable place among healthcare institutions in the United States. Founded by visionary consumers and providers in 1947, Group Health Cooperative is today one of the largest healthcare organizations in Washington State. It has maintained its nonproﬁt status and consumer governance structure even as successive waves of change have altered healthcare throughout the United States. For its entire history, Group Health Cooperative has initiated and sponsored the type of collaborative community intervention that is the focus of this book. It now serves as the parent

xiii

organization of the Group Health Community Foundation, under whose auspices this book was written. Few of the ideas in this book can be claimed exclusively by the authors. Many have been developed by the evaluation team of the Group Health Community Foundation, which has been active in advising and evaluating collaborative community interventions for two decades. Particularly worthy of recognition are Dave Pearson, Sandra Senter, and Allen Cheadle. Special thanks are due to Carolyn J. Stemshorn, who played an important role in preparing the manuscript. We wish to express gratitude to several scholars, commentators, and scientists who have been instrumental in developing the conceptual and factual basis of community collaboration as well as providing important critiques: Tom Bruce, Ed Wagner, Marshall Kreuter, Gary Nelson, Alicia Procello, Gary Yates, Tom David, Joe Hafey, and Maria Campbell Casey. Several agencies and foundations deserve special thanks for providing both funding and encouragement for the projects we have been privileged to help launch, advise, and evaluate: the Henry J. Kaiser Family Foundation, the W. K. Kellogg Foundation, The California Wellness Foundation, The California Endowment, the Partnership for the Public’s Health, the federal Centers for Disease Control and Prevention, the American Cancer Society, the Public Health Institute, and the Group Health Community Foundation. A large number of colleagues from public and community agencies in Seattle deserve our gratitude. Of great importance were agency executives Gregory Davis, John Froyd, Margaret Strachan, Marsha Johnson, and Tom Rasmussen. Key staﬀ included Craig Shimabukuro, Joan Greathouse, Katherine Woolverton, Sally Friedman, Paul Howard, Karen Hulbert, Mary Diggs, Helleyne Summerrise, Candice Adudell, Ruth Famm, and Kathy Kelly. Finally, we thank the many public and private agencies and community residents who have participated in the collaborative eﬀorts reported here. Although too numerous to mention individually, all have made invaluable contributions. xiv

Health for All

PART ONE

Collaboration Past and Present

“Coalition” is a concept that is today embraced in an extraordinary range of contexts. World leaders look to coalitions to address the new century’s most critical concerns. In the United States, oﬃcials have found coalitions useful in addressing public matters traditionally handled by bureaucrats, ﬁnancial movers, or technical experts. Responsibilities ranging from keeping a city’s favorite sports team from moving to promoting opportunities for the chronically unemployed are today delegated to coalitions. The coalition concept speaks to the core American value of participation. Of equal importance, it allows individuals from many walks of life and organizations in diverse specialties to contribute their expertise to problem solving. Coalitions promise to promote solutions to problems that are technically optimal and most likely to gain public acceptance. This book addresses coalitions and collaboratives involving organizations concerned with health. Hospitals, health maintenance organizations (hmos), public health departments, community clinics, and numerous additional entities have joined together for common purposes, perhaps most often in prevention of illness. Grass-roots participation has been invited and often emphasized. By joining coalitions, organizations concerned with health have sought not 1

only to reduce illness and injury, but to demonstrate their public citizenship through measurable community beneﬁts. Part I of this book provides a summary of the objectives that have been sought through coalitions. It discusses the components of coalitions, with special emphasis on collaboratives which are (1) closely tied to the local community and (2) aimed not only at promoting physical health but at enhancing the community’s general wellbeing. Part I provides several examples of community coalitions to illustrate the range of objectives pursued by collaboratives and indicates the diverse forms the structures of these entities may take. Finally, part I familiarizes the reader with the challenges collaboratives must meet to become successful.

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Health for All

CHAPTER 1

The Promise of Collaboration

INTERVENING IN COMMUNITIES

The twenty-ﬁrst century has begun with a fresh-sounding concept in the conversations of people seeking social transformation: the collaborative community intervention. This book addresses the collaborative community intervention as applied to an objective of key importance: improving the health of people in communities throughout the United States. Each element of this concept deserves special attention: • Collaborative. Collaboration signiﬁes association of individuals or organizations with divergent histories, interests, and perspectives working together on projects with a common purpose. According to political scientists, the United States is a pluralistic society. Groups and “interests” in cities and neighborhoods normally compete for political power, business opportunities, public funds, and the attention and support of citizens. When people or groups collaborate, they seek to put aside their diﬀerences and concentrate on objectives they all hold in common.

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• Community. Community reﬂects a feeling of familiarity, loyalty, and pride among individuals about a place they live, activity they engage in, or value they hold. The term community is most often applied to physical location. People consider their block, neighborhood, or city their community. In addition, communities are formed within professions, among people practicing the same religion, and among devotees to the same sport. In every true community, members are able to deﬁne the boundaries of that community. Within community boundaries, members experience a sense of comfort and common interest. • Intervention. Intervention means attempting to take control over something of signiﬁcance in the environment. Often, the term has a negative connotation, as when police intervene in the traﬃcking of contraband or military forces invade a neighboring country. In a more positive sense, intervention signiﬁes taking action to reduce threats to a community’s well-being, such as disease, chronic unemployment, or the criminal element. Intervention may also seek to recognize and enhance a community’s capacities, encouraging residents to use their skills to improve the lives of others or mobilizing resources to enable young men and women to achieve their potential. By powerfully combining and directing material and human resources, the collaborative community intervention can become one of the most eﬀective means in the United States today for improving health and promoting well-being. A collaborative community intervention involves making contact with people outside one’s own organization and mounting a combined eﬀort toward a common goal. Participants are likely to retain their diﬀerences, but, in eﬀective coalitions, most put them aside long enough to allow the common focus to work.

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Health for All

The hospital in a small western town finds its emergency room extensively used for routine healthcare needs. The cost to the hospital is significant. This takes place despite a state program that provides inexpensive health insurance to low-income families. The hospital seeks the community’s help. A coalition is started to make high-quality, accessible care more readily available. Members of the coalition include the health department, the school district, a large employer, a representative of the Migrant Health Service, and several individuals not a;liated with any agency. Intense exchanges take place within the coalition about why people look to the emergency room for everyday needs. It is apparent that most emergency room users are Hispanic people whose employers do not provide health insurance. The comment is made that these families feel uncomfortable revealing to private doctors that they are beneficiaries of the state program. It is further revealed that the only Spanish-speaking nurse practitioner in town works at the hospital emergency room. Coalition members pool resources to address the problem. The hospital provides o=-site space for a community clinic. The employer donates start-up funds. The health department agrees to recruit Spanish-speaking providers. The community residents provide advice about how to make the facility attractive to the community and how to help users complete forms. Everyone agrees to participate in directing the project and seeking funds to make it self-sustaining.

This book concerns health; many examples with aims similar to the intervention described above will follow. However, the principle of collaborative community intervention has been applied to numerous concerns other than health in areas as distinct from health as law enforcement and natural resource management. For example, “community policing,” a concept of growing importance in law enforcement, makes extensive use of community coalitions:

The Promise of Collaboration

5

A city police department finds itself embattled by dissatisfied citizens. Community leaders in several neighborhoods have complained to the city council about police services. These leaders assert that burglary and vandalism are daily occurrences and that drug tra;ckers and prostitutes operate openly at known locations. At the same time, the city’s minorities are angry about alleged “racial profiling.” Blacks, Hispanics, and young Asians argue that police stop them simply because they are minorities. Seeking to avoid reprimands, police o;cers become cautious about stopping members of these groups for investigative purposes. In response to this cross-pressure, the chief of police assembles the Chief’s Advisory Council, which includes community and minority group leaders as well as young people whose age or appearance frequently attracts the attention of police o;cers. The council provides the chief with information regarding where o;cers should be deployed. Police training personnel become better informed about the community and thus are better able to instruct o;cers about who is and is not likely to be involved in crime. Communities throughout the city become better informed about the crime problem in their neighborhoods and receive encouragement to take informed action.

Another example is the management of publicly owned resources, such as rangeland and water, which has become a divisive issue in rural areas. Community coalitions have demonstrated their value in advising government agencies about use of these resources. Actions are taking place in this manner: A valley of streams and rolling hills has been cattle country for generations. Recently, a
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Health for All

Faced with conflicting demands from agricultural interests and environmentalists, the federal Bureau of Land Management establishes a procedure for community-wide decision making. Federal o;cials identify community leaders from both camps. Residents committed to the community but uncommitted to either side in the dispute are also sought. Focus groups and town meetings are held. After much wrangling, the participants find common ground on a core issue. They share concern over potential water diversion due to proposed large-scale housing development. They prepare a memorandum for the federal land managers regarding diversion of water and supporting its limitation. Former disputants establish a local organization to fight excessive development, which they sustain via contributions from the community.

Collaborative community interventions can be initiated by public agencies, private foundations, or communities themselves. They can unite people or interests that are traditional allies or foes. They can make their mark and wither away, or become community institutions, but collaborative community interventions in all forms have the ability to magnify the power of isolated people or groups, pool knowledge and resources, mobilize people to action, and promote acceptance of new ideas. Collaborative community interventions can transform neighborhoods and cities. In addition to their potential eﬃcacy, collaborative interventions ﬁt better with American values than other methods for changing communities. Numerous and highly visible attempts to change communities have originated from outside them. History provides endless examples of attempts by some individuals to change the way others live their lives. Formulas for change, no matter how beneﬁcial, have an undemocratic feel when imposed from outside the community aﬀected. In a society accustomed to self-determination, people resist such initiatives. One of the most compelling features of collaborative community interventions is their ability to empower rather than impose.

The Promise of Collaboration

7

H E A LT H C A R E , P U B L I C H E A LT H , A N D C O M M U N I T Y C O L L A B O R AT I O N

The collaborative community intervention concept has achieved its greatest visibility in healthcare and has done so in a very short time. Ventures carried out that are based on this concept owe their popularity to two circumstances. First, the public has made organizations concerned with health and healthcare feel a need for greater community involvement. Second, health professionals and researchers have become convinced that organizations concerned with health must look outside their boundaries to help solve today’s most important health problems. Hospitals, health maintenance organizations (hmos), and public agencies, moreover, are discovering that they can beneﬁt directly from the gains collaborative interventions bring to the community. Health-related organizations are experiencing pressure to become more involved in their communities, and collaborative interventions oﬀer a means for fulﬁlling these public expectations.

Public Expectations Decline in Public Trust

The late years of the twentieth century saw increasing suspicion by the public toward organizations concerned with health and healthcare. Public health agencies had sunk into the background with the apparent conquest of contagious disease. Like other public agencies, their eﬀectiveness and relevance came into doubt during the boom years of the 1990s. Doctors’ oﬃces were being replaced by managed care organizations, often viewed by the consumer as less caring and of lower quality. Hospitals were special objects of public suspicion. For-proﬁt operations became a visible part of the hospital industry in the 1980s

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Health for All

and 1990s. The fact that for-proﬁt hospitals were often parts of large corporations made the public more suspicious still. Critics charged that for-proﬁt hospitals skimped on care to enhance the bottom line. Trust in nonproﬁt hospitals also dropped. Most hospitals in the United States are nonproﬁt and have been key institutions in American communities for one hundred years. In the 1980s, however, critics began charging that nonproﬁt hospitals were less eﬃcient than for-proﬁt institutions. These critics pointed out that nonproﬁt hospitals enjoyed high levels of public support in the form of tax exemptions and the public dollars that helped pay for training of residents and care for indigent patients. The critics alleged that nonproﬁt hospitals represented a sort of sacred cow in the United States, which translated public largess into bloated payrolls and perks for executives. Certainly, nonproﬁt hospitals provided charity care, but according to critics, the value of this charity care was less than the dollars the public “gave” to the hospitals through tax exemptions. Hospitals of all kinds began fearing for their autonomy. Greater public suspicion could eventually result in tighter regulation. Nonproﬁt hospitals became concerned that they might lose their taxexempt status unless the public viewed them as positive contributors to public well-being. Insecurity regarding tax-exempt status peaked with the passage of Senate Bill 697 (sb 697) in California. Under this measure, nonproﬁt hospitals were required to document the contributions they made to the community’s well-being and report annually on these contributions to a state agency. The law was proposed and supported by organizations representing nonproﬁt hospitals, which wanted to assure the public that they contributed suﬃcient beneﬁt to the community to justify their nonproﬁt status. In response, observers across the country feared that regulatory agencies would lift tax exemption from organizations found to contribute too small a volume of community beneﬁt.

The Promise of Collaboration

9

Need to Document Community Benefit

Hospitals and healthcare organizations have always provided community beneﬁts. Increasingly, however, they believed they would need to document some beneﬁts outside of delivering care to those patients with cash or insurance. Community beneﬁts had to be quantiﬁable to support claims of tax exemption. Initiation or participation in large-scale collaborative community interventions could constitute the concretely visible contributions to community well-being the hospitals knew they would have to demonstrate. For the Books: Many Healthcare Organizations Overlook Their Public Contributions New public expectations, whether or not they have resulted in legislation, have caused healthcare organizations to re-examine the value of the public benefits they provide. In California, passage of sb 697 caught hospital accountants by surprise. Traditionally, hospitals have recognized the importance of liabilities such as bad debt (often resulting from providing charity care) for tax purposes and, of course, cash contributions to charity. sb 697, though, sent managers scurrying to identify other evidence of public benefit. Less traditional contributions appearing in sb 697 reports have included: •

• •

Value of in-kind resources provided by healthcare organizations to community coalitions—for example, meeting rooms and refreshments Value of sta= time allocated to coalition work or hired to participate in community projects Transportation expenses and time required by executives for work in collaborations Managers preparing reports required by sb 697 were often surprised to find how large a volume of resources the hospital

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Health for All

regularly contributed in community-related work. Years had gone by with these contributions remaining unrecognized and unquantified. In the atmosphere of more exacting public expectations, managers must review their customary and often-hidden community benefit expenditures and, for best results, do so in the company of tax accountants.

Newly Recognized Needs

Interest in collaborative community interventions has been stimulated by the discovery that communities and organizations concerned with health have complementary needs. Organizations that provide healthcare rightly see their mission as treating and preventing disease. Strong arguments are being made that fulﬁlling this mission requires community involvement. In a parallel manner, the ability of organizations concerned with health to survive economically seems to depend more and more on the well-being of the communities that surround their facilities. Increasingly, appreciation of the importance of the community’s health is shared by nonhealth sectors of the local economy and by employers of all kinds.

Modern Health Problems

Public health agencies, hospitals, and individual providers have a core mission of reducing the burden that illness and injury imposes on the public. In earlier eras, hospitals and health professionals could feel that they were doing their best for the patient by providing him or her with direct medical treatment. More and more today, however, practitioners are realizing that factors such as social surroundings and individual behavior

The Promise of Collaboration

11

determine a person’s health and longevity. Researchers today argue that up to 80 percent of mortality is preventable, often through changes in lifestyle. Other researchers have highlighted social capital as a key factor in an individual’s health. A community’s level of social capital reﬂects the shared resources available to members of a community, such as parks, community centers, schools, and public meeting places. Social capital also comprises the level of interest people have in their communities and the degree to which residents sense a common bond with each other. Widely respected studies have shown that people who enjoy strong networks of friends and family live longer than people who are isolated. People who live in localities in which income diﬀerences are small tend to have longer life expectancies than residents of areas in which income diﬀerences are large. Treatments of a technical nature carried out by health professionals typically do not change human behavior. People do not usually come to healthcare providers for the purpose of changing their behavior; most healthcare providers are trained to treat illness rather than assist individuals in changing their lifestyles. This is true even in hmos. The label may suggest a capability to improve health, but healthcare providers of any kind do most of their illness prevention using technical procedures, such as immunization and early detection of disease. Hospitals, hmos, and public health departments are not in the business of building a community’s social capital. Alone, they have little or no eﬀect on a community’s overall well-being or its level of social capital. Hospitals act as major employers and have traditionally carried out charitable acts, but they can do little to aﬀect a community’s cohesiveness or ability to do things for itself. Organizations concerned with health have their best chance of addressing the basic causes of illness and injury by participating in collaborative community interventions. In collaboration, they can help build public consciousness regarding prevention, groundswells

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Health for All

of the kind that made the use of tobacco socially unacceptable almost everywhere. They can contribute to development of social capital by providing meeting places, sparking volunteerism, or giving public visibility to neighborhood issues. Acting alone, they may have little impact. Health Organizations and Neighborhoods: A Mixed Heritage Throughout the late twentieth century, relationships between healthcare organizations and neighborhoods were neither consistently positive nor negative. Under lush public and private funding, hospitals and university medical centers grew massively from the 1950s to the present. Many organizations experienced colossal growth and building booms, as wings, buildings, and sometimes entire campuses were added. Increases in physical plant facilities had destructive e=ects on neighborhoods throughout the United States. Housing was razed to make way for hospital buildings and new research labs. Streets were blocked as a consequence of large-scale development. Neighborhood shopping districts became tra;cclogged thoroughfares. Building heights rose and medical o;ce buildings followed in the development’s wake. Formerly bucolic communities took on an urban and industrial feel. These transformations weakened neighborhoods, sometimes fatally. People moved away from the noise and congestion. Those who remained often felt resentful. Community members bristled at every hint of further expansion, mounting opposition at city council and zoning board meetings. As a counterbalance, hospitals could become major employers and symbols of a community’s well-being. Many inner-city neighborhoods look to the hospital as a primary source of jobs. Unlike other businesses, hospitals did not relocate to the suburbs as a neighborhood’s income level declined. Attempting to close an inner-city hospital could spark demonstrations.

The Promise of Collaboration

13

The Dependence of Health Organizations on Communities

Thus far, the rationale proposed for collaborative community interventions has emphasized, ﬁrst, better serving the healthcare organization’s core mission through an updated outlook on illness, and second, a general sense of altruism. But healthcare organizations can make more self-interested use of the concept. The need of nonproﬁts to provide concrete evidence of beneﬁt to the community has already been mentioned. Participation in, if not emphasis on, community involvement may be a necessity for reasons that are even more basic. Far from mere altruism, organizations concerned with health help ensure their prosperity and survival through collaborative community interventions. The prosperity of many healthcare organizations is highly dependent on the quality of the neighborhoods that surround their physical facilities. Strong communities make better environments for healthcare organizations than troubled ones. A successful business organization requires location in a strong community in which low crime rates, desirable housing, high rates of employment, and good personal health are evident. Consider a healthcare facility fortunate enough to be located in such a community: it can attract high-quality employees more easily. People wish to spend time in the area both during the workday and after hours. They are willing to buy or rent housing nearby. They come to work with high morale, feeling good about their surroundings and safe in their workplace. A hospital or hmo located in a strong community can also more easily attract desirable patients. Doctors are more willing to admit patients to a facility with attractive surroundings, which, in turn, promotes patient satisfaction. At the same time, a strong community contributes desirable patients to an hmo: these are people who work, have health insurance, and feel motivated to take care of themselves by avoiding tobacco, excessive alcohol consumption, and exposure to high crime areas. The networks of viable social ties that 14

Health for All

characterize strong communities reduce the likelihood that patients will be dependent on healthcare facilities or social service agencies for assistance in the event of debilitating illness or following hospital discharge. Consider the opposite scenario. Healthcare facilities located in troubled neighborhoods have diﬃculty attracting long-term employees. People on the payroll may have long commutes to and from work, which reduce the amount of energy available for healthcare tasks. A troubled community presents the healthcare organizations with a complex set of interrelated ﬁnancial and patient-care problems. People who are discouraged by their surroundings are relatively unlikely to avoid health risks and comply with medical regimens. Managing their illnesses is made more diﬃcult by the likelihood of underlying chronic conditions. Hospitals that operate emergency departments in troubled neighborhoods face special challenges, including the responsibility of treating people without health insurance or alternative sources of care. The severity of this problem is increased by the high rates of crime and violence that accompany low income, conditions resulting in frequent admission to the emergency room of people with severe trauma and no money or insurance to cover the costs. In summary, organizations concerned with health and healthcare need to help care for their communities as well. The public service mandate that healthcare organizations have traditionally held is consistent with such activity, but maintaining a strong community materially beneﬁts the healthcare organization. Entering into collaborative relationships greatly enhances the ability of the hospital, hmo, or other health-related organization to promote conditions conducive to its own prosperity.

Funding as a Catalyst

The movement toward collaborative community interventions has beneﬁted signiﬁcantly from the availability of funds earmarked for The Promise of Collaboration

15

this purpose. Several large, private foundations have made major ﬁnancial commitments to the fostering of collaboration. During the 1980s, the Henry J. Kaiser Family Foundation initiated the Community Health Promotion Grant Program to stimulate development of collaborative programs designed to reduce health risks. The program funded at least 20 communities throughout the United States. During the 1990s, the W. K. Kellogg Foundation and the Health Research and Educational Trust cosponsored the nationwide Community Care Network (ccn), a 40-community eﬀort designed to promote the emergence of “seamless-web” healthcare systems through collaboration in many localities. California foundations made king-size contributions to the collaboration movement. In 1996, for example, The California Wellness Foundation launched the Health Improvement Initiative, which provided more than $20 million in cash and technical support to community collaboratives. Perhaps a dozen programs providing similar levels of funding for community-level collaboration followed. In 2001, the California Endowment committed nearly $40 million for initiation, development, and evaluation of collaborative interventions involving public health departments and other organizations throughout the state. This initiative, known as the Partnership for the Public’s Health, provided funding to 53 separate organizations. The Partnership for the Public’s Health appears to be the largest program of its kind to have taken place in California. Public agencies have absorbed the concept of collaborative community interventions into their grantmaking. In California, the Department of Health Services funnels much of its extramural grant budget for anti-tobacco interventions not to single organizations, but to collaboratives with proven community ties. Many federal procurements from the National Institutes of Health and the Centers for Disease Control and Prevention now require at least the presence of a community advisory board to ensure responsiveness of organizations involved in research or demonstration projects to the communities in which they operate.

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Health for All

T H E C O N C E P T O F C O M M U N I T Y H E A LT H

The popularity of collaborative community interventions has grown hand in hand with a modern movement in health and healthcare known as “healthy communities.” The key tenet of this movement is that of community health. Community health includes, but is distinct from, health understood as the absence of disease. The concept of community health encompasses the entire array of community features contributing to the quality of life. Healthy communities are not merely those in which epidemics are rare. They are communities whose members have their basic needs met and are hopeful about the future. In healthy communities people have jobs and health insurance. Crime rates are low. Behavior injurious to health is socially discouraged. People take responsibility for their health and conduct their lives with this end in mind. The level of social capital is high. A community of this description is, of course, an ideal, but it is useful for setting direction in collaborative community interventions. Community health encompasses much more diverse issues than physical health or disease. The activities most often undertaken by community interventions focus on health according to this deﬁnition. The healthy community perspective is closely linked with more traditional concepts of public health, as high levels of community health will deﬁnitely lower the individual resident’s risk of physical illness, need for health service, and dependence on public assistance.

THE BUILDING BLOCKS OF COMMUNITY INTERVENTIONS

This chapter closes with a guide to the typical partners in collaborative community interventions. This is not intended as an exhaustive list, but it will provide ideas for potential partnerships to

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readers interested in establishing their ﬁrst collaboration. Each type of organization cited can make a vital contribution to the collaboration.

Community-based Organizations

Community-based organizations (cbos) are a nearly essential ingredient in collaborative community interventions. cbos are deﬁned as organizations that focus in their work on a speciﬁc residential area, hire personnel who reside in that area, and owe their existence and legitimacy to residents of the area. Although the cbo is essentially a local organization, it often draws resources from national foundations, city programs, and federal grants and contracts. cbos may include churches, community clinics, community self-help organizations, and fraternal organizations with a local or ethnic base. The cbo’s presence is crucial in a collaboration for two major reasons. First, the cbo provides a special sense of legitimacy. In many collaborative eﬀorts, the cbo provides visible representation of the grass roots. cbos also have the ability to communicate with residents. They know the residents’ language and can claim their attention because of their familiarity in the neighborhood.

Public Health Departments

Public health departments, most often on the county or city level, are frequent participants in collaborative interventions. Public health departments have long-standing commitments to protecting the community’s health and have traditionally concentrated on control of infectious diseases. In that eﬀort they have monitored water supplies, controlled pests, and kept track of local rates of sexually transmitted diseases. Recently, public health departments have expanded their perspective to include community health as deﬁned above.

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These agencies often have professional employees who are eager to become involved in less traditional work. Departments of public health can often contribute technical expertise to a community collaboration in areas such as data collection and analysis and knowledge of public sector resources (including funding sources) of value to communities.

Municipal Agencies

Municipal agencies have long been involved in coalition-type interventions both in health and in other ﬁelds. An example of the uses made of coalitions by law enforcement agencies appears at the beginning of this chapter. Health-related community coalitions often include school systems and municipal housing departments. Collaborations linking school systems and health-related organizations make sense, particularly in the context of the healthy cities approach: young people in learning situations are good targets for health-related messages. Because housing authorities often serve populations with special needs, such as elders and people with physical dysfunctions, they can gain much from partnerships with healthcare organizations. Municipal agencies add value to coalitions by serving as a link with government. This link may help establish access to public funds and personnel, as well as legitimacy in the broader community. In addition, municipal agencies can promote access to populations that may beneﬁt from health interventions, such as children in school and elders at community centers.

Private Charities

Private charities long predate government programs. In many communities, private charities provide the bulk of assistance associated

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with speciﬁc health problems. American Cancer Society chapters in nearly every city, for example, provide transportation and recoveryrelated services for people with cancer; the United Way funds everything from youth groups to senior residences. People planning to establish community interventions focused on any speciﬁc need can often ﬁnd local charities that have been active in the area for some time. Private charities can contribute to the success of a coalition through expertise. These organizations bring signiﬁcant experience to the table in providing community services and managing service delivery at the person-to-person level. Executives of private charities also have widespread contacts among the rich and powerful in nearly every city.

Healthcare Organizations

Collaborative community interventions often originate through the initiative of a single hospital, hmo, or university medical and research center. Some of the most far-reaching coalitions, however, include multiple healthcare organizations. The atmosphere of competition in healthcare today constitutes a barrier to collaboration among organizations in this industry, but groups of healthcare organizations are in a position to solve each other’s problems rather than shift responsibility for a problem among each other. An individual healthcare organization can beneﬁt from other healthcare organizations that contribute access to additional populations and staﬀ already trained in needed areas. A Coalition Solves a Healthcare Crisis Solano County, a mixed urban, rural, and industrial area east of San Francisco, faced a crisis in the late 1980s. A facility that had provided the majority of services for the county’s indigent people had closed. No other medical safety net was available for these individuals.

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Executives at the county’s private hospitals were alarmed. The medical needs of thousands threatened to go unmet. These executives also feared an onslaught of indigent people seeking care at their facilities, threatening the financial stability of their hospitals and o;ces. The facilities that continued to operate joined together to form the Solano Coalition for Better Health. Each participant contributed financially to the common e=ort to establish a stand-alone clinic for the underserved. Commitments of public sector funds were secured. As the coalition matured, it expanded its activities into the area of community health. Private foundation dollars were obtained; community residents were invited to join the governing board; and a far-flung network of self-governing, community-oriented projects was launched.

SUMMARY

This chapter describes the rationale for collaborative community coalitions. Both science and tradition argue for an increasing dependence on partnerships of this kind. Research in communications and health behavior have demonstrated that large-scale behavior change, as required by healthy communities, is best accomplished in a setting with which targeted individuals can identify and which utilize the power of the group. Actions that include communities as participants reﬂect America’s democratic tradition. Examples of highly successful coalitions are presented. The promise of collaborative community coalitions is compelling. Necessary steps in fulﬁlling this promise include understanding the variety of forms coalitions may take, the challenges faced in making them successful, and the tasks required for assessing their achievements.

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CHAPTER 2

Health Systems and Community Health: Tradition and Innovation

F R O M D O M I N A N C E T O C O L L A B O R AT I O N

Chapter 1 highlighted collaboration as a recently adopted feature of healthcare systems. For many health professionals and administrators today, collaboration with outside people and organizations has not been customary, but traditionally, hospitals and healthcare providers have often sought bridges into the broader community to give assistance to people outside their doors or to seek resources from them. Health systems interested in collaboration today, then, have much to look back on for reference; both distant and recent history illustrate interventions of apparent merit. People intending to plan community collaboration eﬀorts are likely to ﬁnd some approaches highly appealing and others less useful for contemporary purposes. This chapter promotes better choice making among options through a review of the variety of community interventions carried out in the past. People and organizations concerned with health have always considered the community important. Stories from past centuries have celebrated the achievements of physicians who sought solutions to the health problems of their day outside their oﬃces. John Snow

23

(mid-nineteenth century) and Percival Pott (late eighteenth century), both English physicians, looked to the streets of London for sources of patients’ ailments. Pott found testicular cancer to be a disease of chimney sweeps and counseled people in the trade to protect themselves with appropriate clothing. Snow, a legendary ﬁgure in the annals of public health, traced a cholera epidemic to a contaminated public water pump. He stopped the epidemic by removing the pump handle. Hospitals and municipal departments of public health came into their own in the late nineteenth century and looked to the surrounding communities for both problems and solutions. In the early twentieth century, public health departments and crusading physicians focused on epidemics of contagious disease. Their eﬀorts addressed contributors to disease such as mosquitoes, rats, and sewage. Only in the 1920s did the work of healthcare professionals concentrate primarily on activities inside the hospital or oﬃce, which was made possible by technical developments in antiseptics and surgery. The trend accelerated mid-century with the development of antibiotics. Technical medicine seemed to solve the public’s health problems—why look elsewhere? In the same era, the need for resources caused hospitals and physicians to pay attention to the communities in which they operated. Before the advent of health insurance and managed care, people paid their doctors in cash on a fee-for-service basis. The community’s level of prosperity aﬀected the doctors’ likelihood of getting paid promptly if at all. Likewise, hospitals became established and maintained operations primarily through donations from the community’s prosperous members. Even today, many hospitals bear the names of the ethnic communities whose members provided private donations that made their establishment possible: Swedish Hospital in Seattle, Washington; French Hospital in San Francisco; hospitals founded by Catholic and Jewish communities everywhere. Only at mid-twentieth century did insurance, government, and private, proﬁt-seeking investment largely replace these traditional sources.

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These emerging sources of support made ties with communities seem less important. Still, healthcare systems, particularly hospitals, have always worked with communities. Every nonproﬁt hospital seeks voluntary donations from the community and welcomes volunteers. Hospitals, and more recently hmos, have conducted health information campaigns and hosted health fairs. Among the most visible activities have been health screenings, featuring procedures such as blood pressure checks and mail-in stool assays. Of course, lines often blur between “good works” and marketing in these campaigns; evidence of disease detected during these programs feeds patients into the hospital or to networks of physicians aﬃliated with it. Although often laudable, traditional forms of action toward the community have suﬀered from two limitations. First, they are limited and static in nature. Hospitals do not change the quality of life in the community. As noted in chapter 1, safe and attractive surroundings do beneﬁt them, but much larger social forces determine the behavior, and ultimately the health, of people in the community. Even the best-funded and most public-spirited healthcare organizations seem to live with rather than alter the communities around them. They may improve the lives of some but leave those of most community members untouched. Second, traditional actions of healthcare organizations toward the community have tended to be one way, or perhaps more accurately, “top down.” The local public health department is often viewed as just another government agency to be dealt with, grudgingly accepted—as with the police—as a necessity. People sometimes think of public health as a hassle, a kind of ﬁnicky parent to be avoided whenever possible. This view may owe its origin in part to Ellis Island, where immigrants were inspected by uniformed oﬃcials; or settlement house days in East Coast cities, where counselors examined children’s heads for lice. Traditionally, the forays of hospitals and public agencies into the community have had an elitist character. The community coalition,

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with which this book is concerned, represents a deliberate departure from this tradition. Chapter 1 identiﬁed the beneﬁts possible from community coalitions linking healthcare systems and communities; this chapter illustrates the character of these coalitions. It is important to note that some interventions into the community still look a good deal like classic public health, whereas some have a few features in common with the old-time programs and other features quite distinct from the classic models. Observers of community programs have long recognized a broad range of potential relationships among partners. An understanding of the types of community interventions in operation today can be of practical value to organizations planning collaborative projects; interventions that appear collaborative may be top-down operations in disguise. A comparison of community interventions as they exist today can help program planners formulate a structure most conducive to achievement of their objectives. People interested in community collaboration should not simply assume that relationships between institutions and communities are evolving into the collaborative type. The late twentieth century saw a good many interventions planned outside the communities at which they were directed. The discussion that follows will help the reader recognize domination, collaboration, and mixed types in the program he or she encounters or plans.

A CONTINUUM OF PROGRAMS

Health interventions involving institutions and communities range from domination by a single partner to shared decision making by all. Awareness of this range in social interventions is not new. As early as the late 1960s, analyst and critic Sherry Arnstein highlighted the elitist domination present in public programs. Her often-cited continuum recalls the social conﬂicts of the 1960s and 1970s, during which time government agencies tried to quell vocal community 26

Health for All

dissatisfaction and civil unrest. She characterized programs ranging from completely nonparticipatory to fully participatory (Arnstein 1969). The need for community involvement today has less to do with heading oﬀ disruptive protest than building healthy communities, but Arnstein’s schema still provides useful guidelines. Most attempts at collaborative eﬀorts may be ﬁtted into one of the steps Arnstein originally formulated. Expressed in terms of today’s challenges, Arnstein’s continuum appears as follows (individual steps range from programs initiated and run completely from outside to involving and being responsive to the broadest public participation) (Arnstein 1969): • Manipulation. The outside agency launches a public relations eﬀort to promote community support for its objectives and programs, whether or not they directly beneﬁt the community. Eﬀorts to manipulate may include no actual community intervention. • Therapy. A hospital, public health agency, or hmo endeavors to “cure” a community, reducing health risks through an intervention invented and planned from outside. Therapy can include interventions that bypass the interests of the community as individual members see it. A hospital, for example, may seek to improve the community by redeveloping a residential area that it considers blighted. In this instance, “cure” may amount to destroying a community or an important part of it. • Information. The healthcare organization provides information to community members without knowing much about the community itself or providing opportunities for community members to make their voices heard. Much traditional public health takes place in this manner. • Consultation. A healthcare or public health organization seeks “input” from a community but does not commit itself to carrying out the actions the community favors. Hospitals and hmos may undertake consultation for reasons having little to Health Systems and Community Health

27

•

•

•

•

do with the community’s beneﬁt, at least as community members might see it. Consultation activities have been undertaken, for example, in connection with marketing strategies in which public input is sought through surveys and focus groups. The agency carries out consultation for internal rather than communitarian purposes. Placation. Fearing trouble from the community, the outside agency provides beneﬁts to the community to head oﬀ criticism or revolt. Placation may involve “cooptation,” in which agency oﬃcials provide beneﬁts such as paid jobs or prestigious positions on boards. The agency, in eﬀect, buys the community oﬀ, perhaps funding a visible project such as a community center or supporting multiple local charities. Partnership. Community groups are invited to participate in planning and resource allocation decisions. In a partnership, the agency shares decision-making power with important local groups and community-based organizations (cbos). Partnership arrangements serve as a means of reconciling potential conﬂicts of interest between agencies and organizations traditionally holding power in the community, such as churches, businesses, and important local charities. The community organizations exercise considerable inﬂuence, but the agency continues to manage the program. Delegated power. Under this arrangement, the hospital or public health agency gives decision-making power to individuals and groups not under its control. People and organizations with close community ties take over leadership and operations. Citizen control. This format represents the fullest development of community involvement. Under it, individuals from the community exercise full decision-making power. Outside agencies provide ideas, resources, and consultation, but power is not delegated to those outside groups. Community residents who do not hold power, either as oﬃcials of cbos or habitual

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activists in local politics, become regular and important participants. Examples can be found to ﬁt all these descriptions of programs designed to inﬂuence conditions in a community. Manipulation, therapy, and information are largely imposed from outside. Consultation and placation invite participation from selected elements of the community and do not compromise the domination of the hospital, public health department, or other outside agency. A partnership leaves traditional power-sharing in communities intact, as wise hospital oﬃcials have always recognized by establishing ties with those in the community who are most inﬂuential. Delegated power represents a greater challenge because the outside agency rescinds control, often while continuing to contribute material resources. Citizen control, the ﬁnal stage of development in the direction of public participation, is probably represented in the fewest actual programs. It involves active participation and decision making by community members unaccustomed to holding power. “Empowerment” of this kind is actually quite rare. It is best understood as an ideal that programs should pursue as an ultimate outcome. Although the concept of a collaborative community intervention is relatively new, intervention in communities by health-related agencies is not. The survey of interventions that follows demonstrates the great variety of interventions already in place. Most may be found at a point on the continuum presented above somewhere between manipulation and citizen control. A survey of community interventions of varying types helps identify the degrees to which programs are noncollaborative or collaborative. The programs described below are not randomly selected, and the array is not intended to be representative of the entire volume of community intervention activity currently or recently in progress. Rather, the examples help specify the distinct characteristics of collaborative programs. This survey of programs also

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demonstrates the kind of objectives and methods these programs have adopted. A sampling of the accomplishments of collaborative community programs is also provided.

TRADITIONAL COMMUNITY INTERVENTIONS: EXAMPLES OF TOP-DOWN PROGRAMS

Interventions intended to improve health in communities have most often taken the form of top-down operations. These interventions are planned by specialists often living outside the communities at which the eﬀorts are directed. Planners of these interventions appear to assume that reasonable members of the community will receive their eﬀorts positively and behave in a manner consistent with the action they advised. These traditional approaches assume a broad correspondence of interest between program planners and “targets,” or those members of the community who are intended to be aﬀected.

A Historical Case: Vaccination

Vaccination is one of the oldest interventions carried out to advance public health. Traditionally, vaccination programs have involved little if any collaboration. The following example recalls interventions that may have been typical at the close of the 1800s, an era when the cities of the United States were hosting large numbers of newcomers seen by better-established Americans as in need of direction, sometimes of a decidedly ﬁrm nature.

Background

The actions of the Boston Board of Health in 1903 can be considered a classic public health approach to disease prevention. In response 30

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to a smallpox epidemic, the Board of Health mandated vaccination and sent physicians to work sites, schools, and homes. Boston was one of the many cities across the United States that suﬀered from the devastating eﬀects of smallpox epidemics. The disease came to the United States with the early settlers, with the ﬁrst epidemics reported in the early 1700s. Throughout the centuries, epidemics of smallpox waxed and waned, infecting half of the population, killing between 20 and 40 percent of those infected, and leaving survivors with disﬁguring scars. A vaccine was developed in the late 1700s and became widely available by the 1800s. However, the quality of the vaccine varied and was not always eﬀective. Throughout the nineteenth century, the Boston Board of Health took steps to control the disease by quarantining the ill, oﬀering free vaccinations, and sending physicians to workplaces to vaccinate employees. By December 1901, more than 400,000 individuals in a population of 570,000 had been vaccinated. Despite these eﬀorts, cases of smallpox continued. In May 1901, several smallpox outbreaks occurred in Boston neighborhoods. In the next three years approximately 1,600 cases of smallpox were reported, resulting in 270 deaths. Those aﬄicted were primarily male African Americans or European immigrants. Half of those contracting the disease had received the vaccine, reﬂecting the inconsistent quality of pharmaceuticals at the time.

Intervention

In response to the continued epidemic, the Boston Board of Health issued an order requiring all inhabitants of the city who had not been vaccinated to be vaccinated, and all those who had been vaccinated before 1897 to be revaccinated. The city used forceful tactics to execute the vaccination campaign. Physicians were recruited for service against the disease, and they were given supplies of vaccine and dispatched to the hardest-hit communities to administer Health Systems and Community Health

31

the medication door to door. Individuals who refused to be vaccinated were subject to ﬁnes or 15 days in jail. Not all members of society in Boston were happy about mandatory vaccination. An organization called The Anti-Compulsory Vaccination League was formed and fought vocally with the Board of Health. One member, a physician, contended that smallpox was not a threat to healthy individuals. To prove his case, he paid a publicized visit to a smallpox ward. Ironically, contemporary accounts indicate that he contracted smallpox and almost died.

Outcomes

No formal evaluation studies were conducted of interventions such as these at the turn of the century. The epidemic that sparked the Boston program ended in the spring of 1903. From 1903 to 1932 a total of 104 cases of smallpox were reported in the United States, and the last case of smallpox was recorded in 1949. It is still uncertain whether vaccination eﬀorts helped eradicate the disease or whether the virus had simply run its course.

Analysis

The Boston smallpox campaign of 1903 is a clear case of therapy applied to the community. An outside body, the city health department, sought no participation from representatives of the communities at which the campaign was targeted. The campaign reﬂected a paternalistic sense of the time of mainstream institutions toward the socially disadvantaged. Even so, the element of collaboration was not absent in the campaign. The city’s physicians had to be recruited as public health agents. The city’s police force had to be enlisted to enforce the mandatory vaccination program, sometimes going as far as physically restraining and arresting those who refused to be inoculated. History is mute about how collaboration was achieved 32

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among public health oﬃcials, physicians, and police oﬃcers, or the form that collaboration took.

A Traditional Intervention: Public Health Education

Education programs directed at the community as a whole or particular community segments are another familiar type of public health intervention. Such campaigns date from at least the mid1800s. Ultimately based on the knowledge of “experts,” education campaigns also tend to have a top-down quality. These campaigns feature delivery of knowledge developed by scientists and clinicians and given to community members who are presumed to be relatively ignorant. A modern health education program in West Virginia illustrates this type of intervention.

Background

Many scientists believe that consumption of appropriate foods can reduce cancer risks. Diets high in fat are widely believed to increase the likelihood of heart disease and stroke and to contribute to the alarming increase in overweight observed among Americans over the past generation. Public education campaigns, such as the 1 Percent or Less eﬀort in West Virginia, have been widely used in an attempt to change public food consumption habits.

Intervention

The 1 Percent or Less campaign took place in Wheeling, West Virginia, over a period of two months in 1996. Sponsored by the county health department, the intervention utilized a mass media campaign. Paid advertisements were designed by a professional advertising agency and appeared on television, on radio, and in newspapers. The Health Systems and Community Health

33

ads emphasized that switching from whole or 2 percent milk to 1 percent or skim milk could cut saturated fat intake and reduce the risk for heart disease. The campaign included several press conferences: a kickoﬀ event, a mid-campaign press conference including prominent physicians, a press conference announcing mid-campaign results, two milktasting events, and a press conference at the end of the campaign. A community advisory board was chosen by the local campaign director, a faculty member at West Virginia University. Community leaders were also chosen, including representatives from business, politics, healthcare, and the media. The campaign drew on experience obtained from similar eﬀorts conducted several years earlier in several diﬀerent communities, which included community-based events in addition to advertising and public relations activities. The earlier interventions had featured, for example, more taste tests, a supermarket program, and schoolbased educational programs. More than 25 television, radio, and newspaper outlets featured stories on the Wheeling campaign, including ﬁve front-page articles in the daily newspapers, a ﬁve-part television news series, and a newspaper editorial endorsing the campaign. Phone interviews also indicated signiﬁcant diﬀerences in milk-drinking habits between the intervention and comparison communities. The 1 Percent or Less campaign was estimated to have had the potential to reach approximately 420,000 people in Wheeling and the surrounding communities at a cost of approximately ten cents per person.

Outcomes

The campaign was evaluated though (1) pre- and post-intervention surveys of approximately 350 households in Wheeling and a comparison community in another city and (2) a statistical analysis of milk sales in both communities. Before and after the intervention,

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surveys were conducted by trained community volunteers who collected demographic information and data on milk-drinking habits and other questions. The campaign appeared to be successful. In Wheeling, 34 percent of the high-fat milk drinkers switched to low fat milks. In the comparison community, only 3.6 percent changed their milk-drinking habits. Also, the volume of high-fat-milk sales decreased signiﬁcantly in the intervention community, but not in the comparison community.

Analysis

The Wheeling 1 Percent or Less campaign was primarily a therapytype intervention, which included an element of consultation. An advisory board was recruited by the health department and appeared simply to give advice rather than determine the characteristics of the program. The earlier campaign discussed above appeared to have a more participatory ﬂavor, as it included community members. The 1 Percent or Less Campaign was planned and funded by public health professionals and commercial media ﬁrms. The evaluation method used volunteers for data gathering, but it was clearly designed by professionals. The 1 Percent or Less campaign had a narrow focus and was apparently successful in its pursuit of its limited objectives.

C O L L A B O R AT I V E I N T E R V E N T I O N S Specific Purpose of Collaborative Interventions

Programs such as the traditional interventions described above are familiar to everyone involved in public health or health services administration and to most people who have taken an interest in their

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communities as activists or volunteers. Traditional interventions are tied closely to the sciences of immunology, dietetics, and communication and have several features in common. They are basically nonparticipatory, with few program features (and certainly no objectives) determined by community residents. These programs tend also to have narrow objectives that are easily speciﬁed and readily subject to widely recognized measures of success. The two programs described below are diﬀerent: both include participation of targeted individuals in the initiation and implementation, their objectives are more closely connected with the concept of “community health” than that of traditional “public health,” and the methods used for outcomes assessment are less traditionally biomedical than the traditional programs described earlier. Still, the following two programs have aims conﬁned to a single set of health-related issues and utilize a narrow range of procedures.

A Modern Immunization Campaign Background

An eﬀort with objectives similar to the smallpox immunization drive in Boston began in Virginia in the late 1990s. Beginning in 1995, Project Immunize Virginia (piv) has promoted vaccination throughout the state, with a special focus on young people. piv is organized as a coalition, the members of which include public agencies, private ﬁrms, and the military services. The coalition’s mission is to link health service providers, payers, local coalitions, and families and to provide technical support, including public and professional education. The coalition, which meets on a quarterly basis, was initiated when the Virginia Department of Immunizations at the state health department contracted with the Center for Pediatric Research at Eastern Virginia Medical School, located in Norfolk, Virginia, for assistance in carrying out several federal mandates regarding 36

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immunization. The Center for Pediatric Research had developed a successful community coalition, which the state wanted to use as a model for a statewide coalition.

Intervention

The Center began contacting potential members, such as local coalitions and organizations with an interest in immunization, to join piv. Coordinators recruited participants representing all parts of Virginia: urban areas, rural areas, and military bases. A broad-based coalition was necessary, organizers felt, to ensure an understanding of the many issues regarding immunization across diverse communities. By 2000, piv’s membership comprised more than 200 representatives from across Virginia, including: • local public health agencies; • private healthcare institutions, including hospitals, managed care systems, community health centers, and private providers; • community-based coalitions; • private sector corporations and foundations; • service agencies and religious institutions; • health insurance companies; • state agencies; • professional associations; • academic institutions; • military agencies; and • the federal Centers for Disease Control and Prevention. These representatives are considered the most active, core participants. Additional members are recruited when speciﬁc interventions create a need. The coalition’s work is divided into four functions: Health Systems and Community Health

37

1. Immunization awareness. Coordinating statewide immunization awareness activities and linking communities with state and local resources 2. Immunization assessment. Assessing piv’s progress on reaching its immunization goals 3. Education and training. Improving the knowledge and practice of members, local coalitions, and healthcare providers regarding immunizations 4. Resource development. Assessing and directing the funding needed to sustain piv. Speciﬁc activities of piv have included: • producing the Governor’s Report Card; • sponsoring a statewide public awareness campaign; • developing an oﬃce-based educational program for immunization providers and an educational module for medical students; • helping form local coalitions and partnerships; • holding an annual workshop; • holding a statewide poster contest; • sponsoring an adolescent hepatitis b campaign and initiating hepatitis awareness month; • providing wellness baskets for ﬂu patients; • sponsoring the National Infant Immunization Week Green Ribbon Campaign; and • helping promote a state system allowing public and private healthcare providers to share immunization records. One of piv’s priorities is helping local communities form coalitions. Members of piv identify their own communities as potentially beneﬁting from a coalition. In addition, the State Division of Immunizations makes recommendations of communities that would beneﬁt from a coalition and targets communities with poor immunization rates.

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piv’s core funding is provided by the state health department. Partners such as pharmaceutical companies are asked to contribute funds, and the agency seeks support through grants and contracts. Members provide in-kind donations, for example, hosting meetings, providing staﬀ time, and contributing consultant services.

Outcome

At the time this book was written, piv was entering its sixth year of operation and coalitions were still operating throughout Virginia. Baseline data on immunization rates were collected and compared with rates following operation of several piv programs. Prior to the adolescent hepatitis b awareness campaign, school nurses observed that only half the eighth graders had been vaccinated. After three years of the intervention, they determined that 92 of the youths had been immunized.

Analysis

From this description, it is diﬃcult to determine whether piv comes closer to a consultation or partnership-type intervention. Clearly, the operation involves consultation by public oﬃcials and experts regarding the expectations, beliefs, and resources of communities, but it is not clear whether the state has given any control over the immunization program to the localities represented in the coalition. A partnership would be marked by at least some sharing of decisionmaking power. Clearly, however, piv approaches immunization in a manner different from Boston in 1903. Instead of simply issuing orders and enlisting the police to enforce them, piv seeks to share knowledge community members have about their neighbors and to enroll people from many walks of life as agents of change.

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A Peer Safety Intervention Background

Like immunization, automobile safety is a classic public health concern. Agencies other than public health departments and healthcare systems typically carry the responsibility for automobile safety: police and traﬃc departments, perhaps, as well as schools. Automobile safety, however, ﬁts well within the concept of community health as it is discussed in chapter 1, a concept that includes factors which give rise to or prevent physical illness or injury. Community health concerns can include reducing crime, fear, and risk of physical injury or death due to trauma.

Intervention

In 1987, a judge in Brown County, Ohio, concerned about the number of juvenile traﬃc oﬀenders seen in his court, asked the extension service of The Ohio State University to establish a peer-led trafﬁc safety program. Extension agents recruited ten junior leaders from local 4-h clubs to design and implement a peer-intervention program for traﬃc oﬀenders. To develop the program, the junior leaders ﬁrst thoroughly researched the issue by contacting the National Highway Safety Administration and state and federal government oﬃcials and visiting local law enforcement oﬃcials. The young people developed a safety intervention program known as “Caring and Responsible Teens,” or carteens, a safety program developed and run by the junior 4-h leaders and other teen facilitators. Material for the intervention was written by the teens based on their research, the advice of experts, and their own experiences. Sessions may include defensive driving techniques, the importance of using safety belts, rural road safety, the consequences of unsafe driving, and how to avoid or respond to negative peer pressure. Some sessions include simulations of a rollover, a mock funeral, 40

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brain injury demonstrations, skits, videos, and a variety of other techniques used to engage the audience. Technical assistance is provided by the Ohio State Highway Patrol. Extension agents assist with public speaking, group dynamics, conﬂict resolution, and interactive teaching techniques. In addition to developing material for the sessions and leading them, youth facilitators are also expected to stay informed about Ohio state laws and to act as intermediaries for teens, law enforcement, and the courts, keeping the relationships strong between carteens and these important partners. Clients are referred to carteens by the courts for any ﬁrst time juvenile traﬃc oﬀense. Attendance is mandatory and is in lieu of ﬁnes, license suspension, or other traditional punishment. carteens sessions are oﬀered three to four times per year, are generally attended by 40 oﬀenders, and are run by 10 to 12 facilitators. In recent years, youths who complete the program often return as facilitators. carteens is supported by a $10 fee paid by the youth referred into the program and through grants from the Ohio Department of Public Safety, the Allstate Foundation, Metropolitan Life Foundation, and local insurance agencies. Funding is used for program operation and to develop other educational experiences beyond the scope of the original program. Since its ﬁrst development in the early 1990s, carteens has grown and expanded to 34 counties in Ohio as well as one site in Indiana. In 1996, an AmeriCorps-funded program, Teen bridges (Building Responsibility in Teen Drivers Through Growth in Self-Esteem and Safety), incorporated carteens into its eﬀorts. The mission of Ohio Teen bridges is to “empower Ohio teens to be safe and responsible drivers through educational awareness, prevention, and safety programming” (Ohio Teen bridges/AmeriCorps 1996). This statewide program is a collaborative eﬀort among the Corporation for National Service, The Ohio State University extension, 4-h Youth Development, 40 local community agencies, organizations in 20 Ohio counties, and the Ohio Governor’s Community Service Council. bridges has placed AmeriCorps volunteers into Health Systems and Community Health

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20 diﬀerent counties to coordinate statewide educational eﬀorts focused on driver safety for teens. These volunteers assist with carteens and coordinate another curriculum called the “Mock Crash Safety Docudrama,” aimed at a broader teen audience. The docudrama uses teen volunteers acting as victims and wrecked automobiles as props to teach high school students about the results of drinking and driving, with a focus on the long-term eﬀects the accidents have on the students’ families, classmates, and community. Other communities involved with bridges have developed curricula focusing on needs in their community such as those related to seatbelt use or child safety seats. Organizations collaborating to support carteens include the Ohio State Highway Patrol, local sheriﬀ and police departments, the juvenile court system, emergency medical personnel, health departments, high school administrators and staﬀ, local Students Against Driving Drunk (sadd) and Mothers Against Drunk Driving (madd) chapters, and local insurance agencies and businesses.

Outcomes

By 1998, Teen bridges enrolled 2,639 ﬁrst-time teen traﬃc oﬀenders via its intervention and provided driver education to approximately 30,000 other teenages. A qualitative assessment of the impact of Teen bridges was conducted by The Ohio State University, based primarily on focus groups. Themes occuring in the focus groups included the following: • Clients felt the program made a positive diﬀerence in the lives of youth participants. • Volunteers felt they had gained valuable experience and enhanced their public speaking skills. • Adult volunteers developed a positive attitude toward volunteerism and had a strong desire to become involved in other

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volunteer programs that may aﬀect the lives of young people in their community. • The program had increased awareness of teen vehicular safety issues in communities. Despite dwindling funding from the state, the program has survived and gained funding for an additional year of operation from the time this book was written, because the extensive data collected demonstrated its importance to the community.

Analysis

carteens appears to reﬂect the principles of a partnership-type collaboration. It is supported and operated through the pooled resources of a wide variety of organizations, some traditionally concerned with health and others specializing in areas related to more general dimensions of community well-being. The program does not delegate power to groups traditionally occupying subordinate positions. It does, however, allow young people to take a more active role in correcting hazardous driving patterns among their peers. Instead of being merely passive bystanders or recipients of instruction, young people take charge of the instruction of their peers and their own development.

C O M P R E H E N S I V E C O M M U N I T Y C O L L A B O R AT I O N S

As the two preceding examples illustrate, collaboration can take place in interventions with highly speciﬁc and traditional purposes. Immunization programs in the past have operated with little community collaboration, and traﬃc safety programs for young people have functioned routinely within the walls of established institutions, as generations of high school drivers’ education students will

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attest. But the most eye-catching developments in community interventions have diverted markedly from this format. Unlike piv and carteens, interventions have been taking place that embrace community health in its broadest sense. Implicit in these interventions is that community health cannot signiﬁcantly improve without simultaneous action in multiple areas. Leaders in these programs often assert that the “system” itself must change, leading to resident control over neighborhoods and participation of previously underrepresented groups in formulation of public policy. The comprehensive community intervention has become important in part because of the ﬁnancial support it has been given. Across the United States, large health-oriented foundations have provided hundreds of millions of dollars for formulation and support of interventions of this kind. Mainstream healthcare and public health organizations have served as the lead agencies in comprehensive community interventions, but agencies not ordinarily thought of as concerned with health can do so as well. Schools, religious organizations, and freestanding community-based organizations have spearheaded eﬀorts of this kind. Comprehensive community interventions have two characteristics: (1) they are highly collaborative, seeking very broad participation and (2) they pursue multiple objectives. Beyond this basic deﬁnition, a wide variety of community organizations have launched and operated community programs. They have employed diverse methods for both achieving their objectives and evaluating their performance.

Toward a Healthy Community: Recapturing Community in Orlando Background

With the coming of Kennedy Spaceport and Disney World, many in Orlando, Florida, felt the city’s small-town feel and recognizable 44

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community were in danger of collapse. Large numbers of newcomers were moving in. The city was encountering the maladies of sudden, large-scale growth, including a shortage of housing and diﬃculties with traﬃc and transportation. Leaders of civic organizations, businesses, media, and hospitals became concerned about the city’s problems. They shared a feeling that programs carried out by individual organizations and agencies had been unable to meet the challenges with which they were faced. For several years, this core group of stakeholders met to discuss their concerns and what action could be taken. They realized their views were limited, so they held focus groups with more than 300 citizens and invited people diﬀerent from themselves to construct an action plan. In 1996, the Healthy Community Initiative (hci) was launched to pursue comprehensive solutions in areas such as: • strengthening families and supporting children; • promoting community ties and collaborative eﬀorts; and • the acceptance, appreciation, and encouragement of diversity.

Intervention

As part of the community-building eﬀort, hci sponsored “listening projects,” in which hci works with people in neighborhoods to organize around common concerns, create an action plan, and implement the plan. A core group of community members attend a planning session facilitated by hci staﬀ to set goals and develop a survey. More community members are recruited to interview other members of community. After the organizing committee agrees that all of the community has been heard from, a community meeting is held to discuss the results of the survey, develop an action plan, and identify who will implement each step. The hope is that this listening process will bring community members together. Health Systems and Community Health

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Outcomes

In Haralson Estates, one neighborhood that participated in the listening project, several positive developments were observed following the intervention. These included a reduction of crime by 50 percent, the paving of all the streets, and the installation of street lights. In addition, the neighborhood organized a successful drive for annexation to the City of Orlando, a community crime watch program was instituted in collaboration with the sheriﬀ’s department, and clean-up activities were organized. Regarding hci’s work with Haralson Estates, it is important to note the value of mobilizing the community for the purpose of encouraging action by public agencies. Allocation of funds for street lighting, for example, required approval of the expenditure by voters. In an era when elections often draw a small minority of eligible voters, hci realized the importance of publicizing the beneﬁts that street lighting would bring to the community. hci also helped mobilize community residents to lobby local oﬃcials to enforce building and maintenance codes for the neighborhood. Lax enforcement had encouraged drug dealers to occupy houses in the area, but enforcement of codes requiring window repair and lawn maintenance forced the dealers out. It is noteworthy that annexation to the City of Orlando could not have taken place without these onthe-ground improvements, because the city would have taken steps to prevent annexation of an area with high crime and weak infrastructure.

Analysis

The Orlando Healthy Communities Initiative can be viewed as a partnership-type coalition because it has engaged in signiﬁcant consultation with the community. Development of delegated power from healthcare organizations and public agencies seems to be a

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future possibility. Ability to raise funds for the coalition’s operation has allowed its functioning to continue. A high proportion of the coalition members’ time appears to have gone into making contacts, holding meetings, and identifying needs, a hallmark of most such coalitions. Only a few ground-level undertakings have been launched.

Rebuilding Community on Chicago’s South Side Background

Riots in the 1960s and 1970s destroyed housing and businesses in Chicago’s West Garﬁeld Park neighborhood. Following the riots, the area further deteriorated, suﬀering from high levels of poverty and unemployment. Members of Bethel Lutheran Church decided that serious action was need to save their neighborhood. In 1978, members passed the hat among themselves and raised $9,600. These funds enabled the group to buy and renovate a small apartment building. The group incorporated into Bethel New Life, a nonproﬁt, community-based organization focused on rehabilitating neighborhood housing and helping residents obtain loans for the refurbished properties. With the sister of the Lutheran Church’s minister as executive director, Bethel New Life was able to secure grant funds and leverage the equity in its real estate. In addition, money was repeatedly borrowed against the assets of the church.

Interventions

In its 20 years of operations, Bethel New Life has founded a wide variety of operations intended to create jobs, enhance the employability of community residents, and promote health in the neighborhood. Bethel New Life has received ﬁnancial support from the

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MacArthur Foundation, the Chicago Community Trust, the Annie E. Casey Foundation, Loyola University (Chicago), Astra Merck, and the federal government. With the aid of grant and contact funding, Bethel New Life grew into an organization employing more than 450 people by the mid-1990s. In 1989 Bethel New Life purchased St. Anne’s Hospital’s campus, with seven buildings on 9.2 acres. On this site, Bethel New Life established the Bethel Anne Life Center, which housed services such as: • the Molade Child Development Center, providing day care for 80 children and providing parenting education • the Small Business Center, providing technical and professional assistance for small business ventures as well as space for meetings, banquets, and performances • a cultural and performing arts center Bethel New Life also operates: • 125 units of housing for elders, including an adult day care center • 45 units of assisting living for 85 low-income seniors • the Professional Oﬃce Building, owned by Westside Holistic (also operated by Bethel New life), the tenants of which now include First Bank of Oak Park, the Austin–West Garﬁeld Credit Union, a Head Start program, and professional services • a two story building housing outpatient mental health services • a ﬁve-story parking garage with space for more than 500 cars Speciﬁc services oﬀered by Bethel New Life include: • an employment center oﬀering counseling and placement (often in workplaces operated by Bethel), helping community residents move from welfare to work

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• senior services oﬀering housing, in-home care for seniors, adult day care, housing repair, and opportunities to stay involved in the community • family support services oﬀering Women’s, Infants’ and Children’s nutrition program (wic) services, family case management, and housing placement • community organizing services, including organizing community events such as “Take Back the Streets” campaigns, community clean-ups, job fairs, and “Get Out the Vote” campaigns • housing and real estate development, including revitalizing housing, helping communities make plans to develop their neighborhoods, and helping residents obtain grants and loans for home ownership In 1989, Bethel New Life became a managed care provider. The organization’s Umoja Care targets those frail elderly with at least ﬁve diagnosed medical conditions. Participating elders received primary care, physical therapy, speech therapy, occupational therapy, rehabilitation therapy, in-home care, and adult day care. Bethel received funding for this project through a multistate demonstration project called Program for All-Inclusive Care for the Elderly (pace). In 1995, Bethel discontinued the project because of high costs. Bethel New Life has initiated a variety of other programs, including a lead abatement program, aids counseling and education, and a series of health fairs. Toward these eﬀorts, Bethel New Life partners with numerous groups and agencies, including the United Way, the University of Illinois, the Chicago Police Department, Rush–Presbyterian–St. Luke’s Medical Center, and the American Lung Association. The operation is governed by a steering committee, which includes representatives from the healthcare industry (providers, public health oﬃcials), the United Way, public schools, universities, police, churches, block clubs, and others.

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Healthcare Career Training Ladder When Congress decided to “end welfare as we know it,” Bethel New Life stepped up to the plate. The organization developed the Health Care Career Ladder (hccl) Training Program for individuals moving from welfare to work. This innovative program allows participants to try out a healthcare career, gaining experience and earning money. For the first step in the ladder, homemakers are employed as caregivers for seniors. The caregivers provide in-home care— cleaning, cooking, and spending time with seniors. In the second level (or step) homemakers receive training to become certified nurse assistants (cnas). The 12-week training course, which leads to state certification, is o=ered by Chicago City College in conjunction with work as homemakers. In the third and fourth levels of the program, the cna graduates are encouraged to take cna enhancement courses or advance to nursing programs. Bethel o=ers participants progressive placements throughout the program and post-placement support. Bethel also supports the trainees with housing, transportation, family services, day care, and obtaining a General Educational Development (ged) credential. Bethel is committed to ensuring their trainees receive about $7 an hour, almost one-third more than minimum wage.

Outcomes

The volume of jobs and services provided by Bethel New Life is considerable. Bethel New Life has made more than 1,000 new units of housing available to the community, and the employment center places more than 500 people each year in jobs. The outcomes of the hccl program illustrate the success of the organization’s educational interventions. Since 1996, 96 people have completed the program; 65 percent of the cna graduates are working in the healthcare ﬁeld, and more than 50 percent have obtained additional career training (cna enhancement, licensed practical nurse training, or registered

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nurse training). The average wage for cnas without additional career training is $7.41 per hour; cnas with additional training earn an average of $7.79 per hour.

Analysis

Bethel New Life appears to incorporate many elements of the citizen control model. Community residents initiated action to renew their neighborhood. The early members of Bethel New Life established a self-help approach in the late 1970s when many others abandoned their neighborhood and its resources. By taking charge and garnering the required resources, the community maintained initiative and control through Bethel New Life. Of all programs reviewed while preparing this chapter, Bethel New Life appears to have best embodied the concept of a comprehensive community intervention, with far-ﬂung initiatives addressing the general objective of increased employment, health, and community resilience.

A National, Multisite, Collaborative Intervention Background

The Henry J. Kaiser Family Foundation Community Health Promotion Grants Program (chpgp) was active from 1986 through 1993. The initiative was of an unusually large scale. It focused on fostering community health promotion activities directed toward cardiovascular disease, cancer, substance abuse, adolescent pregnancy, and injuries. chpgp allowed communities to design and implement the interventions of their choice, not dictating program areas to grantees. In awarding grants under this program, the Foundation emphasized support for disadvantaged and minority populations. The

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strength of the applicant organization and level of community support was also taken into consideration. In the Western United States, 11 communities were selected for funding under the project. Each intervention community received approximately $150,000 per year for three years, with the possibility to renew the grant for another two years.

Interventions

The 11 programs included diverse aims and methods. The work of two communities is presented here for illustration: the “Cowboy Community,” and the “Suburban County.” The Cowboy Community. A grant was awarded to a mid-sized (pop. 42,000), predominantly white, aﬄuent community. An observer noted that the locale prided itself on a “cowboy culture, two-ﬁsted drinking, and conservative values”; hence, the ﬁctitious designation, “cowboy community.” A series of teen suicides motivated the community to form a community coalition focused on increasing mental health and social skills and reducing substance abuse among the children and teens in the county. The coalition’s governing body included members from school administration, school personnel, law enforcement, local government, parents, teens, media, business, churches, healthcare, industry, community service clubs and organizations, and mental health organizations. The chair was a county supervisor, and the co-chair was the director of nursing at the local public health department. Membership in the council was highly prized and considered a political position. Attendance at the monthly meetings was high, from 70 to 80 percent, and little turnover in membership occurred, indicating a fairly functional coalition. Administered through schools, interventions consisted predominantly of educational programs, such as life skills, peer helping, and parent training. In addition, the schools held special events such as 52

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retreats and barbecues focused on youth sexuality issues, trust-building activities, and career days. In order for schools to be awarded funding for participation, they were required to agree to form a campus council, conduct focus groups of the students, have the council select at least one intervention from each category, and develop a budget. Suburban County. The second community was located in a large suburban county with three separate communities. This community focused on improving nutrition and preventing tobacco use among teens and children. The program relied heavily on a community coalition for direction and support of its activities. Members of the coalition were identiﬁed and recruited by the administering agency and by the project director. Among the members chosen were people viewed as having the power to inﬂuence health promotion activities. These included a city council member and heads of the local American Lung Association and American Cancer Society. Task forces were established in nutrition, tobacco use, parent education, media, fundraising, public education, and future planning. In general, interventions included primarily news stories, public service announcements, presentations to service groups and at local health fairs, and information provided to community organizations, healthcare providers, coworkers, families, and friends. Nutrition interventions included nutrition education activities and shopping tours at local grocery stores, promoting the adoption of healthy catering guidelines by community organizations, and recipe contests for healthy, low fat foods. The centerpiece of the nutrition campaign was a store education campaign composed of posters and pamphlets encouraging shoppers to eat more fruits and vegetables, low-fat products, and ﬁber. The tobacco intervention began with minors attempting to buy cigarettes from merchants, an illegal act. When the attempts were successful, the program provided informational materials to the merchants. Later, the program decided to adopt a more controversial Health Systems and Community Health

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model of “sting operations,” in which merchants who sold tobacco to minors were arrested or ﬁned. The program worked closely with law enforcement and judges to ensure that the perpetrators were prosecuted.

Outcomes

In the suburban community, the sting operation generated a considerable amount of media attention and reportedly resulted in decreased cigarette sales to minors. The media attention helped identify tobacco as an issue in the community. An ordinance was passed banning cigarette vending machines. Outcome data did not show behavioral changes among the community’s young people due to the intervention, but it did indicate that tobacco sales to minors decreased and new policies were created governing youth’s access to tobacco.

Analysis

The chpgp represented a large, well-funded program designed to test the concept that communities identifying and developing interventions of their choosing would be eﬀective in reducing the community’s health risk. The communities operated programs that were sometimes partnerships and sometimes delegated (as when the school system permitted a coalition board to carry out a program for delivery to students). Citizen control prevailed in some of the programs, in which community residents were given decisionmaking latitude on program planning and management. It is important to note that, of all the collaborative programs initiated over the past decades, the chpgp had perhaps the most carefully designed evaluation. The evaluation procedure will be discussed more fully in chapter 7.

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C H O I C E S O F H E A LT H O R G A N I Z AT I O N S A N D COMMUNITIES

All the interventions discussed in this chapter involve resources, eﬀort, and initiative from healthcare providers, public health agencies, and organizations with related purposes. Interventions such as the Boston smallpox program and Project Immunize Virginia have clear connections to the healthcare system, as does chpgp. Healthy Community of Orlando included several hospitals in its coalition, and carteens incorporated eﬀorts by health departments and emergency medical workers. The examples described in this chapter trace a picture of community intervention that is by no means complete. Even these limited examples, however, suggest that collaborative interventions may take a wide variety of forms. For people seeking basic change in a community, the most important diﬀerence may be the inclusiveness of the collaboration. None of the programs described here are unambiguously citizen controlled; most community interventions of a collaborative nature are governed by a partnership of agency representatives. At times, a health department, school system, or other established agency will delegate responsibilities to an outside coalition or consult outsiders regarding action to be taken. In summary, community interventions can be categorized simply as top-down or bottom-up, and the key programs discussed in this chapter are shown as such in Figure 2.1. This ﬁgure also summarizes the characteristics of these illustrative programs. In addition to the top-down versus bottom-up designation, comprehensiveness is an important distinction among the programs described here. Comprehensiveness ranged from narrow, as in the case of piv, to extremely broad, as in Bethel New Life and chpgp. Greater comprehensiveness has a compelling feature, promising broader impact, but comprehensiveness comes at the price of focus. A comprehensive intervention is more diﬃcult to evaluate than a narrow one. Immunization rates, for example, are easier to measure

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Figure 2.1: Examples of Top-down and Bottom-up Approaches top down

bottom up

Boston Smallpox Campaign (1902)

Project Immunize Virginia

Participation of community: no Outcome: Although no formal evaluation was conducted, the epidemic in response to which the program was started abated soon after the program began. 1% or Less Milk Campaign Intervention: A mass media campaign in Wheeling, West Virginia, encouraging drinking lower-fat milks as a way to lower intake of saturated fat and decrease risk for heart disease.

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Intervention: Project Immunize Virginia is a private/public coalition with a mission to link immunization providers, parents and children, payers, and community coalitions with technical support, public and professional education, and community resources so that all Virginians will be properly immunized. Participation of community: Members of the coalition represent the diverse regions and communities from across the state. One of the core functions of the coalition is to work directly with communities to assist with the formation of local coalitions. Outcome: Rates of vaccination for hepatitis b and influenza appear to have increased. Healthy Community of Orlando Intervention: Community-based “Healthy Communities” initiative focused on a broad range of activities to improve the health and sustainability of the community. Participation of community: Extensive community organizing e=orts from the beginning of the movement. Participants represent the broad range of residents in Orange County, including youth, the

Bottom Up

Top Down

Intervention: In response to reports of people diagnosed with smallpox, the state board of health mandated smallpox immunization and reimmunization of all citizens in Boston. Physicians made rounds in the hardest hit communities to reimmunize people. Those who refused immunization were fined or taken to jail.

Figure 2.1: Examples of Top-down and Bottom-up Approaches (continued) top down (continued)

bottom up (continued)

Participation of community: A community advisory board composed of stakeholders in the medical and media community had limited involvement in the implementation of the intervention.

homeless, the Hispanic community, and the African-American community.

carteens Intervention: A youth-led interactive curriculum about tra;c safety, drunk driving, seat belt use, etc. is presented to other youth who have committed their first tra;c o=ense. Participation of community: Youth create and lead program. Outcomes: Participants appear more aware of car safety issues.

Bethel New Life Intervention: A faith-based community organization o=ering a range of services for people living in West Garfield Park, Chicago. Initially started to renovate housing and provide interest-free loans, Bethel now o=ers direct services such as employment services, healthcare, child care, and elder care. It is also active in organizing the community around issues the community deems important. Participation of community: Extensive. Started by a local church and driven by local e=orts. It is active in community organizing and collaborates extensively with other organizations to improve the community. Outcomes: Significant numbers of housing units and job training made available to the community. Job training and health service delivery functions have been e=ective.

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Bottom Up

Top Down

Outcomes: Individual consumption of low-fat milk apparently increased, according to surveys of community members and milk sales records.

Outcomes: Community participation and a strong coalition resulted. One community reported a drop in crime rates, a successful campaign for streets lights, and the approval of their request to be annexed into the City of Orlando.

than personal growth, a focus of the cowboy community funded under chpgp. Program comprehensiveness creates other challenges, which are the subject of chapter 3. Within the limited number of programs described here, great disparity is apparent in outcomes. The Healthy Community of Orlando and Bethel New Life, for example, have many of the same goals, yet Bethel New Life can boast clearly visible, large-scale achievements. This diﬀerence suggests that many lessons can be exchanged among communities, enabling them to emulate each other’s successes.

REFERENCES Arnstein, S. R. 1969. “A Ladder of Citizen Participation.” Journal of the American Planning Association 35 (4): 216–24. Ohio Teen bridges/AmeriCorps. 1996. Year 3 Renewal Proposal Narrative. Promotional material, provided to authors.

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CHAPTER 3

Partnership Challenges

W H Y C O L L A B O R AT I O N I S D I F F I C U LT

Why should working together be diﬃcult? Of even greater importance, what factors create diﬃculty for people and organizations to work together on issues that, although complex, messy, and seemingly intractable, are of great and immediate signiﬁcance? Our stories, our conventional wisdom, our political correctness, and our everyday language suggest that working together, cooperation, and collaboration is possible, encouraged, and appreciated. Barn raisings oﬀer a historical image, manufacturing work teams oﬀer a model, lyrics such as “we can work it out” have broad appeal, and phrases such as “two heads are better than one” are unchallenged. Collaboration is part of American culture and has accounted for many of the nation’s achievements. Perhaps the strongest argument for collaboration in healthrelated, community-based work is the fact that collaboration brings with it multiple and diverse resources that no single group possesses. Those resources include dollars, perspective, expertise, access, knowledge, trust, and commitment. And of critical importance in community health improvement, this diversity enhances the likelihood that improvement will be sustained. 59

The appeal of collaborative, community-based partnerships is strong, and their beneﬁts would seem to outweigh potential diﬃculties or liabilities. Given the complexity and importance of community health improvement, it is understandable why a collaborative, community-based orientation would be a ubiquitous model. Community health planners and organizers, funders, and public health experts are increasingly investing their resources in support of eﬀorts that use the power of collaboration to advance community health improvement. Basic features of collaborative community partnerships raise challenges for healthcare providers. The very diversity of membership that feeds and energizes collaborative eﬀorts can present barriers to their process and success. Grass roots organizations and nonhealthcare agencies have diﬀerent histories, concerns, and objectives from hospitals, managed care organizations, and other healthcare organizations. This chapter explores the challenges to health-related collaboratives and partnerships. The content is informed largely by our experience as participants, developers, evaluators, and students in the work of coalitions. The focus on challenges is not intended to argue against collaborative approaches or the establishment of coalitions—we are convinced of the role and potential of such work. Our intention is to elucidate areas that can threaten, compromise, or limit the work of coalitions. To the extent that problems are anticipated or avoided, the work may be more successful and more eﬃcient.

B A S I C TA S K S O F C O A L I T I O N S

A coalition’s or collaborative’s development can be viewed as a series of challenges. Although a collaborative must address some of these challenges in its earliest days, many early challenges must be faced again and again. Solutions to one challenge may cause problems in resolving another. Challenges earlier thought to be overcome 60

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re-emerge, often in new forms, as the collaborative matures. Challenges of fundamental importance include: • • • • • • • •

deﬁning purpose forming collaborative commitment establishing governance and a decision-making process obtaining resources and appropriate staﬀ developing and implementing an action plan providing direct service to the community monitoring facts and evaluating actions achieving sustainability

These challenges are addressed in sections of the chapter that follow. Although this list is not intended as a complete array of critical tasks for collaboratives, the day-to-day problems encountered by community coalitions can be understood as resulting from the challenges listed above. Successful collaboratives may not fully resolve all these problem areas, but the coalitions with the most impact will overcome, or at least manage, most of them.

Defining Purpose

Coalitions usually form in response to awareness of a distinct problem or issue in a community. People in the community recognize that issues around which collaboratives form require cooperation among multiple organizations and individuals. Solutions may appear to require intellectual, ﬁnancial, and political resources beyond those of any single partner. Coalitions form for other reasons as well. Today, many collaboratives come into being in response to a grantmaker’s stipulation that applicants take a collaborative approach as a prerequisite for funding. This increasingly frequent stipulation has spurred the development of collaboratives nationwide. Partnership Challenges

61

Whether a collaborative arises spontaneously or in response to a grant opportunity, deﬁnition of purpose constitutes its initial challenge. The purpose identiﬁed by a collaborative must be straightforward and instrumental. Coalitions form to assemble and review data on the community to raise issues, identify priorities, and increase public awareness. Examples include the publication of healthrelated data linked to quality of life or identifying leading causes of morbidity and mortality. The increasingly familiar “community report card” exempliﬁes purposes of this nature. A coalition’s basic direction can develop from several distinct points of origin. Often, an outside event deﬁnes a collaborative’s purpose; an accident, disease outbreak, or emergency can focus the community’s attention and resolve. Alternatively, a speciﬁc advocacy group may seek to raise the awareness of an issue that claims its attention and commitment. Whatever the origin of its sense of purpose, the collaborative’s ﬁrst challenge is to develop from a group of people sharing common inspiration to an organization with a shared vision, concrete objectives, and a deﬁnite goal. Collaboratives that meet this challenge identify purposes which are clear, signiﬁcant, and capable of being achieved. For a collaborative to achieve real success, its purpose must be meaningful to the broader community. Goals that are highly abstract or very long term constitute barriers to engagement of broad segments of the population and, often, to many of the collaborative’s participants. If a purpose is not easy to understand and communicate, the formation of a collaborative to pursue it and achieve success will be more challenging. Formal organizations (government agencies, established nonproﬁts, etc.) are usually more comfortable with abstract and longterm goals than community-based organizations (cbos) or individual community members. The relative security of funding and staﬃng in established organizations allows them a greater degree of patience. Individuals and smaller cbos usually need to focus resources and attention on more concrete, immediate priorities. A 62

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highly understandable and distinct focus is crucial to coalitions; the more focused the purpose, the more likely that measurable success will ultimately be achieved. The purpose must be seen as relevant to multiple stakeholders, justifying the investment of time and resources by groups and individuals.

Forming Collaborative Commitment

Given an understandable purpose, eﬀective collaboration requires a membership that works eﬀectively together in pursuit of that purpose. This challenge has two dimensions. It is readily apparent that the coalition must create and maintain good working relationships. In addition, and in a manner which can strongly aﬀect this capability, the coalition must recruit individuals and organizations of appropriate type, diversity, and quantity. Communities vary in their readiness to form cooperative working relationships. Some communities have a history of collaboration and can draw on successful experience in cooperative eﬀort, while others have no such past. Whatever its history, establishing (or reestablishing) strong, day-to-day working relationships constitutes a key challenge to the collaborative. Recruitment of partners is made easier in those communities in which the relative beneﬁts of participation can be deﬁned. Other communities (because of demographics, resources, stability) have much less experience in working together, and potential participants will require more speciﬁc estimates of the balance between cost and beneﬁt. Once again, abstract and long-term purposes discourage broad participation. Whereas the “public” reason for joining a coalition is deﬁned by the purpose, each participant (individual or organization) may have speciﬁc, and in some cases, unique motivation for joining. Attention to these diﬀerences can be important as recruitment of participants takes place, but coalition leaders must emphasize the overall purpose in their communications. Partnership Challenges

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Most individuals and participant organizations will hesitate to relinquish all individual objectives for the purposes of the collaborative eﬀort. Many successful coalitions recognize and appreciate that the goals of the coalition and those of the participants overlap but do not necessarily mirror each other. Such diversity can bring conﬂict, but it can also bring multiple perspectives, alternative approaches, more complete lessons learned, and access to a more complete set of resources. Size and inclusiveness can increase the diﬃculty to meet the challenge of creating suﬃcient collaborative commitment. Due in part to advertising and our society’s consumer orientation, the axiom, “the bigger the better,” drives many of our decisions. But this principle can apply poorly to the formation of a coalition. It is correct to assume that a coalition with a large number of participants will enjoy a broader range of ideas, perspectives, and leverage points, but larger numbers can create additional complexity. Greater numbers of people and organizations under the coalition umbrella can overburden processes of communication, organization, and decision making. The burden that large numbers of participants places on a coalition’s capacity can, and often does, compromise its ability to focus its eﬀorts. A majority of coalitions of which we are aware are limited in their eﬀectiveness because of their attempt to be too comprehensive—to meet the needs and demands of too many audiences. This attempt to address broadly deﬁned, comprehensive agendas is likely to result in a “peanut butter” approach, spreading the interests and resources of the coalition too thin and failing to achieve signiﬁcant outcomes in speciﬁc areas.

Establishing Governance and a Decision-Making Process

Establishing eﬀective governance and decision-making structures and processes constitutes crucial challenges for community coalitions. These resources are of central importance in making eﬀective 64

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operations possible. The community-based nature of collaboratives itself makes establishment of governance and decision-making processes more diﬃcult. The community-oriented nature of coalitions creates expectations that lead to diﬃculty in reaching decisions and enabling leaders to assert the authority of these decisions. As Larry Green, a widely recognized expert on health coalitions, has written, “not everyone insists on being the coordinator, but nobody wishes to be the coordinatee” (Green 2000). Coalitions are essentially a gathering of volunteers, a herd of cats, driven by each participant’s understanding of the purpose modiﬁed by individual objectives. Coalitions can spend years trying to make a decision as to how decisions will be made, struggling with deﬁnitions of “consensus,” “representation,” “majority,” “leadership,” and “assignments.” These struggles are attractive by their nature. Everyone has an opinion. There is no “best” way. It keeps the coalition occupied and busy. These very struggles, however, delay the real work of coalition— work that is diﬃcult and lacking a map. For example, a large, diverse, health-related coalition spent six months putting in place a consensus model of decision making prior to employing staﬀ, and then found that the model was not strong enough to survive its ﬁrst attempt to make a decision. In theory, it is appealing to commit to a coalition that includes large organizations, small groups, and individuals. In practice, it is diﬃcult to negotiate the diﬀerence in inﬂuence that large organizations expect, enjoy, and often demand. These organizations often come to the table with the belief that they represent a large constituency, that they control substantial resources, that they have experience in organizational development, and that power sharing is inappropriate. Small groups and individuals may come to the table with the expectation that they will be able to inﬂuence decisions because they have an equal voice. As mentioned in chapter 2, Arnstein (1969) wrote of the “ladder of participation” in the community development/organization literature. She described a goal of power sharing that often had to proceed through steps that include Partnership Challenges

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manipulation and simple information sharing. Attention to this possibility is no less important today. No single approach to decision making or governance can be expected to overcome the diﬃculties in bringing together diverse groups and perspectives. However, more successful coalitions appear to quickly put in place a process and begin to focus on program implementation and small successes. It is easier to adapt a governance structure that has contributed to action and decisions than it is to continue to design a perfect process before implementation begins. Initial discussion regarding governance and decision making will be of considerable interest to a small number of “coalition groupies” and will be tolerated by most participants. On the other hand, protracted discussions may retain the interest of the few but may strain the patience of the many. The goal of a governance/decision structure is to make progress and achieve results. If improvement of the structure is the goal rather than the use of that structure to advance the goals of the coalition, one may be left with a support group or a discussion group rather than an action group.

Obtaining Resources and Appropriate Sta=

Obtaining concrete resources, both material and human, constitutes yet another fundamental challenge for community coalitions. In no organization can purpose alone ensure cohesion, continuity, and coverage of maintenance tasks. Highly labor intensive, coalitions often rely strongly on volunteers, but by itself, a coalition’s purpose is not a strong enough glue to hold volunteers together. Without dedicated staﬃng (in many cases paid) and other dependable resources, coalitions cannot eﬀectively launch and maintain their activities. The ability of a coalition to continually recruit new participants adds to its diversity of perspective and representation, but continuous recruitment creates a ﬂuid organization. To be eﬀective, an organization of this ﬂuidity requires great stability of orientation, 66

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materials, and processes. Such stability is diﬃcult if not impossible to achieve without staﬀ assigned speciﬁc, ongoing responsibilities. Selection, deployment, support, and supervision of such staﬀ are among the ﬁrst important decisions that a coalition will face. The manner in which a coalition meets the staﬃng challenge can have signiﬁcant implications for its later development. Decisions regarding staﬀ and resource allocation often set expectations for all decisions that follow. Those who control the staﬀ, after all, control the coalition’s agenda and operations. Lack of paid, long-term staﬀ in many coalitions compounds the challenge of creating a stable decision-making and administrative structure. Most coalitions do not have suﬃcient resources to hire full-time dedicated staﬀ and lack a legal structure to administer funds and personnel. Thus, coalition members must agree among themselves about which participants will serve as sponsor, ﬁscal caretaker, and staﬀ home for activities. Lack of a stable, long-standing structure challenges staﬀ members themselves. Most employees function better with a clear understanding of who their boss is, what his or her expectations are, and how performance will be evaluated. All of these are diﬃcult to negotiate and implement in a situation in which power relationships, governance issues, and procedures are ill-deﬁned. One might expect that some of these diﬃculties decline in frequency and importance as more ﬁnancial resources become available. Our experience has revealed examples of just the opposite: an inﬂux of dollars can dominate the attention of a coalition; relationships, decisions, positioning, advocacy, and agendas are about dollars; participants keep score and assign worth based on dollars; factions develop, and competition replaces collaboration. We have found this most likely to occur if signiﬁcant ﬁnancial resources precede an agreement on purpose and action plans. The ﬁeld of community health improvement often operates on scant resources. Coalition participants see new dollars as a way to sustain their own activities apart from the purpose of the collaborative as a whole. Partnership Challenges

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The most important set of resources for any coalition is the participants. Coalition members and their energy toward the commitment drive the coalition. The care and feeding (ﬁguratively and literally—do not underestimate the power of food as a motivator of participation) of this group is essential to maintaining participation. Any coalition faces the issue of turnover of participants, and that turnover can be accelerated if participants do not feel their contributions are organized and appreciated. It is not uncommon for founding participants to delegate attendance and responsibility to staﬀ with less authority to make decisions. Close attention to the support of participants who are critical to the functioning of that coalition can promote stability. Turnover, however, is a fact of life in collaboratives. New member orientation must be conducted in a timely fashion. Moreover, turnover may have a positive aspect, particularly in the initial stages of the coalition’s development. Those participants with special interest, contacts, and skills in coalition formation may not be ideal for action planning and implementation. Staﬀ and leadership should anticipate that the coalition membership in place as formation turns to implementation is critical to progress and success. Transition from development of the coalition to initiation of the action plan may include planned, orchestrated participant replacement. A major resource for a coalition is its identity—how the community deﬁnes it and places it among other organizations and how the coalition ﬁts into the larger picture of community needs and interests. The development and communication of that identity is a challenge when the coalition requires a “parent” organization, administrative home, or oﬃce location. An organizational home for the coalition can deﬁne the coalition in ways that are more congruent with the home than the purpose of the coalition. Many coalitions seek to promote an independent identity by becoming free-standing, tax-exempt 501(c)3 organizations. Although this may provide a unique identity, it is also accompanied by considerable administrative costs and commitments which may overwhelm an immature organizational structure. 68

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Developing and Implementing an Action Plan

Making plans and putting them into action constitute core challenges for community coalitions. Unforeseen factors arise in the initiation of nearly every program. The sooner implementation begins, however, the sooner these factors can be identiﬁed and addressed. Although the planning stage is important, too much time can be spent in program planning. It is better to err on the side of early implementation. This is especially true in small projects, pilot efforts, or components with clear, short-term results. The achievement of early wins by a coalition can do more for development of structure and procedures than months of planning. Early successes, no matter how small, can provide the coalition encouragement and can increase the conﬁdence of participants in the collaborative model. All projects beneﬁt from an agreed-upon action plan. Such a plan is often of more importance to a coalition given the ﬂuidity of the actions of its multiple partners. A particular challenge for coalitions is to balance a level of detail that is necessary to maintain implementation activities and the need to maintain the ﬂexibility that multiple partners require. Speciﬁcity and concrete action steps contribute signiﬁcantly to this objective. As in our discussion of purpose and goals, abstract or comprehensive language may frustrate the implementation process. Coalition participants are much more likely to contribute to program implementation if they can answer the question, “What speciﬁc actions should I take?” Too often, the decisions of a coalition are to meet again, talk some more, plan, and prepare for action. Reports on progress may include measures of ﬂip charts ﬁlled, audio tapes ﬁlled, hours spent meeting, and procedures adopted— not a list to inspire conﬁdence, new participants, or funders. As if action plans were not challenging enough, successful coalitions seem more likely to be able to articulate a “theory of action” or “logic model,” that is, a sequence of intended events that demonstrate progress. Few coalitions actually use the term “theory of action,” but the process of agreeing on major steps and their pattern Partnership Challenges

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or sequence is beneﬁcial in tracking, monitoring, and evaluating progress. If a coalition has no targets, then every shot hits a center circle. A major challenge of a coalition is to make outcomes matter, and without discussion of a theory of action, outcomes are not even completely deﬁned.

Providing Direct Service to the Community

Achievement of clarity of purpose, concrete action plans, and early wins have been mentioned as dimensions of the community coalition’s basic tasks. Unlike research professionals and employees of stable administrative agencies, community residents require concrete beneﬁts to attract their interest and cement their support. Although they may not express themselves in such direct language, “put up or shut up” is the sentiment felt by many community members. Providing concrete services of direct value to a community, then, constitutes a challenge the importance of which is too often overlooked by coalition leaders. A package of direct services may seem mundane when compared with “visions” and “theories of action.” Coalition participants of idealistic orientation often devalue projects of a more concrete nature. Street lights, speed bumps, ﬂu shots, or rides to healthcare facilities, it is argued, do not change the basic conditions aﬀecting community health, such as the presence of hazardous chemicals in the environment or the uneven distribution of wealth in society. But to community members, these services indicate evidence of the collaborative’s eﬃcacy because they help meet the community members’ needs. Because they are valued, direct services attract the interest of community members in a coalition, induce community members to attend the coalition’s events, and encourage residents to contribute resources such as their volunteer labor. The controversy between “visionaries” and “service providers” recreates a debate often carried out by social critics in Europe. Some have argued that only fundamental change in the government and 70

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economy can improve the lives of working people. However, successful political movements of working men and women have typically emphasized legislation to promote public healthcare, social security, and other programs which help meet the worker’s day-to-day needs. Supporters of these movements have argued, convincingly, that most people pay more attention to immediate achievements on their behalf than abstract visions of the future. In our work with community coalitions, we have observed many direct-service programs that have improved the lives of community residents. Examples include provision of rides to senior centers, opening of multipurpose community centers for literacy, job skills training and placement assistance, and extension of bus service to isolated developments. It would be a mistake to assume that the effect of day-to-day service oﬀerings is limited to the community resident’s physical needs. The presence of a community clinic, visible even to the non-user through its signage, makes the passer-by see that his or her community has not been forgotten. A facility of this kind often inspires pride and hopefulness about the future. Finally, establishment of a direct-service program is often necessary under a coalition’s funding agreement. Foundations and government agencies often require community coalitions to provide concrete, visible services. This is particularly true in states such as California, the major foundations of which function under legal requirements to provide health and health-related services to the population. Even coalitions not required by their funding partners to provide direct services can beneﬁt themselves by doing so, as direct-service provision serves as evidence of concrete accomplishment. Many collaboratives have little or no experience in providing direct services. Members of coalitions such as a hospital or hmo have signiﬁcant experience but have provided direct services of a traditional nature and on their own. Determining which services to provide, planning for their provision, obtaining the required resources, and putting plans into eﬀect constitute diﬃcult and often vital challenges. Partnership Challenges

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Monitoring Facts and Evaluating Actions

Another set of challenges associated with coalition formation and achievement may be characterized as “factual.” The leadership’s ideas and the history of the community both contribute to formulation of purpose and development of action plans in any eﬀective coalition. But such thinking does not take place in isolation from facts. The best coalitions formulate their purposes and action plans with the aid of systematically collected facts about the surrounding community. In many coalitions, challenges associated with accumulation and processing of facts takes its most visible form in program evaluation. The stakeholders that invest in community coalitions—most notably foundations, government agencies, and other bodies that contribute material resources—hold the coalitions accountable for fulﬁlling their commitments and missions. Stakeholder expectations of this kind require the collaboratives to measure whether their eﬀorts actually improve health, achieve change in the surrounding society, and are sustainable. The mandate for evaluation is a particularly diﬃcult one for community coalitions because the traditional tools of the program evaluator may be impractical for collaboratives. Traditional evaluation methods, which require quantitative measures of achievement, also may be impractical. Such methods, moreover, often appear to result in “false negatives,” indicating little or no achievement by the collaborative in instances where meaningful achievements have in fact been made.

Monitoring the Environment

Data and their analysis constitute resources for coalitions of great potential value. Coalitions concerned with health need to know the health threats most important to the communities they serve. They can beneﬁt from an understanding of which segments of the population are at greatest risk. They need to be aware of trends in 72

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conventionally deﬁned illnesses such as asthma and diabetes, and less traditionally deﬁned threats to community health such as teen pregnancy. They can proﬁt from knowing how far community residents reside from healthcare facilities and the transportation barriers that may reduce access. Challenges regarding the use of data resources are multiple. First, community coalitions may lack the capacity to monitor and utilize facts about their surroundings. Even fairly well funded coalitions often lack ﬁnancial resources for collecting and analyzing data. Few collaboratives have suﬃcient resources to conduct systematic polls of their service areas. Few coalitions have personnel available with the time and training needed to utilize low-cost or free sources of data, such as the United States Census, county- and state-level vital statistics, behavioral risk polling data from the Centers for Disease Control and Prevention or state agencies, public use ﬁles of hospital discharge data, or federal survey databases. Those collaboratives that do possess suﬃciently expert personnel to collect and analyze data may have trouble integrating such material into the discussion of decision makers and members. Coalition leaders are often people of action, whose skill set omits competency regarding data and whose personalities are ill-disposed to lengthy review of data or other kinds of facts. Many community residents are unaccustomed to viewing quantitative data. A coalition’s data specialist faces an important challenge in making quantitative data meaningful to community residents. Community report cards— clearly and attractively presented and concretely interpreted summaries of facts about a community, its health issues, and its quality of life—illustrate methods for meeting the data-monitoring challenge.

Program Evaluation

In community coalitions, challenges arise associated with using data for developing purpose and monitoring the community. Collaboratives contemplating evaluation must agree on goals, develop Partnership Challenges

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indicators, identify data collection techniques, analyze data, and communicate results to audiences that matter. At least three primary challenges are found in the evaluation of community-based coalitions. The ﬁrst is in the creation of coalitions to improve the health of the community. Participants often disagree on the deﬁnition of “the community” or the “target area” and who best represents that community or target area in the context of the evaluation. Tension may also exist over who “owns” the evaluation. Is it the participants? The funders? The evaluators? If all share ownership, are there separate evaluations for each group? And to whom do the evaluators report? Second, accommodating multiple stakeholders presents its own set of challenges. Evaluations must integrate diverse participants who have their own perspectives, goals, questions, and standards of success. These diﬀerences complicate selection of health indicators, measures of change, and appropriate (if any) comparisons. Evaluators are often in the conﬂicting roles of ally for the community and provider of feedback to current and potential funders. A third area of challenge relates to measuring longer term outcomes with short-term funding. Few evaluations are supported for a suﬃcient period of time to measure and report the long-term success of coalition activities. Deﬁnitions of success change as these programs evolve, mature, and adapt. Inadequately supported evaluations can result in the reporting of lessons learned that are not impressive and can contribute to low expectations for communitybased coalitions. Communicating results of coalition activities and successes in a timely way and to diverse audiences is diﬃcult, and often the expectations of nonparticipants are unrealistic. These challenges to evaluation are diﬃcult to address and require the combined energies and commitments of coalition participants, funders, and those assigned evaluation responsibilities. As coalitions seek to address these challenges, they should consider exploring ways to build community capacity, build trust, and improve communication.

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Elements of capacity building might include: • evaluation training for community members; • designing evaluations that are suﬃciently ﬂexible to recognize unplanned success and unanticipated outcomes rather than focusing exclusively on goals; and • recognizing continuous quality improvement and evidence of progress. Elements of building trust might include: • establishing an advisory board to the evaluation with participation and leadership from all stakeholders; • encouraging all stakeholders to participate in the design and implementation of the evaluation; and • maintaining realistic expectations and time lines. Elements of improving communication could include: • tailoring dissemination products and customizing presentations according to the needs of each stakeholder group and • curtailing the use of technical language, creating a glossary of evaluation terms, and providing feedback on a regular and frequent basis.

Achieving Sustainability

The challenge of sustainability involves the question of whether the coalition’s eﬀorts should be sustained. If the decision is yes, the challenge becomes how to sustain the coalition or its work. If the decision is no, the challenge becomes how to end the work. An important piece of this work is deﬁnitional—what is to be sustained? Is it the coalition itself, with its participants, staﬃng, procedures,

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schedules, and identity? Or is it the work or purpose of the coalition in another form or with diﬀerent sponsorship? Is the work distinct or is it integrated into other community organizations and resources? Successes are the fuel of coalitions. If participants feel they are involved in successful activities, their continued participation will be more easily recruited. The challenges of sustainability are best addressed by the ability to communicate progress, outcomes, and success to audiences that matter. If a decision is made to end eﬀorts of a coalition, the major challenge will be to communicate that decision to participants in a way that will acknowledge the value of their contribution, time, and resources. Many times we have seen coalitions that are not sustained because of inattention, loss of interest, weariness, conﬂict, or lack of leadership without an oﬃcial decision to end the coalition. The meetings stop. The process halts. The energy is redirected. The activists move on to more fertile ground. And the “coalition groupies” ﬁnd another coalition. The development, maintenance, and success of coalitions to improve the health of communities present many challenges. Almost always, these challenges are addressed by identifying tensions and seeking to achieve some balance that will allow progress toward the goals. It is important that potential participants agree that a collaborative approach is appropriate for the goals they seek to address. Coalitions are powerful; they can move communities. Coalitions are hungry; they must be fed with commitment, energy, and time. Coalitions are demanding; they should be pursued with caution.

REFERENCES Arnstein, S. R. 1969. “A Ladder of Citizen Participation.” Journal of the American Planning Association 35 (4): 216–24. Green, L. W. 2000. “Caveats on Coalitions: In Praise of Partnership.” Health Promotion Practice 1: 64.

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PART II

A Case Study: The Mutual Partnerships Coalition

The Mutual Partnerships Coalition (mpc) illustrates a partnership of the kind described conceptually in the preceding chapters. Operating between 1992 and 1996, mpc exempliﬁes the modern community coalition: both grass roots and mainstream organizations participated in the enterprise; the coalition looked to community residents for leadership; and organizations participating in mpc hoped to both strengthen the community and their positions within it. mpc also illustrates the challenges that often face partnerships seeking to promote health and improve quality of life in the community: it pursued ambitious goals and applied methods that had not been tested systematically elsewhere. These self-imposed challenges were suﬃcient to create anxiety regarding the project’s potential success. In addition, signiﬁcant conﬂict occurred among partnership staﬀ. Issues arose regarding allocation of authority and supervision of personnel. Disputes took place regarding how accomplishments should be evaluated, either of individuals or of mpc as a whole. Considerable eﬀort was expended toward dispute resolution, with imperfect results.

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Nevertheless, mpc carried out a broad array of concrete interventions. Some of these had been planned as part of the project’s early thinking. Others developed after the project was underway. Evaluation of both process and outcome was conducted. Each intervention carried out under mpc may be thought of as a separate experiment. Outcomes of these experiments helped build knowledge about which concrete interventions were most likely to be eﬀective. Lessons also emerged about the process of making community partnerships work.

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CHAPTER 4

An Ambitious Partnership: The Mutual Partnerships Coalition

The Mutual Partnerships Coalition (mpc) began as a collaborative eﬀort of ﬁve organizations in Seattle, Washington. The original coalition included: • The Central Area Motivation Program’s Rites of Passage Experience (camp/rope), an inner-city cultural and educational program serving young people • Seattle Housing Authority, a city department which provides public housing • Senior Services of Seattle/King County, a private, nonproﬁt agency oﬀering a broad range of services for elders • United in Outreach, a faith-based, community-supported organization providing food to needy and homebound Seattle residents • Group Health Cooperative of Puget Sound, a nonproﬁt, consumer-owned healthcare organization committed to prevention and community well-being. As their names and missions suggest, each organization had a history distinct from the others in the partnership. The organizations

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had separate (although sometimes overlapping) missions, stakeholders, and sources of support, but all of them shared a core set of values: All believed it important to promote the independence, health, and social participation of people in Central Seattle, an area highly diverse in age, race, income, and culture, and all considered the wellbeing of elders to be a major element of its mission. A powerful force gave birth to and sustained mpc throughout its existence: the concept that people of any age or walk of life have gifts and capacities. These gifts and capacities, it was believed, could enable any individual to help others, lessening another person’s dependence on social agencies and the healthcare system. The partnership focused on a segment of the population whose gifts and capacities are often ignored: the elderly.

GUIDING CONCEPTS

Two concepts guided the establishment and operation of mpc: gifts and capacities and human community. Advancing these concepts and making their implications a reality constituted the partnership’s goals.

Gifts and Capacities

Throughout its planning and operational phase, the visionary work of John McKnight provided mpc with inspiration and challenge. Attaining great popularity in the 1990s, McKnight believed that everyone possesses gifts and capacities, whether young or old, able-bodied or challenged, advantaged or disadvantaged (McKnight 1995). According to McKnight, social service agencies and professionals often overlook gifts and capacities. Viewing individuals with whom they come in contact as “clients,” professionals tend to focus instead on “problems” and “needs.” Similarly, public oﬃcials tend to view poor neighborhoods as blighted and in need of intervention. In McKnight’s thinking, these neighborhoods have gifts and 80

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capacities as well. Unrecognized resources available to communities might include long-established institutions such as community centers and churches, unused buildings and lots, and the experience and talents of residents (McKnight 1995). This principle has two major consequences for action. First, people committed to strengthening their communities must alert others to the abundance of gifts and capacities that may be mobilized. People must develop an awareness of their own gifts and those of people around them. Second, communities can beneﬁt greatly by cataloging the gifts and capacities of local individuals and groups. Recording these in a systematic way facilitates creation of partnerships that link individuals and groups. McKnight has remarked that most people choose their life’s work because someone has told them, “you have a gift.” Awareness of one’s gifts raises expectations and releases energy. When people become conscious of their gifts they are able to develop them in practical ways and apply them to assist others (McKnight 1995). Yet many people never receive encouragement to recognize or develop their gifts. People in disadvantaged communities are likely to hear much more about their problems and needs than their gifts. The labels people receive from society—“delinquent,” “mentally ill,” “disabled,” “elderly,” etc.—endanger their ability to appreciate their gifts. According to this thinking, people who do not recognize their own gifts tend to view those of others inappropriately. A person unaware of his or her capabilities may diminish the gifts of others— or even exaggerate these gifts, thus diminishing the value of his or her own.

Human Community

Fostering of human community was mpc’s second guiding concept. Human community, it was reasoned, beneﬁted strongly from fostering of gifts and capacities among the people of Central Seattle. An Ambitious Partnership

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The exchange of gifts and capacities among individuals appeared capable of promoting increased contact among people. The organization’s name was intended to reﬂect such exchange. Early discussion focused on the potential of mutual exchanges among individuals as a method for reweaving the fabric of communities that had come unraveled in the late twentieth century. Human community has signiﬁcant practical importance for helping healthcare organizations achieve their objectives. Researchers from a variety of backgrounds have identiﬁed isolation as a serious problem. In his landmark essay, “Bowling Alone: America’s Declining Social Capital,” Putnam (1995) established personal isolation as a general social concern. Epidemiologists and public health researchers, moreover, have documented relationships between isolation and morbidity, quality of life, and mortality. As early as the 1970s, researchers reported signiﬁcantly greater mortality risk among socially isolated people than among those with extensive social ties. Numerous investigators, working at diverse locations throughout the United States and abroad, have conﬁrmed the importance of community for human health and well-being. As a public health concern, isolation among the elderly appears to merit special attention. Neighborhood change combined with limited options for relocation, departure of children, and death of friends and family members comprise special risks for isolation among elders. Relationships between isolation and mortality are as strong among elders as they are among non-elders. Advanced age and dysfunction (both physical and emotional), moreover, coincide with relative isolation among elders.

T H E C H A L L E N G E O F I M P L E M E N TAT I O N Past Experience

Because of the health risks known to accompany isolation, earlier projects have attempted to develop eﬀective interventions. Familiar 82

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examples include support groups of cancer patients and the recently bereaved. Other deliberate interventions aimed at reducing isolation have used the talents of outgoing individuals (people who actively initiate conversation and other social contact) to promote socialization and disseminate information among the potentially isolated. Researchers and program planners, however, have not yet devised interventions proven to reduce isolation or protect against its consequences. Discussion of the eﬀect of interventions is often anecdotal and comprehensive for only the period immediately following the intervention. In one study, investigators tested the eﬀect of deliberately created social, recreational, and practical interventions on social contacts, self-perceived health status, function according to activities of daily life (adl) measures, and mortality. The threeyear, randomized study found no evidence that the interventions produced improvements (Clarke, Clarke, and Jagger 1992). Similarly, another study focused on creating helping networks for dementia patients failed to demonstrate improvements in areas such as depression and agitation (Cohen, Hyland, and Devlin 1999).

Practical Steps

In its day-to-day operations, mpc had aimed at reducing isolation and dependency among elderly and disadvantaged people by fostering relationships of mutual assistance and support. Initially, the organization stated its objective as the creation of one-on-one relationships of mutual assistance among elderly people at risk of isolation. If an elder with good eyesight occasionally read the newspaper for a blind neighbor, it was reasoned, one would receive a practical service and both would reduce their risk of isolation. Early thinking within mpc envisioned networks of elders helping each other by trading practical services such as shopping, preparing taxes, doing home repairs, or simply exchanging conversation and company. Mutual assistance relationships such as these, it was reasoned, would reduce the dependence of elders on government An Ambitious Partnership

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and public service agencies and renew the ﬁber of community as neighbors increased their familiarity with and reliance on each other. This thinking responded directly to McKnight’s (1995) criticism of the social service professions for focusing on the deﬁcits of the elderly, poor, and physically challenged, helping perpetuate the status of such people as dependents. mpc, by contrast, sought to celebrate these individuals’ gifts and capacities. mpc engaged in a variety of practical tasks, but all had the common objective of creating “matches” between people in the community. On the most basic level, matching involved creation of partnerships between individuals for practical assistance or companionship.

ORGANIZING THE PARTNERSHIP The Service Area

Seattle’s public image underwent a transformation during the 1980s and 1990s. Prior to those decades, the city and its environs were known for attractive scenery and continual precipitation. Loggers, ﬁsherman, and Boeing assembly workers dominated the area’s public image if not its actual economy. As the years went by, the area became famous for its high-tech industries and gourmet coﬀee. What had been an out-of-the-way corner of the United States seemingly become a mecca of the young, highly educated, and talented. But the city’s Central Area, where the mpc concentrated its activity, did not conform to this image. The densest concentration of Seattle’s African American population lived in this part of the city. New immigrants, predominantly from Southeast Asia, had settled in the city’s International District. Among white adults, people from two extremes of the age spectrum predominated. Elders continued to live in the single-family houses in which they had raised their families or moved into the area’s many apartment buildings. Seeking a central location close to their jobs, young adults also found homes in the area. 84

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Elders faced special risks of isolation in these neighborhoods. Multiple languages began to be spoken on once-homogeneous blocks. Familiar businesses closed, replaced by establishments catering to the young. Gang activity was evident in the area. Factors responsible for isolation and fear were exempliﬁed in some of the facilities maintained by the Seattle Housing Authority. Traditionally, African American and white elders had occupied these buildings. Now, their neighbors included families whose languages they did not share. Laws intended to help the disabled also promoted the housing of people with drug histories in Seattle Housing Authority units. People in age groups and with appearances and cultures very diﬀerent from the long-term, elderly residents moved into the buildings. These changes were of great importance to the mpc partners. All had physical facilities in the area. All counted large numbers of the area’s residents among their clients, patients, or tenants. Several of the Seattle Housing Authority’s largest facilities were in the area, as was Group Health Cooperative’s main hospital.

THE COALITION’S DEVELOPMENT Initiation

Group Health Cooperative of Puget Sound, a health maintenance organization with strong historical commitment to social causes, initially convened the coalition. Founded in 1947 as one of the ﬁrst hmos, Group Health Cooperative maintains a governance structure highly responsive to consumer input. Personnel responsible for helping encourage the input of consumers were instrumental in identifying McKnight’s (1995) work as important to Group Health Cooperative. mpc began as a discussion group among Group Health Cooperative personnel interested in developing the organization as an asset not just for its members but the community as a whole. Valuing An Ambitious Partnership

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perspectives from outside Group Health Cooperative, they searched the city for partners. It was also clear that the experience and networks of partner organizations would be crucial. Discussions continued involving four key partners: United in Outreach (uio), a church-based food bank; the Central Area Motivation Project (camp), a grant-funded agency providing education, recreation, and job-readiness services to central city residents; Senior Services of Seattle/King County, a United Way agency providing a wide variety of services to elders; and the Seattle Housing Authority, which operates public housing in Seattle.

Organization

Group Health Cooperative initially convened mpc and provided staﬀ support for early meetings and discussion, and later served as the organization’s ﬁscal agent. But mpc was not a subunit of Group Health Cooperative. Clear boundaries had developed between Group Health Cooperative and mpc by 1992. At that time, mpc enacted bylaws vesting ﬁnal decision-making power in a steering committee, on which all participating organizations enjoyed equal voting power. Coalition partners viewed the steering committee as a mechanism to ensure community control of the prospective project and soon extended invitations to community residents to participate as individuals. The steering committee met regularly, almost always on the premises of constituent organizations other than Group Health Cooperative.

Funding

A crucial event in mpc’s history occurred in late 1992 in the form of a major grant from the W. K. Kellogg Foundation. Group Health Cooperative enjoyed long-standing ties with the Foundation and had early on inquired about the possibility of funding for the 86

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project. The prospect of receiving funds from the Foundation inﬂuenced both mpc’s structure and goals. Before mpc’s establishment, Group Health Cooperative had inquired about the Foundation’s interest in supporting an in-house eﬀort to foster one-on-one relationships of mutual assistance among residents of the community surrounding its central hospital. The Foundation agreed to fund such a project, providing that it be carried out by a “community-based” organization, focus principally on minorities, emphasize continuous expansion to include new organizations and communities, and eventually become selfsustaining. The Foundation also indicated a strong interest in seeing mutual assistance relationships established not only among elders but between elders and young people. These comments encouraged Group Health Cooperative to look outside its own boundaries and led directly to mpc’s development as an independent organization striving to achieve community control. The W. K. Kellogg Foundation awarded mpc a grant of $1 million on November 1, 1992. Over the ensuing four years, coalition partners contributed additional resources (largely in-kind) valued at about $400,000. Foundation funding allowed mpc to begin concrete operations. Group Health Cooperative received the grant and acted as ﬁscal agent on behalf of mpc.

S TA F F I N G , S U P E R V I S I O N , A N D D E C I S I O N M A K I N G Sta;ng

Several persons who had participated in mpc’s initial development became paid staﬀ. In addition, mpc hired six new staﬀ members. These included four community specialists, individuals whose duties included identifying isolated elders and helping establish oneon-one relationships of mutual assistance among them; and a project assistant, who provided secretarial and administrative support to the project. Of key importance, mpc hired a project coordinator, An Ambitious Partnership

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whose duties included helping set project direction, expanding the number of agencies and community groups involved in the project, and raising funds to help achieve self-suﬃciency. The project coordinator was also charged with supervising the project assistant and contributing to supervision of the community specialists. mpc made a strong eﬀort to select community specialists and a project coordinator who both knew and reﬂected the interests of the community. Job descriptions and qualiﬁcations included knowledge of the Central Seattle community and prior involvement with community agencies or grass-roots organizations. Job announcements were advertised in community newspapers. Community residents, some of whom were recruited to serve on mpc’s governing board, participated in screening applications and selecting candidates.

Structure and Governance

Following these milestones, mpc assumed the organizational structure which characterized the remainder of its active existence. A chart of major organizational relationships appears in Figure 4.1. The community specialists comprised mpc’s ﬁeld staﬀ. Each of these individuals was attached to uio, camp, Senior Services, or the Housing Authority and received their paychecks from these agencies. Each community specialist received supervision from both the project coordinator and the steering committee member who represented the agency to which the community specialist was aﬃliated. Personnel attached to Group Health Cooperative occupied important positions in the structure of the emerging organization. A Group Health Cooperative executive assumed the title of project director, serving as liaison with the W. K. Kellogg Foundation and mpc’s ﬁscal agent vis-à-vis the Foundation. An employee of Group Health Cooperative assumed the role of training specialist and a consultant was assigned responsibility for evaluation. Both the training specialist and evaluation consultant reported to the project director. The project coordinator was instructed to act with the advice 88

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Figure 4.1: Organizational Structure of the Mutual Partnerships Coalition

Steering Committee

Training Specialist

Project Director

Evaluation Consultant

Project Coordinater

Project Assistant

Community Specialists

and consent of the steering committee but was formally an employee of Group Health Cooperative under the supervision of the project director.

E A R LY I M P L E M E N TAT I O N

Project activity began with an emphasis on training and discussion. The training specialist began with a series of instruction modules designed to sensitize the community specialists to community members’ “gifts and capacities,” which would serve as the basis for matching individuals at risk of isolation. The project coordinator organized a two-day retreat at a remote location, the ﬁrst day including only community specialists and the second day working with steering committee members and other staﬀ. The project coordinator, steering committee members, and community specialists traveled to An Ambitious Partnership

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Montreal, Quebec, Canada for a week-long seminar with John McKnight. Preliminary ﬁeld operations commenced with a telephone survey of elderly residents in a sample of Housing Authority buildings. The principal objective of this survey was to develop baseline data for evaluation. In addition, surveying individuals from the project’s target population was felt to promote valuable perspective among the community specialists. The community specialists received training in telephone survey techniques and completed 164 interviews. Field work then began in earnest. The community specialists designed activities to develop matches, one-on-one relationships among individuals with whom their agencies came in contact: elders on outreach lists maintained by Senior Services, food recipients at uio facilities, residents in Housing Authority buildings, and young people taking classes in African American history and consciousness at camp. These assignments demanded signiﬁcant energy and creativity of the community specialists. Earlier discussion had identiﬁed contexts for making matches but speciﬁed no procedures. Developing techniques for establishing mutual assistance relationships constituted one of the major objectives of the project, and this task fell to the resourcefulness and creativity of the ﬁeld staﬀ. Day-to-day operations relied heavily on the initiative of individual project staﬀ. Community specialists focused on community residents associated with the agencies that formally employed them. The project coordinator, located in an oﬃce suite away from Group Health Cooperative’s premises, concentrated on making contacts throughout the city and meeting with representatives of community groups and public service agencies. To ensure coordination, the steering committee adopted a format under which speciﬁc sets of staﬀ and steering committee members would meet. Community specialists were to meet weekly as a group with the project coordinator. Senior staﬀ, including the project director, project coordinator, training specialist, and evaluation consultant, were to meet biweekly. The steering committee itself met once each month. 90

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INTERVENTION TECHNIQUES: OVERVIEW

mpc developed three strategies to pursue its objectives to help people become aware of their own and each other’s gifts and capacities and create partnerships. These included: • training: to increase awareness of gifts and capacities, both one’s own and those of others • mapping: to identify gifts and capacities throughout the community as a resource for creating partnerships • matching: to foster development of partnerships by bringing participants together and encouraging them to share gifts and capacities on a continuing basis Developing mutual partnerships was not conceived as a job reserved for specialized professionals. Almost everyone, it was believed, could help create mutual partnerships. mpc saw itself as an initiator of recognition of gifts and capacities and building community. But mpc did not conceive of its mission as making matches or creating a permanent place for itself in Central Seattle. Rather, mpc articulated its mission as developing and demonstrating techniques for achieving and promoting mutual partnerships and training others to use them. Eventual delegation of mpc’s responsibilities to a new, fully community-based group was a key project objective.

Training The Need for Training

Consistent with mpc’s concept of itself as a catalyst, it emphasized training. Coordinated by the training specialist and assisted by the community specialists, training took place in a variety of settings, including community organizations, public agencies, and private ﬁrms. mpc carried out the procedure detailed below to instruct its An Ambitious Partnership

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own staﬀ. These sessions were also included in the numerous community workshops held during the course of the project in the hope that they would form the basis for spontaneous creation of mutual partnerships in a broad variety of settings.

The Training Module

Consisting of ﬁve steps, the mpc training module was intended to diﬀer from standard educational products. Rather than emphasize speciﬁc procedures and techniques in creating partnerships, it was designed to alert and sensitize the audience to the widespread presence of gifts and capacities in the community. This process takes place through exercises that encourage participants to identify gifts and capacities of everyone present at the training session. Although the module included speciﬁc steps, it was not a standardized product. The content of each step was intended to be adapted to the objectives of participating individuals and groups. Each instance in which the module was delivered began with an eﬀort to increase acquaintance with the participants and help them clarify their objectives. The ﬁve steps documented in the mpc Guidebook, a background and procedures manual created by mpc, were speciﬁed as follows. 1. Greeting exercise. Every module begins with a greeting exercise which highlights community ideals: free communication, spontaneous expression, creativity, and fun. The greeting exercise contrasts community values with life in traditional service agencies. As people arrive for training, some are sent to a “community circle,” others to an “institutional square.” People in the community circle are free to select their own topics and talk in an unstructured manner. People in the institutional square are given rules governing communication and assigned discussion topics. The greeting exercises serves as both an introduction and an icebreaker. 92

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2. Workshop overview. Facilitators and presenters provide a “guided tour” of topics to come. They ask participants for comments on experiences in the community circle and institutional square. Key concepts in partnership and community building are introduced. Participants are informed of the processes that will take place and the skills they will receive. 3. Approach to community. Continuing in lecture format, speakers provide details on the nature and workings of communities developing gifts and capacities among their residents. The nature of community networks is explained. Key roles in community building are identiﬁed. These include “bridge builders” (people who help others achieve independence from service agencies) and “community guides” (people who link individuals they know with the broader community). 4. Gifts and capacities exercise. In group settings, participants identify their own gifts, learn about the gifts of other group members, and talk about the gifts they would like to share. Individuals begin by making lists of their most important gifts. Next, they circle two or three gifts they would most like to share. Participants then answer questions about whom they wish to share their gifts with and how they would locate the person or group identiﬁed. 5. Match process. This step returns to lecture format. The speaker outlines the process for making matches and provides illustrations. Included are vignettes illustrating a wide variety of successful matches. In addition, the speaker provides detailed descriptions about how the partnerships were formed, the diﬃculties that were encountered in putting them together, and the means by which these diﬃculties were overcome.

Appreciative Inquiry

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to important aspects of others’ lives and capacities within the community. Staﬀ used the concept of appreciative inquiry as a guiding philosophy in the training process. Cooperrider and Srivastava (1990) have used the term appreciative inquiry to denote the kind of thinking and question-asking most eﬀective in learning about the gifts of others and building partnerships: Appreciative inquiry assumes that the life-giving reality in any complex human system lies in the passion and responsibility people express in the everyday decisions and activities they carry out. It anchors transformational change in discovering, reporting, and learning from personal stories generated within the system: stories people tell about the community or organization functioning at its best. In most organizations and communities, these stories are told privately—in gossip, at coﬀee breaks, in informal sessions with family and friends. Appreciative inquiry recognizes the public value of those stories—for community-building and learning. If the stories which are uncovered as a result of appreciative inquiry are told via newspapers, newsletters, radio, and television, a community can rapidly learn from what it is doing best, from what is really working for people.

MAPPING The Rationale for Mapping Assets

The writings of Kretzmann and McKnight (1993) emphasize systematic examination of a community’s assets. Among the devices they formulate for this purpose is one known as a community map. Informal application of the concept took place as part of mpc’s work. A community map in this sense is not one that shows locations of streets and physical features. Rather, it is a chart illustrating the most important characteristics of the population. Information for 94

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making this kind of map is obtained through surveys which ask people about their current lives, their families, their health, and their challenges. Kretzmann and McKnight (1993) distinguish two types of maps that may be used to describe communities. The neighborhood needs map is based on needs assessments by service agencies and researchers. It enumerates perceived community problem such as preventable illnesses, births to single mothers, drugs, crime, and other undesirable features of modern urban life. Most news media seem to base their stories on maps of this kind. The community assets map emphasizes the neighborhood’s positive features and indicates concentrations of gifts and capacities. Most apparent are local institutions such as businesses, schools, libraries, and parks; churches and clubs represent a second layer of community assets. Most basic are the gifts and capacities of individuals, located among all segments of the community population. The community assets map works as maps traditionally have: guiding people to where they want to go. Community leaders can beneﬁt greatly from making maps of their neighborhoods that detail the gifts and capacities of as many people, groups, and institutions as possible. These may be concretely useful, such as car repair and bricklaying, or softer yet equally valuable, such as teaching music or storytelling.

Steps in Community Mapping

The mpc Guidebook speciﬁes practical steps consistent with Kretzmann and McKnight’s (1993) thinking. Assembling a community assets map requires (1) collecting information and (2) cataloguing that information in a manner which will permit ready access. The map must guide the community builder in the direction of viable partnerships. Information from people in the community provides the basis for maps of community assets, and systematic procedures for obtaining this information are of great value to people who desire to An Ambitious Partnership

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create them. A major part of mpc’s work involved community mapping, and the tools and procedures used by mpc should have valuable application everywhere. Mapmakers can approach community members individually or in groups. mpc staﬀ talked to individuals in door-to-door campaigns to assess individual gifts and capacities. mpc also held numerous group meetings, which ranged from community get-togethers and employee training sessions with only a few participants to large, regional conferences with hundreds of attendees. The process of mapping is quite similar in both settings. The following sections describe speciﬁc procedures used in accordance with the mpc Guidebook.

Explaining the Concept

It should be explained to groups unfamiliar with community mapping that many people today do not appreciate their own capabilities. Too often, people fail to recognize the gifts of others. Time is never wasted in reminding people that they possess gifts and capacities and that neighborhood resources are often ignored. At the beginning of a door-to-door visit, training workshop, or community meeting, people should be encouraged to think about their own gifts. They should be encouraged to think of their skills, talents, experience, personal capabilities, or hobbies as community assets; some of the most important assets are personal attributes such as a sense of humor or the ability to listen to others. Personal gifts and capacities, networks and skills within local groups, and resources possessed by large businesses and government can all become community assets. Community mapping helps identify these assets and achieve their mobilization. Individual assets are easy to identify when people understand the concept of gifts and capacities. Educational institutions, both schools and colleges, also comprise community resources, as do police and ﬁre departments, which have much to give beyond the basic services they provide. 96

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Physical resources are also important community assets, but these are often underutilized. Everyone recognizes the importance of a site for community recreation and events, but materials associated with urban decay can become important assets as well. Vacant land can become a resource if it is made into a community garden. An unused warehouse can become an art studio. “Waste” lumber can become a useful structure.

Identifying Assets

mpc used a formal procedure to help identify assets. A capacity inventory served as an important aide in thinking and discussion. The capacity inventory should begin with a checklist of speciﬁc skills individuals often possess which, although perhaps unrecognized, have great potential value for asset-based community building. Speciﬁc areas on the capacity inventory include: • health—caring for the sick, mentally ill, and elderly • oﬃce work—word processing, bookkeeping, taking messages • construction and repair—painting, rooﬁng, electrical • maintenance—housekeeping, gardening • food provision/cooking—planning menus for large events, serving, washing dishes • transportation—transporting people, hauling goods or waste • management and supervision—report writing, budgeting, fund-raising, planning work for a team • miscellaneous—child care, security, singing, sewing The capacity inventory asks individuals (1) to indicate whether they have any of the numerous skills listed under these headings, (2) which skills they think represent their best and which they would like to teach, and (3) what the individual’s interests and experience are, related or unrelated to these skills. An Ambitious Partnership

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The capacity inventory may be used in face-to-face meetings in door-to-door campaigns or in small groups at community gatherings. Either activity is likely to produce a long list of skills. Awareness of the presence of these skills in the local population itself encourages people as individuals and points the way to community empowerment. mpc created a useful exercise to emphasize the value of oftenunrecognized gifts. Facilitators instructed people in small group settings to identify a project of value to all participants. Then the facilitator asked group members to identify the skills needed to carry out such a project. Finally, group members were asked to see how many of the required skills were present on the capacity inventories they had completed earlier. Through this process, many imagined projects came to be seen as highly feasible.

Creating the Map

Representing the skills and resources of the community in a graphic form constitutes the ﬁnal step of the mapping process. The conference or community setting provides an excellent opportunity for developing the “big picture.” Small group discussions give rise to representation on blackboards and ﬂipcharts of each skill or resource and the volume of its presence in the community. Using these, discussion leaders can digest ﬁndings into maps patterned after the format developed by Kretzmann and McKnight (1993). These can be published in community newsletters and distributed at meetings of community groups.

A N I L L U S T R AT I O N

Kretzmann and McKnight (1993) illustrate how the logic behind community mapping—a search for unidentiﬁed assets—can improve

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community life. They characterize the following examples as “ﬁnding buried treasure”:

Example 1

A neighborhood park sponsored an art class for teens and adults that would provide them with the drawing and painting skills necessary for creating a community mural. Local artists were brought in to discuss their work as well as to demonstrate the techniques appropriate for mural work. The class was also placed in contact with a local historical society that could provide essential information about the evolution of the neighborhood. As a possible site for the mural they planned to paint, the group chose a park wall that was sprayed with graﬃti.

Example 2

In New York City’s Hunt’s Point, young people start a business from throw-aways: Youth gather wood that is being illegally dumped in a vacant lot in their neighborhood and start a ﬁrewood business. They print ﬂiers, make contracts with landscaping companies, and deliver their wood to businesses where it is sold. The youths work on commission and many earn between $100 and $300 per week. The youth have also developed other enterprises: silk-screened t-shirts with neighborhood scenes, handmade postcards, Christmas tree deliveries, frozen coconut ice, and manure and wood chips.

Example 3

Fertilizer for a community gardening project is collected at the recycling center compost heap. Composting materials are gathered

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from neighborhood kitchens, local supermarkets, and the horse manure stockpiles of the local police precinct. Excess compost is made available to other community groups with garden projects and for neighborhood associations to mulch the base of trees. The group also provides technical assistance to community groups interested in developing gardening projects.

Database Support

The computerized database constitutes a virtual community map. The personal computer revolution of the late twentieth century made data-related tools available to nearly everyone. People who never used such equipment before have ready access today. mpc made extensive use of electronic databases for monitoring, recording, and tracking matches, as well as facilitating other activity. Community meetings, door-to-door canvassing, and other activities designed to identify potential partners can produce much paperwork. Community builders can reduce paperwork and increase eﬃciency by building a database on a personal computer. Community people who have never worked with computers should be encouraged to start. Today, computer technology is easy to use. Excellent guidebooks written in nontechnical language are now available. Often, college students volunteering for community work can serve as computer instructors or support personnel. Powerful computers, moreover, are often being given away by businesses to schools and local service organizations that require more up-to-date machines. mpc’s work illustrates the usefulness of a computerized database for making matches. mpc compiled a database to record gifts, capacities, and community assets, and each person or group with which mpc had contact was entered into this database. Records for each individual or group included name, address, telephone number, and the gifts and capacities. mpc compiled its database using the version of Microsoft Access® current in the mid-1990s. Use of the database required only 100

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two or three keystrokes. A report on a single zip code in the mpc database identiﬁed gifts and capacities from 93 records, which constitute points on the virtual map: • • • • • •

people able to speak Spanish (4) people interested in attending a block watch meeting (39) people who identiﬁed themselves as outgoing (10) people experienced with computers (11) people experienced in childcare (4) people who walk for exercise (11)

A community map is always changing. People move into and leave communities. Some physical assets are used up or taken away, and others appear unexpectedly. People who were always busy with children and jobs no longer have these responsibilities and need things to do. Community maps, therefore, must be updated regularly and be expanded continuously as community builders make contact with additional individuals and groups. Records of individuals and groups with characteristics of interest were instantly displayed on a computer screen; people with compatible or complementary interests were identiﬁed in moments. This capability helped make a key part of building mutual partnerships, the matching of individuals and groups as described below, considerably easier than it would have been through manipulation of papers and ﬁle folders. Ideally, community mapping comprises only part of the community-building enterprise. Mapping should take place alongside gifts-and-capacities training. Each activity reinforces the other.

M AT C H I N G

mpc’s eﬀorts to foster partnerships in the community relied most directly on a process known as making matches. Recognizing and mapping gifts and capacities can play an important part in promoting An Ambitious Partnership

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community empowerment, but bringing individuals out of isolation, uniting diverse generations, and unleashing forces for change require human contact—matches between actual partners.

Criteria for Matches

mpc placed special emphasis on distinguishing matches from casual contacts or traditional professional-client relationships. Based on numerous internal discussions and impressions from authors such as McKnight, mpc developed an “oﬃcial” concept of the match. According to this deﬁnition, a match takes place when two or more partners: 1. 2. 3. 4. 5.

have direct contact with each other, help meet each other’s needs, maintain relationships over time, see or talk with each other as equals, and recognize and build on each other’s gifts and capacities.

The most valuable matches were considered to be those that took place between peers. Ideally, they might develop on their own. They continue over time, as partners visit, call, and meet each other at gathering places in the community. Traditional leaders play an important but limited part in matches. Professionals and grass-roots community leaders may identify potential partners and make introductions, but relationships between professionals and clients or community leaders and group members are not usually peer relationships; therefore, they are not true matches. mpc personnel often cited a match at a Seattle Housing Authority facility as ideal: Two older women lived in the same building for several years. They seldom left their own small apartments. They had both

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lost many loved ones in later life and were reluctant to seek new friends. Both women feared going outside their own, private space. Di;culty in walking proved a barrier, and both also feared they might fall and find themselves without help or become victims of assault. A community specialist with the Mutual Partnerships Coalition discovered that these women had much in common. She introduced them to each other and invited them to social events in their building. Gradually, a friendship grew between them. The women began taking walks together around the halls. Neighbors greeted and encouraged them as they performed their routine.

This partnership produced important outcomes. Seeing each other regularly and becoming visible to their neighbors, both decreased their social isolation. Walking together frequently, both reduced their health risks through moderate exercise. This story depicts a match because the partners enjoyed mutual beneﬁts and continuing contact. A paid professional helped initiate the relationship, but the two women developed their capacities to communicate and reach out. Their friendship will endure without outside support.

Types of Matches

All aspects of community life were seen as creating opportunities for matches. Matches between two individuals, such as the two older women described above, are the most familiar. But individual-toindividual matches represented only one possibility identiﬁed by mpc. Matches linking individuals with groups were seen as equally valuable, and matches linking groups with other groups were believed to contribute to the community as well. Discussion within mpc identiﬁed a speciﬁc character and function for each type of match. An Ambitious Partnership

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Individual-to-Individual Matches

Individual-to-individual matches were considered as the most basic form of partnering. One-on-one relationships are arguably the most crucial parts of many people’s lives. These include relationships with brothers and sisters, marriage partnerships, and close friendships. One-on-one relationships provide opportunities for sharing the deepest of secrets and most profound of fears. One-on-one relationships help determine an individual’s entire outlook on the world. For many, such relationships serve as major guideposts throughout life. One-on-one relationships may constitute an extremely powerful force in strengthening the community. Thus, every communitybuilding eﬀort should include attempts to foster individual-to-individual matches. Individual-to-individual matches may unite people with highly similar backgrounds and interests. Alternatively, individual-toindividual matches may unite partners who are highly diverse, belonging to diﬀerent generations, social classes, cultures, or ethnic and racial groups.

Individual-to-Group Matches

Linking individuals with groups represented a second approach to matching. An individual-to-group match may be less intense than an individual-to-individual match. But in the view of most mpc personnel, the individual-to-group match oﬀers several distinct advantages. People may feel more at ease in a group than in an individual-to-individual, face-to-face setting. Groups oﬀer a variety of activities. Groups are more reliable. They continue to function even when some members may be ill or busy with other things. Some individual-to-group matches resemble traditional volunteer service. Matches of this kind often result in exchanges of beneﬁts. They encourage individuals to recognize and make use of their 104

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gifts. The story of one volunteer provides a valuable illustration of mutual assistance via individual-to-group matching: Virginia, an elderly woman, had trouble getting around. She had an artificial leg and used a walker. Feeling vulnerable to injury, she was reluctant to use the city bus system. A woman from the local food bank delivered bags of food to Virginia. After getting to know her, the woman encouraged Virginia to help out at the food bank. For the last two years, Virginia has worked at the food bank one day each week. She helps assemble bags of food for others to deliver to sites throughout the community. This work requires little physical strength, but food bagging must precede distribution. The food bank operates on a strict budget and requires volunteers to perform this function. Virginia has benefited greatly from working at the food bank. She has made personal friends. Training and volunteer recognition activities have expanded her network of social ties. She has increased her sense of being a person who contributes to the well-being of others. The need to travel to the food bank has motivated her to overcome her fear of traveling outside her home. Matching Virginia with the food bank has benefited both the individual and the group: Virginia has recognized and expanded her gifts and capacities, and the food bank has obtained assistance necessary for its functioning.

Other individual-to-group matches emphasize primarily social exchanges. Many groups in the community hold regular social events. mpc staﬀ made consistent use of these events. One of the most prominent was the weekly tea held at a senior center operated by an mpc partner. It was hoped that individual-to-group matches would have broader impact on the lives of individuals than periodic attendance at a social hour. Group settings provide individuals with many opportunities to meet other people. Individual-to-group matches have An Ambitious Partnership

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the potential for spawning individual-to-individual matches, as people meet others with similar interests.

Group-to-Group Matches

Another form of matching focused exclusively on groups. Matches of this kind were intended to link social, volunteer, and advocacy groups in the community. Almost any group, it was believed, could do a better job in cooperation with other groups. Group-to-group matching would make this possible. Every community houses groups dedicated to improving health, preventing crime, beautifying streets, or a dozen other familiar causes. These groups contribute much to community life. They help individuals ﬁnd companionship and apply their gifts. But many community groups work in isolation. They have their own oﬃces, staﬀs, and volunteer groups. Typically, they operate with very limited budgets. Often, community groups select goals that are diﬃcult to reach and may require years to accomplish. Both staﬀ and volunteers face risks of “burn-out.” Almost everyone becomes discouraged at some time. Group-to-group matching may allow community groups to share goals and resources. A match between groups opens the door to combining resources. Groups may plan and execute campaigns together. They may share staﬀ and oﬃce space. Most important, they strengthen community feeling. Leaders, staﬀ, and volunteers beneﬁt from the expanded resource base. More faces provide the emotional support group members need to remain committed. More hands provide the practical means for getting things done. mpc acknowledged that group-to-group matches might not help individuals directly, but many individuals might eventually beneﬁt from matches of this kind. Group-to-group matches represent an ideal opportunity for exchanging gifts and capacities on a large scale.

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A successful group-to-group match engineered by mpc involved a neighborhood arts center, which provided instruction to amateur artists. mpc introduced representatives of the art center to the Training for Interprofessional Collaboration (tic) program at a local university. tic’s job was organizing ﬁeld work for students interested in community organizing. tic students wanted to learn skills in communication and developing projects in the community. Staﬀ members of the art center met with tic representatives at the mpc oﬃce on several occasions. Individual tic students became aware of the art center’s interests. A group of tic students developed a community-based, intergenerational arts program. They contacted elder and youth groups in the city to inform their members of the opportunity. Both the arts center and tic beneﬁted from this exchange. The arts center expanded its classes and workshops into the broader community. The time, energy, and enthusiasm of the tic students made this possible. The students gained the experience in collaboration and community work they had sought.

Techniques for Making Matches

Throughout the project, mpc personnel expended eﬀort on determining methods for creating or promoting matches. No standard method was available for this procedure. A major element of the community specialist’s mission was to develop methods for matching. Many experiments were tried. From this process, several steps seemed particularly essential.

Identifying Match Partners

Finding people who can beneﬁt from matching constitutes the ﬁrst step in any matching program. Identifying isolated people is clearly

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important. Such individuals either have no natural networks or very weak ones. They tend to live alone, have no friends or relatives with whom they communicate regularly, and belong to no clubs, churches, or social organizations. Second, it is important to identify potentially isolated people. These individuals may have social networks but remain vulnerable to isolation as aging friends and spouses contract terminal illnesses or otherwise decline. Signs of potential isolation may occur among young people as well. Youth moving into a new school district or with unusual interests also face risk of isolation. The nature of isolated people makes them diﬃcult to identify. By deﬁnition, they are not highly visible. They do not usually frequent social or community events and may act in a withdrawn manner when they do. These individuals may have the most to gain from matching, but identifying them requires special eﬀort. Matches also have value for people who are not isolated. Some people have many friends and acquaintances but know nobody outside their own age group. Such people can beneﬁt from a broader range of contacts. People in active social networks, moreover, may have the most to give. In addition to having personal gifts and capacities, they are likely to know other people who may be good match partners. As discussed later in this chapter, these individuals may play a crucial role in making matches and building community. Both isolated and nonisolated people may present problems for matching. Socially active individuals may be reluctant to ﬁt new people in lives that are already full. Currently isolated people may have had diﬃculties with social relationships throughout their lives. People interested in building community should not forget the importance of matching groups. Groups provide a community with its framework and serve as resources for individuals. Ironically, groups may become as isolated from potentially valuable partners as individuals.

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Of all steps required for matching, identifying appropriate participants is the most basic. The following sections provide several suggestions for accomplishing that essential task. Observing People. Keeping one’s eyes and ears open is the most fundamental technique for matching. Everyone who works with people has opportunities for identifying potential match partners. Social workers, staﬀ members at residential facilities, teachers, and individuals active in community groups all have opportunities to become familiar with large numbers of people. All have gifts to share and needs that the gifts of others may help meet. Personal observation within a residence facility illustrates a method of identifying isolated people. Within such a facility, an observant staﬀ member will notice people who rarely talk with others and belong to no identiﬁable group. Over time, the staﬀ member may make note of those who rarely participate in organized activities, receive visitors, or leave their rooms. Staﬀ members also have the opportunity to learn the interests and capacities of residents. They may notice that an isolated woman enjoys knitting and introduce her to other women with the same interest. They may notice that a few residents watch carefully as others collect their mail and ask for unusual stamps. These observations may form the basis for a stamp club. Utilizing Membership and Client Lists. All organizations maintain lists. Clubs and churches have lists of members. Public agencies in areas such as housing and public assistance have lists of residents and beneﬁciaries. Service organizations such as the Visiting Nurses Association and senior centers have lists of clients and participants. Health plans have lists of enrollees. These may be very useful for identifying people for matching and thus may form the building blocks for a matching eﬀort. They provide names, addresses, and telephone numbers. However, they do not provide any indication of an individual’s gifts and capacities; people hoping to promote

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matches must learn these. Having an individual’s name does not mean that one has his or her cooperation or conﬁdence. These must be earned and developed. Two methods are suggested: 1. Personal contact. Over the years, an organization’s staﬀ, oﬃcers, and service providers develop a sense of its membership or client base. Reviewing the membership or client list helps renew memories of the actual individuals. A service provider can often recall the family situation and lifestyle of a person whose name appears on the list. People intent on promoting matches should acquaint service providers with the goals of matching. These individuals should be requested to review the organization’s lists to identify potential partners. 2. Cold calls. Everyone has experienced “cold calls”—telephone contact from persons one has never met. Many such calls come from salespeople or poll takers. Cold calls using membership or client lists may be valuable tools for identifying match partners. A cold caller should expect many disappointments. People will often say they are not interested or just hang up. But a cold call may open the door to a signiﬁcant match. The individual at the other end of the line may be eager for the opportunity to meet others. Moreover, cold calls may be one of the only ways to reach people who are completely isolated—the ones who do not become familiar to an organization’s leaders, service providers, or other members and clients. A letter introducing the caller sent in advance can make cold calling much more comfortable and productive. Canvassing. mpc community specialists performed intense experiments using this on-the-ground technique. This process seeks to identify potential match partners in a limited and speciﬁc geographical area. Activity may concentrate on a speciﬁc neighborhood: it may focus on a single block or residential high-rise building. 110

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Canvassing is a commonly used community organizing technique. Organizers initially go door-to-door to distribute ﬂiers introducing themselves, their project, and the purpose of a forthcoming visit. Then the organizers make door-to-door visits at the scheduled times. They introduce themselves personally and describe the organization they represent in informal language. Building a relationship may require several visits. When this technique is used to make matches, the matchmaker helps the individual identify the gifts and capacities he or she has to share. The facilitator uses intuition as well as language to assess the individual’s gifts, capacities, and interest in becoming part of a match. If the individual at the door says he or she is not interested, the canvasser may still leave ﬂiers announcing forthcoming events or explaining the matching program. Such material should also be left at the door if no one is home when the canvasser calls. Networking. Other than direct observation and personal contact, networking may be the most eﬀective method for identifying potential match partners. Networks are chains of friends, acquaintances, and professional associates, which serve to transmit information. Networks reachpeople one does not know personally and enable people to learn or tell others about available resources, business opportunities, job openings, and good deals. Networks are excellent resources for learning about people who would make good match partners or letting others know that resources for matching are available in their communities. Meeting with members and staﬀ of organizations with which one is not aﬃliated provides good networking opportunities. Community group meetings and professional conferences are excellent networking sites. A leader in a group of seniors may meet a high school teacher who has a pupil looking for community service opportunities. A clergyman may hear of an opportunity to bring social contact to his isolated parishioners. Networking may play a particularly important role in bringing about group-to-group matches. Representatives of groups and An Ambitious Partnership

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organizations involved in the community must constantly seek out other organizations with similar interests. These organizations gain much from sharing resources and providing mutual encouragement. Community meetings, campaigns, public events, and professional conferences provide opportunities for starting these crucial linkages. Publicizing the Program. Many people today seek closer contact with others. They are receptive to the concept of matching. For this reason, public presentations, stories in the media, and communication in professional publications can prove highly eﬀective. People seek out programs that promote gifts and capacities and reduce isolation. News stories, particularly in local media, result in telephone calls from people who want to be part of the eﬀort. Parents of young people and children of elders may call on behalf of their loved ones living in or fearful of isolation. Using “Community Guides.” The concept of a “community guide” occupied a crucial place in mpc’s activities. Community guides are natural leaders in the neighborhood. They know the challenges faced by community members because they reside alongside them, and they also know the community members’ gifts and capacities. The community guide already knows many match partners quite well, so he or she can skip the ﬁrst few steps in the process of matchmaking. Any organization or agency desiring to make matches should devote signiﬁcant eﬀort to identifying and developing community guides. This process requires time and presence in the community, and these individuals then require training, but they extend the eﬀectiveness of a matching eﬀort far beyond the capabilities of program staﬀ. Collaboration with a community guide named Lloyd was one of mpc’s most signiﬁcant success stories. A retired professional in his mid-80s, Lloyd was a man of action. At community meetings and events, he expressed his desire to “get things going” and impatience with “the system.” A community specialist at the Central Area 112

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Senior Center formed a special relationship with Lloyd and discussed the mutual partnership concept with him. Lloyd immediately put the concept into practice. He developed a system of telephone chains linking elders who were in danger of isolation. Appropriately, Lloyd named his system “Linkage.” Chain members agreed to call each other every day. They checked on each other’s well-being. In addition, they provided companionship and emotional support. A chain captain ensured that the chains functioned smoothly. He or she encouraged individuals who did not make their calls consistently and identiﬁed vacancies in the chain. Lloyd communicated regularly with the chain captains and served as the system’s troubleshooter.

S U M M A R Y O F M AT C H I N G P R O C E D U R E

Although actual development of matches is a highly personal process, mpc staﬀ developed practical guidelines. The basic components they identiﬁed include the following: • • • • • •

Meet the partner or partners Explain the purposes and goals of matching Build a relationship with the partners Introduce partners; be present at their ﬁrst meetings Step aside—let the partners work out their relationship Check back—call or visit a few months later to see how things are going and help out if necessary

ACCOMPLISHMENTS AND ISSUES

In some respects, mpc represents the ideal collaboration of a healthcare system with a community. A diverse set of agencies was involved. Community residents were recruited and, in some instances, had an important eﬀect on project operations. Signiﬁcant resources An Ambitious Partnership

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were obtained from outside. Enthusiastic staﬀ members were recruited and exercised creativity in developing new methods for community building. Group Health Cooperative attained greater visibility in its community. But unforeseen events occurred which created signiﬁcant management problems and perhaps reduced mpc’s ultimate eﬀect. These problems may be more typical than unusual in community partnerships; they are discussed in detail in chapter 5.

REFERENCES Clarke, M., S. J. Clarke, and C. Jagger. 1992. “Social Intervention and the Elderly: A Randomized Controlled Trial.” American Journal of Epidemiology 136: 1517–23. Cohen, C. I., K. Hyland, and M. Devlin. 1999. “Can Evaluation of the Use of the Natural Helping Network Model Be Used to Enhance the Well-Being of Nursing Home Residents?” The Gerontologist 39: 426–33. Cooperrider, D. L., and S. Srivastava. 1990. Appreciative Management and Leadership: The Power of Positive Thought and Action in Organizations. San Francisco: Jossey-Bass. Kretzmann, J. P., and J. L. McKnight. 1993. “Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets.” Evanston, IL: Northwestern University, Center for Urban A=airs and Policy Research. McKnight, J. L. 1995. Careless Society: Community and Its Counterfeits. New York: Basic Books. Putnam, R. D. 1995. “Bowling Alone: America’s Declining Social Capital.” Journal of Democracy 6: 65–77.

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CHAPTER 5

A Case Study in Conflict

mpc personnel at all levels showed strong and consistent commitment to the project’s success. Nevertheless, severe conflict occurred. Several staﬀ developed antagonistic relationships with each other, many experienced anxiety or discouragement, and heated arguments and emotional outbursts occurred at staﬀ meetings. That the project accomplished as much as it did is testimony to the hard work and, ultimately, the goodwill of most participants. This chapter describes the conflict as it occurred day-to-day. It recapitulates procedures carried out as attempts to reduce or remedy the conflict. This chapter also traces the conflict to root causes that might be present in any coalition. Finally, the chapter suggests strategies for identifying and managing conflicts similar to these. As part of mpc’s process evaluation—a concept described in chapter 7—the evaluation consultant used several procedures for tracking mpc’s development as an organization during its active period. He took extensive notes at staﬀ meetings, leadership group discussions, and project retreats. Review of meeting minutes plus documents such as proposals, mission statements, and personnel resumes provided background. The evaluation consultant and other staﬀ also carried out extensive, structured interviews with all project personnel. Finally, the 115

staﬀ conducted focus groups with people who had been involved with mpc and knew the project but had no oﬃcial role.

SIGNS OF CONFLICT

Problems became apparent a few months after the completion of project staﬃng. A major disagreement developed over where the project should focus its eﬀorts.

Disagreement over Matching

Discussion prior to receipt of funding had emphasized making and promoting individual-to-individual matches. The project director, training specialist, and evaluation consultant continued to take this position. They believed that the project had been funded to directly address the needs of individual, isolated elders. The newly hired project coordinator, however, contended that many diﬀerent types of matches merited the project’s resources. These included individual-to-group matches, mainly comprising the introduction of an elder into a group activity such as teas held by the local senior center, and group-to-group matches, attempts to promote networking and collaboration among agencies and community groups throughout the city. The project coordinator argued that mpc should shift its focus from working with pairs of individuals to organizing the community as a whole. Social action by community residents, he reasoned, amounted to mutual assistance.

Resistance to Monitoring and Evaluation

A second set of conflicts emerged in the areas of reporting, monitoring, and evaluation. The project director, training specialist, and 116

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evaluation consultant felt committed to developing and maintaining explicit procedures for monitoring the number, duration, and impacts of matches made. In negotiation with the W. K. Kellogg Foundation, they had agreed to make approximately 1,400 matches during a four-year period of performance and to assess whether these matches reduced isolation or improved health among the matched individuals. Monitoring and evaluation required an explicit deﬁnition of a match, forms, and record keeping. The evaluation consultant developed a standard match deﬁnition. Under the deﬁnition, a match required at least two face-to-face meetings between two individuals, an individual and a group, or two or more groups. The evaluation consultant also drafted a “match tracking form” on which community specialists were to record each match, its content, and its duration. The project coordinator and community specialists resisted implementation of the monitoring and evaluation system. Initially, the project coordinator declined to discuss the drafts of the match tracking form. He explained that the form was no longer needed because the “community had taken over the project.” Eventually, intervention by the steering committee mandated that all community specialists use the form.

Sta= Revolt

The community specialists did not fully accept the steering committee’s decision. As the project’s ﬁeld staﬀ, the community specialists held primary responsibility for making and reporting matches. Very few match tracking forms were received during the project’s ﬁrst year. Conversations with the community specialists during this period revealed several reasons for this. First, the community specialists agreed strongly with the project coordinator’s position that community organizing would be more eﬀective than “matchmaking.” A Case Study in Conflict

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Second, the community specialists disagreed with the project evaluator regarding the deﬁnition of a match. The community specialists argued that the most valuable of human relationships are often brief, consisting many times of one-time encounters. Such encounters, they contended, might change the entire course of an individual’s life. Third, the community specialists expressed discomfort with the match tracking form itself, commenting that the responsibility for ﬁlling it out—a procedure that required recontacting the individuals initially introduced—interfered with their substantive work. Finally, the community specialists objected that the forms would be used to keep records of their performance and enable the project managers to compare the output of individual community specialists with that of others.

A TENSE EQUILIBRIUM Compromise and Accommodation

These conflicts remained clearly active and visible for the ensuing two years. Throughout this period, a tense dialogue simmered between two groups: the project director, the training specialist, and the evaluation consultant on one hand and the project coordinator and community specialists on the other. A series of compromises and accommodations allowed project work to take place. The evaluation consultant developed a very brief match tracking form and obtained the community specialists’ approval for its adoption and use. The project director proposed that the community specialists carry out 200 “prototypical matches” conforming to the criteria of two face-to-face meetings and a speciﬁc mutual assistance purpose. Attempts were made to allow everyone to spend part of his or her time pursuing objectives each considered important. The community specialists were encouraged to cite and record qualitative information they considered particularly valuable. Community 118

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organizing was formally recognized as an element of the community specialists’ job description. The project coordinator was supported in building broader community support for mpc and developing a community-based organization to eventually assume its functions.

Accomplishments and Limitations

mpc accomplished important milestones during this period. The organization held two community-wide workshops which featured nationally known speakers and attracted hundreds of participants. The community specialists reported making 556 matches, including 220 individual-to-individual and 278 group-to-group matches. Project staﬀ carried out two follow-up surveys, attempting to contact and reinterview all of those interviewed in the baseline study to help assess the impact of matching, eventually obtaining follow-up data on 87 of these people. The project, however, had very limited success in achieving its most important objectives. The matches made were less intense in nature than early discussions envisioned, predominantly comprising the introduction of elders into group activities. Few of these elders appeared severely isolated before being contacted by mpc. Many matches were made outside Central Seattle, the initially targeted area. Matching outside the target area limited the ability of staﬀ to obtain baseline and follow-up data on the people who were matched. This limited the strength of the ensuing outcome evaluation (see chapter 6). Little evidence emerged that mpc made a lasting impression on the community. Only one in seven community residents initially contacted by mpc recalled the organization or its activities two years after it had ceased activity in their buildings or neighborhoods. As part of its funding agreement with the W. K. Kellogg Foundation, mpc had promised to develop an independent community organization to carry on its work indeﬁnitely. Eﬀorts to establish this organization failed. The project coordinator did succeed in A Case Study in Conflict

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launching a discussion group, initially called the Mutual Partnership Coalition Community Association (mpcca), for which an executive director was recruited and given some ﬁnancial support. But the mpcca primarily attracted representatives of existing service organizations and public agencies rather than the individual community residents it had hoped to recruit. Meetings were sparsely attended. The executive director resigned in a dispute over funding, and the fledgling organization disbanded. High levels of tension and conflict undermined mpc’s ability to achieve a greater level of success. Conflict often occurred between the project coordinator and the evaluation consultant. Each would accuse the other, openly and in private, of undermining the project’s objectives. Community specialists clashed with the evaluation consultant over reporting requirements. Steering committee members raised questions about the adequacy of the project coordinator’s supervision of the community specialists. The project director, formally the project coordinator’s supervisor, came close to ﬁring him at the project’s midpoint because of lack of attendance at project meetings.

THE FINAL CRISIS

A ﬁnal crisis occurred early in the project’s third year. The project coordinator concluded an agreement with a local hospital, a competitor of Group Health Cooperative, to serve as the site for the second community workshop. This led to a heated conflict with the project director, who felt that the competitor should not receive public recognition for a project Group Health Cooperative had launched. The project coordinator contended that he had chosen the competitor because he felt it had better community ties. He refused to modify arrangements for the conference in a manner that would grant Group Health Cooperative equal public recognition. This was the “last straw” for the project director, who then negotiated a

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severance agreement with the project coordinator. A member of the steering committee was appointed project coordinator and played a caretaker role for the remainder of the project’s active life.

AT T E M P T S AT R E M E D I AT I O N

Project staﬀ engaged in serious attempts to remedy the interpersonal problems and achieve the project’s objectives. These attempts included eﬀorts of four types: (1) project retreats, (2) revised work plans and management communications, (3) senior staﬀ meetings, and (4) joint evaluation meetings. Most of these attempts achieved some positive, although limited, results. But examination of the processes and outcomes associated with these interventions illustrates the extent to which fragmentation proved a persistent problem for mpc.

Retreats

In an attempt to develop solutions to problems that had become evident as early as the project’s ﬁrst year, two retreats took place close to the project’s midpoint. These retreats constituted the most intense eﬀorts at remediation of mpc’s problems. Signiﬁcant resources were expended in each retreat, including individual meetings with the facilitator and preparation of written material. Each retreat was facilitated by an outside consultant skilled and experienced in conducting meetings. The second retreat consisted of three one-day sessions. Both retreats attempted to promote a sharing of perspectives by project leadership and staﬀ. At each retreat, participants were encouraged to indicate their views on the project’s objectives, accomplishments, and barriers to success. It was hoped that this discussion would result in a diminution of the diﬀering perspectives that seemed to hamper goal attainment.

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The First Retreat

The ﬁrst retreat, taking place closest to the project’s midpoint, aimed at developing a consensus on goals and procedures. In the months preceding this retreat, disagreement over the importance of matches over community organizing had become intense. The community specialists expressed diﬃculty over the evaluation procedure’s emphasis on counting and tracking of matches. They argued that evaluation should give them more “credit” for activities other than matchmaking. The community specialists also felt they should be allowed to participate in project planning and decision making on a basis equal to all other staﬀ. This retreat was planned with exceptional care by the facilitator. She met with all project staﬀ and steering committee members, asking each to prepare written comments on the project’s goals and the barriers they had encountered in reaching them. The retreat took place in a scenic facility on a nearby university campus. At the end of the retreat, the facilitator proposed several areas of agreement: • that evaluation design would pay attention not only to matching but to organizing • that the community specialists’ job description be expanded to include community organizing • that a joint meeting of the steering committee and the community specialists would be held yearly • that matching should remain a critical part of the project to which all would be committed. The retreat appeared to be adjourning amicably. But as participants were preparing to depart, the project coordinator stood up and, in an emotional outburst, proclaimed his disagreement with the principles. Clearly, a fundamental cleavage remained in the group. A week later, the project director remarked that he “felt that

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a consensus had not been reached and that further work needed to be done.”

The Second Retreat

The second retreat took place six months later. A new facilitator organized and led the proceedings, the former consultant having felt she had not succeeded. Similar to the ﬁrst retreat, this procedure aimed at identifying shared goals and agreeing on acceptable measures for project outcomes. But a more general issue received primary emphasis: improving relationships within the project team and reducing high levels of tension and conflict that had become evident in day-to-day operations. The facilitator instructed participants to indicate what people involved in the project should stop doing, and what they should start doing, to move forward. It became apparent in this retreat that great diﬀerences of opinion existed regarding project goals and personal expectations. The community specialists, for example, asserted that they had a right to greater participation in decision making and setting project direction. A poignant interchange occurred in connection with the project assistant, who worked in the oﬃce of the project coordinator and was supervised by him. The project assistant complained that the steering committee and some staﬀ did not respect her decisions regarding project procedures and direction. Subsequent discussion established that the project organization plan designated the project assistant position as one of secretarial and administrative support rather than decision making. This retreat appeared to produce several positive outcomes in the months that followed. For example, the project assistant ceased to express discomfort at not being a major decision maker and began concentrating on database management, and one supervisor commented that the level of trust between him and his community specialist had improved. However, another supervisor reported that his

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situation vis-à-vis a comparable staﬀ member had not changed, community specialists still asserted the claim that they should be autonomous, and staﬀ associated with Group Health Cooperative argued that original goals still needed to be pursued and evaluated.

Work Plans and Management Communications

Throughout the project, staﬀ and steering committee members reexamined goals and objectives, reiterating those originally stated and, recognizing the legitimacy of activities initiated after the project’s funding, formulating new ones. To promote achievement of both the old and new objectives, project staﬀ developed detailed work plans and task assignments, including elements requiring speciﬁc, numerical indicators of success. These work plans were updated every six months. Initial drafts were presented for discussion and appropriate revision to the steering committee and individuals responsible for each task. In addition, the project director and the project coordinator expended considerable eﬀort in communication with each other. These communications included weekly one-on-one discussions intended to explore issues, share perspectives, and formulate solutions. These eﬀorts aimed not only at coordinating the thinking and activities of the project director and project coordinator, but allowing the project director to follow the work of the community specialists in whose supervision the project coordinator played an important role. Like the retreats, work plans and management communications produced some valuable results. For instance, the project coordinator began communicating the need to develop at least some prototypical matches to the community specialists. However, no evidence indicates that the project director and project coordinator drew closer together as a result. Similarly, the work plans produced only limited beneﬁts. They were formulated and presented primarily as guidelines rather than 124

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ﬁrm performance requirements. Supervisors did not conduct formal reviews of personnel based on these work plans. In addition, the work plans themselves underwent discussion and occasionally debate before they were deemed ﬁnal. Time required for this discussion often delayed their acceptance by the steering committee until well after the dates associated with major milestones had passed.

Senior Sta= Meetings

Senior staﬀ meetings were instituted shortly before the project’s midpoint and were intended to include the project director, project coordinator, training specialist, and evaluation consultant; that is, participants in the senior staﬀ meetings were staﬀ members with key policy-related responsibilities. Regular meetings of this group, it was hoped, would promote mutual understanding and result in supervision of the community specialists in a manner more consistent with objectives shared by the broad range of the project’s managers and professionals. Senior staﬀ meetings took place regularly until the conclusion of the project. They allowed the project director, training specialist, and evaluation consultant to converse and release tension. These individuals met regularly to discuss project issues and often to share each other’s feelings of frustration over perceived lack of progress toward mpc goals. Instrumental accomplishments of the senior staﬀ meetings, however, were limited. Chronic absenteeism by the project coordinator made decision making diﬃcult, as his participation in the process was indispensable. The project coordinator failed to attend at least half the senior staﬀ meetings during the ﬁrst six months they were held, sometimes calling in sick and sometimes just not showing up. His nonattendance became an expectation of the other senior staﬀ members and the subject of numerous jokes. Interpersonal conflict also limited the productivity of the senior staﬀ meetings. Heated exchanges occurred, for example, between the A Case Study in Conflict

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project coordinator and the evaluation consultant. One such exchange involved development of a form to track matches made by the community specialists. The evaluation consultant, who had drafted and begun circulating a form, asked about its status. The project coordinator responded that he and the community specialists had taken charge of its development. Visibly irritated, the evaluation consultant asked, “Why wasn’t I involved?” In an emotional outburst, the project coordinator shouted, “Well, you could have been involved if you came to the community specialist meetings!”

Joint Evaluation Committee

At the ﬁrst retreat, the evaluation consultant suggested the establishment of an evaluation committee, which would draw members from the three major categories of project participants: senior staﬀ, the community specialists, and the steering committee. As indicated above, evaluation had become a major focus of conflict within mpc. The evaluation consultant felt that a committee representing all project “interests” would promote sharing of information so that no one would feel a procedure or requirement was being developed without his or her knowledge. The evaluation consultant hoped that the individuals who participated would transmit the perspectives of their near colleagues to the committee as a whole, would represent the decisions of the evaluation committee to these same colleagues, and would support the evaluation committee’s decisions in projectwide discussions. It was hoped that a broad sharing of the responsibility for evaluation and development of procedures and instruments would increase everyone’s level of comfort and acceptance. The evaluation committee achieved many of these aims. Members collaborated on development of several forms for collection of both qualitative and quantitative data. The evaluation consultant presented raw data to the committee members and shared the process of data interpretation with them. Reports on evaluation 126

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ﬁndings for the steering committee and the W. K. Kellogg Foundation captured the perspectives of all committee members. All project participants were welcome at evaluation committee meetings. One community specialist and one member of the steering committee accepted the responsibility of participating in the committee and, along with the evaluation consultant, of comprising its core. The evaluation consultant was fortunate in the availability of a community specialist who had a special interest in evaluation and exercised considerable influence among her colleagues. The evaluation committee did much to defuse the issue of evaluation as a focus of conflict within the project. After its establishment, evaluation per se ceased to cause openly emotional arguments. Individuals still voiced objections to the procedures formulated by the evaluation committee, however, and, most important, neither the project coordinator nor the community specialists as a group placed major emphasis on matching, the factor on which the evaluation design depended to measure progress and success.

CAUSES OF CONFLICT I: PERSONNEL DIFFERENCES

Diﬀerences among the individuals involved in mpc contributed to the atmosphere of conflict. Project participants tended to fall into three groups, each of which diﬀered according to background and orientation from the other two.

Steering Committee

Active membership in the steering committee numbered between ﬁve and eight during most of the project. Core membership comprised representatives of the original partners: the Seattle Housing Authority, Senior Services, the Central Area Motivation Project (camp), and United in Outreach (uio). One member of the core A Case Study in Conflict

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group was a white male, one was an African American male, and two were white women. All members of the core group held bachelor’s degrees. These individuals shared basic career experience emphasizing management of social service delivery. The orientation toward the project that prevailed among steering committee members may be characterized as “service delivery executive.” These individuals tended to focus on the practical aspects of running a project, such as personnel and budget management. The organizations that employed these individuals received funds from the grant for the support of the community specialists they employed. Each steering committee member represented his or her organization in formulating and managing budgetary arrangements with Group Health Cooperative and in obtaining data for reports to the W. K. Kellogg Foundation. Outside this core, the project director and a small number (one to three) of the community representatives served on the steering committee. Community representatives included elders and youths. As a group, these individuals tended to say little at meetings and exercised little influence on the direction of the project.

Senior Sta=

Senior staﬀ included the project director, the training specialist, the evaluation consultant, and the project coordinator. With the exception of the project coordinator, senior staﬀ members shared a basic orientation that might be characterized as “project professionalism.” In this sense, the three were primarily concerned with carrying out the project principally as it had been formulated originally, viewing the project as an opportunity to demonstrate the eﬃcacy of a concrete procedure. This orientation was consistent with an emphasis on carrying out a project successfully in the eyes of the W. K. Kellogg Foundation, with which the project director and evaluation consultant enjoyed

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a long-term relationship. The project director and training specialist held master’s degrees and the evaluation consultant held a doctorate. The project director and evaluation consultant were white males, the training specialist a white woman. All had management experience, ranging from 20 years of executive responsibilities in social and health services for the project director to chairmanship of an academic department for the evaluation consultant. The project coordinator’s experience resembled that of the project director and training specialist in that his resume indicated experience in management of training programs for disadvantaged people. His more recent experience emphasized advocacy. The project coordinator was a minority male with some college training.

Community Specialists

The project maintained four community specialists throughout its active existence. Turnover occurred in one position very early in the project. Afterward, all incumbents remained in their jobs until the project began its phase-out. Except for a male who quit after the project’s ﬁrst year, the community specialists were females, two African American and two white. One community specialist had a master’s degree in social work, two had bachelor’s degrees, and one had no college experience. Two had had careers in social services, one had held an executive position in a large corporation, and one was retired from retail work. The orientation of these individuals may be characterized as one of “neighborhood advocacy,” emphasizing both participation in community organizing and responsiveness to the immediate needs of individual community residents. At least three of the community specialists, in taking jobs with mpc, indicated that they sought to avoid the hierarchies that characterize the typical workplace and the competitiveness of corporate life.

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C A U S E S O F C O N F L I C T I I : C U LT U R A L F R A G M E N TAT I O N

The interpersonal relationships and events described above depict a process of cultural fragmentation. Features of this fragmentation included absence of consensus regarding objectives, disagreement over appropriate evaluation procedures, and a persistent “us versus them” feeling among members of diﬀerent groups. The social fragmentation described here was the existence of two distinct cultures under one “organizational roof.” Proponents of each culture shared some goals and values, but these were too far removed from concrete practice to promote the comprehensive coordination of actions that characterizes an eﬀective organization. Management scientists such as Edgar Schein have studied culture within organizations, describing corporate culture as a means of bringing people together. Shared assumptions about the world outside and inside the organization help people think alike and coordinate their activities (Schein 1985). Two distinct and antagonistic cultures seem to have developed in mpc. Each appeared to have been carried by a distinct group within the organization: one comprising the project coordinator and the community specialists, and the other the senior staﬀ members (except the project coordinator) and about half the steering committee.

Shared Goals and Values

As noted earlier, these two groups shared some basic goals and values. Rebuilding community in the central city was a goal all participants undoubtedly shared. Similarly, recognizing and making the most of the gifts and capacities of everyone in the community constituted a common value. Comments by mpc participants in meetings and conversations as well as formal interviews included the phrase “gifts and capacities” in nearly every setting. But “reweaving 130

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the fabric of community” and “recognizing gifts and capacities” constituted goals and values at the deepest level of abstraction. The presence of these elements alone provided insuﬃcient basis for the formation of a unifying organizational culture. More immediately applicable assumptions and paradigms diverged markedly.

Divergent Assumptions Assumptions About the External World

Divergent assumptions characterized the outlook of the two groups regarding the external world. The term “external world” here encompasses features of the social environment important to mpc’s work. Each group held distinct and contradictory assumptions about challenges facing the community, resources available to it, and strategies for improving its social and economic conditions. The sets of assumptions held by each group are summarized below based on the labels reflecting the fundamental orientations of their proponents, “neighborhood activism” and “project professionalism.” Outlook on “Institutions.” An important set of assumptions concerned “institutions.” In phraseology that developed among project participants, the term “institution” (used interchangeably with the term “systems”) denoted any formally organized entity with a constituency or resource base extending outside of the immediate community. Accordingly, community specialists referred to most organizational participants in mpc as institutions, including Senior Services, the Seattle Housing Authority, and Group Health Cooperative. Because camp and uio were more clearly anchored in the locale and had narrower resource bases, they usually escaped the often-pejorative label. McKnight’s (1995) writings caution against belief in institutions. He comments that public agencies, nonproﬁt service organizations, A Case Study in Conflict

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and charitable foundations are important to communities because they are repositories of assets. Institutions, however, are typically captives of bureaucracies and politicians unfamiliar with the community and not necessarily interested in its well-being. These very agencies emphasize the community’s deﬁcits rather than its assets. Consistent with this thinking, community specialists and the project coordinator regularly asserted that the institutions were detrimental to the community or, at the very least, ineﬀectual at helping solve its problems. A comment by the project coordinator identiﬁes institutions and communities as opposites if not adversaries: “We are following McKnight’s philosophy. Communities allow chaos to take place. Communities look at the glass half-full. Systems are good at replicating things but not creating something new.” Expressing her view of “communities” and “institutions” as sharply diﬀerent in orientation, a community specialist commented, “The project coordinator and I can relate to the community approach, but my (agency supervisor) is more oriented toward paperwork.” As representatives of established agencies, steering committee members often found the claimed superiority of community over institutions diﬃcult to accept. A steering committee member addressed these comments to the project coordinator: “You are using loaded words, as if to say ‘everybody with some standards is a system and everybody without standards is a community.’ The system does some things which are good and should be respected in the mpc.” “Power to the People.” A major assumption related to choice of strategy among those in the neighborhood who subscribed to the activist culture was highly consistent with their assumptions about institutions. Subscribers to this culture believed mpc should devote its primary eﬀort to strengthening the community in its relationships with institutions, changing the institutions, and capturing their resources for the community’s beneﬁt. Comments by the project coordinator at a community association meeting demonstrate this perspective. The project coordinator 132

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cited concessions won by community groups from the city government during an episode of urban redevelopment. A participant asked him, “Are you looking to teach communities how to improve themselves and gain power?” The project coordinator answered, “Yes.” In an interview, the project coordinator explained his emphasis on community organization in the work of mpc: “This is the approach I have used since the ’60s: ‘power to the people’ and ‘community control.’” The divergence between the neighborhood activist and project professional cultures on this dimension should not imply that only the project coordinator and community specialists believed existing institutions needed to be changed. Subscribers to the project professional culture shared this fundamental objective, but believed the process needed to demonstrate the beneﬁts of recognizing gifts and capacities on a person-to-person level. This process could take place by carrying out matches in the community and evaluating their eﬀects or by training people in organizations to recognize the gifts and capacities of both their colleagues and clients. “Natural” versus “Artificial” Processes. Two other assumptions represented related to processes and interventions were considered eﬀective in reducing isolation and bringing about a stronger community. The neighborhood activist culture placed much value on spontaneous, unstandardized, opportunistic action. Resistance expressed by the community specialists throughout the project to making matches according to a standardized deﬁnition and using forms to report and follow matches underscores this point. Insistence by the project director, training specialist, evaluation consultant, and members of the steering committee that such deﬁnitions and forms be used reflects the opposite assumption. These individuals often commented that mpc constituted a demonstration project and thus had an obligation to its funders to apply and evaluate a standardized procedure. Similarly, the neighborhood activist culture viewed “natural” processes in the community as the only true means of bringing A Case Study in Conflict

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about positive change. This proposition was alleged to be consistent with one of McKnight’s major principles, that social change must occur “from the inside out,” that is, through the community’s own initiative and resources rather than the intervention of an outside agency (McKnight 1995). Community specialists often argued that they had no need to make matches, but could simply monitor matches that took place spontaneously. As one commented, “Naturally occurring matches are best because they result from mutual selection. Lots of people do not want to be ‘match-made.’ When I see two people bonding I can capture them as a natural phenomenon.” Emphasis on Personal Service. Finally, at least two of the four community specialists concentrated their activities on serving as companions to individual community members or maintaining their presence in community settings rather than making matches according to the designated deﬁnition. One community specialist, for example, expended most of her eﬀorts in visiting homebound individuals. She contended that this visitation was a matching process, in which she herself served as one of the partners. Another community specialist occupied an oﬃce on the premises of a youth program, devoting her eﬀorts almost entirely to giving advice to adolescents about the challenges they would face in the years to come. Together, these community specialists submitted the fewest complete match forms. The importance these individuals placed on personal services to community members seems at ﬁrst to contradict the assumptions that “natural” processes taking place inside the community constitute the most important means of community betterment. The fact that both community specialists were African American helped them resolve this seeming inconsistency, as they considered themselves community members and thus were acting spontaneously and on the inside. Proponents of the project professionalism culture, on the other hand, insisted that the eﬀorts of all community specialists should

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focus on helping bring about relations between people in the community other than themselves. Signiﬁcant debate occurred early in the project over whether community specialists could constitute one of the two parties in a match.

Assumptions About Internal Functioning

Other assumptions on which mpc participants diverged concerned the internal functioning of mpc as an organization. “Empowerment” versus “Accountability.” The leading assumption in the neighborhood activist culture appeared to be that internal relationships should operate under an “empowerment” model, putting aside principles of work organization traditionally characteristic of industrial society. Under the empowerment model, a strong measure of equality among all participants in the organization’s functioning were assumed to prevail. Participation in major decision making would be widely shared. Hierarchy and traditional supervisor-subordinate relationships would be de-emphasized. The broad capabilities of all personnel would be recognized and utilized. Proponents of the neighborhood activist culture assumed that the concept of recognizing gifts and capacities should be applied directly and forcefully within mpc as an organization. They often commented on mpc’s shortcomings in this respect. In an interview, for example, the project assistant remarked: “[mpc’s functioning] has been a source of frustration to me. The administrative staﬀ has not walked its talk. I have oﬀered my skills outside traditional secretarial work, but this has been dismissed or ignored. Institutional change needs to overcome the traditional demeaning of secretarial and support personnel.” In a discussion, a community specialist identiﬁed the existence of hierarchy within mpc as a fundamental contradiction to the goals it was trying to achieve in the community: “The problem [with

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mpc] is that the hierarchy is making the decisions, and this contradicts the goal of institutional change.” Consistent with the assumptions of the project professional culture, however, a steering committee member commented in an interview, “There is too little decisiveness [in mpc]. It can’t be a democracy. Otherwise we will never leave stage one. The tail has been wagging the dog.” Subscribers to the neighborhood activist culture also challenged the legitimacy of formal accountability in the work process. The most visible challenge of this nature concerned development and utilization of forms for reporting and tracking matches. A comment by one community specialist was typical of many heard through the course of the project: “My aversion to paperwork and meeting deadlines is a barrier to making matches.” Persistent eﬀorts by the project director and the evaluation consultant to obtain systematic data on the results of matching activity reflected the assumption, a core element of the project professional culture, that a concrete system of accountability was essential. Performance Assessment. Another set of contrasting assumptions associated with the two cultures focused on assessment of individual performance. Quantity, if not quality, of completed work varied considerably among the community specialists. The evaluation consultant kept records on two areas of their performance: baseline interviews conducted at the beginning of the project and matches made during the project’s active period. In the baseline interviewing procedure, one community specialist completed more than 80 telephone interviews while another completed fewer than 10. Similar divergence occurred in the number of matches completed by these community specialists. Throughout the project, however, the community specialists and the project coordinator argued strongly against bringing direct comparison of performance levels into senior staﬀ or steering committee meetings or into the community specialists’ performance reviews. When the evaluation consultant described those who were 136

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completing relatively few interviews or matches as “laggards,” he was strongly criticized. The neighborhood activist culture fundamentally dictated that only members of a given work group should have responsibility for evaluating the group’s performance. Even after match tracking forms and a compatible data system had been developed, some community specialists continued to assert this position regarding the making and tracking of matches. One community specialist argued that evaluation of this group’s work should depend on “stories” she and her colleagues could develop on the basis of personal experience. The project professional culture assumed that outside evaluations of an objective nature were needed. At a mid-project retreat, the training specialist remarked, “It is time to concentrate on ensuring timely information-gathering. [We must follow] a rigorous process to determine how an activity contributes to accomplishment of project goals.” Representing the Community. Assumptions about who best represented the community’s voice in mpc proved a major although infrequently discussed focus of contention. Conflicting claims in this area reflected divergent elements of the neighborhood activist and project professional cultures. The community specialists and the project coordinator presumed themselves to be part of the community rather than employees of an “institution.” Early in the project’s history, the project coordinator asserted that the “community,” apparently represented by himself and the community specialists, had “taken over the project.” Years later, in a heated argument, the project coordinator asserted that he “worked for the community, not the mpc.” At one of the retreats, a community specialist commented, “the people who were involved in the project early should let go and let the process happen.” A major assumption within the neighborhood activist culture, therefore, was that the community specialists and the project director embodied the community’s interests by virtue of their relatively weak attachments to institutions or systems. A Case Study in Conflict

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The assumption prevailed within the project professional culture that community representation within mpc came from an entirely diﬀerent source. At a mid-project retreat, a steering committee member commented that “the community specialists were not in the best position to advise on community interests.” According to him, this position fell to the steering committee, which included organizations with long histories of community involvement as well as people representing their neighborhoods as individuals.

Contrasting Paradigms

Assumptions comprising the core elements of the neighborhood activist culture have strong logical interconnections. They are easily linked into a set of paradigms: (1) mpc should support natural processes within the community aimed at empowering and improving the lives of disadvantaged residents, and (2) mpc should promote equality and autonomy among all staﬀ. Paradigms expressing core elements of the project professional culture, on the other hand, might read: (1) mpc should concentrate on developing, reﬁning, and evaluating a speciﬁc intervention to be introduced into the community, and (2) the project’s formal leadership should make major decisions, monitor performance, and apply discipline if necessary.

Personal Needs, Divergent Cultures, and Conflict

Two distinct and opposed organizational cultures prevailed side by side within mpc. mpc never developed a single culture that was truly dominant. Elements of the formal leadership, such as the project director and one or two steering committee members, subscribed to the culture of project professionalism, but other leadership elements, the project coordinator and an occasional steering committee member, subscribed to and advanced the neighborhood activist culture. A stand-oﬀ in basic thinking which underlay disputes regarding 138

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concrete activity and allocation of resources prevailed throughout the organization’s active existence. Personal backgrounds and needs of mpc staﬀ members oﬀer a basis for explaining the development and persistence of the two cultures. Proponents of the project professionalism culture had enjoyed successful careers in obtaining foundation and government support for large projects, developing concrete interventions, and systematically testing outcomes. Similar success with mpc would advance their careers, increase the likelihood of future funding, and provide a sense of personal achievement. Subscribers to the neighborhood activism culture were more diverse. The project coordinator’s values clearly focused on community organizing; his life history indicated departure from convention. Most community specialists, having experienced some form of dissatisfaction in the world of work, sought an alternative structure in which to attain professional and communitarian goals and to earn a living. One community specialist, in poor health nearing retirement, may have primarily sought a less demanding work environment than she had experienced earlier. Although the existence of opposing cultures may have been detrimental to the success of mpc as a whole, each culture appears to have been functional in terms of divergent needs of the project participants as individuals.

OTHER POTENTIAL CAUSES

Fragmentation resulting from causes other than individual outlook may have given rise to the conflicting cultures. Divergent goals within mpc, for example, seem to have predisposed the organization to fragmentation. Although the concept of mutually beneﬁcial matches may have initiated the core group’s interest, developing a coalition and obtaining foundation funds resulted in adopting new goals. These included formation of a continuously expanding community-based coalition and generally contributing to community A Case Study in Conflict

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building. The original goal was highly compatible with the culture of project professionalism, whereas the goals adopted later legitimized at least some elements of the community activist culture. mpc’s organizational structure also appears to have produced fragmentation. “Cosupervision” of the community specialists proved an unreliable arrangement for management of this important staﬀ component. Neither the project coordinator nor appropriate agency representatives seemed to take a decisive management role in this area. In one instance, the community specialist was a near relative of her agency supervisor, a factor which probably reduced the eﬃcacy of supervision. Lack of focused and sustained supervision left the community specialists to develop their own objectives, procedures, and ideology. The project coordinator clearly had little interest in matching individuals within the community. In addition, he often appeared ineﬀective as a manager. His attendance at meetings of staﬀ for whose performance he was responsible was irregular. A knowledgeable informant commented that the project coordinator was unprepared or simply uninterested in concrete management tasks. Techniques used by the project coordinator for community organization, moreover, seemed problematic, as indicated by the failure of attempts to launch the community association. A project coordinator with suﬃcient gifts for and commitment to bringing together diverse individuals and interests might have laid the foundation for a highly successful project. The incumbent in this position tended to aggravate rather than heal disagreements.

W A S C O N F L I C T I N E V I TA B L E ?

The diversity of personnel involved in mpc did not appear to cause the degree of conflict described above. With that assumption, development of the mutually antagonistic cultures could have been prevented or their impact reduced.

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Value of a Dominant Culture

Modern formal organizations have proven quite adept at containing dissidence and channeling diverse motivations toward common goals. Most such organizations, however, possess a dominant corporate culture. A dominant organizational culture in mpc would have better controlled the situation. A dominant set of assumptions about how a community intervention should operate would have served as a cohesive force. Subgroups such as the community specialists may have felt at odds with the dominant culture, and a dominant culture would have forced them into a “subculture.” While holding to and mutually reinforcing views consistent with neighborhood activism, this would also have included a true commitment to making matches and supporting evaluation eﬀorts. Similarly, the presence of a dominant organizational culture might have forced the project coordinator and his immediate oﬃce staﬀ into a “counterculture.” Like the famed countercultures of the 1960s, the project coordinator’s counterculture might have held views opposed to those of the mainstream, but never attained suﬃcient resources or conﬁdence to mount a serious challenge to it.

Lack of Decisive Action

Timely, decisive action may have prevented fragmentation. But such an option was not exercised. Rhetoric reflective of the community activist culture was expressed by the project coordinator and the community specialists quite early. The seeds of the community activist culture were apparent on their return from training with McKnight in Montreal. As a body, the steering committee never rejected arguments that mpc should be organized diﬀerently from conventional work organizations and that it should concentrate its eﬀorts on supporting

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existing community activities rather than developing and testing a new intervention. Lack of decisive action by the steering committee represented underutilization of an organizational resource, which could have prevented it or aided its correction. Bylaws developed early in the project allocated ﬁnal authority for management and policy to the steering committee. The steering committee never developed a consensus within itself on where the project’s principal focus should lie or whether staﬀ member behavior required speciﬁc redirection

REDUCING RISK OF CONFLICT

Standard management practices for conflict management were ineﬀective in mpc. Stronger forces were at work. These forces need to be recognized by managers of community interventions and their impact mitigated. Several features of an organization’s mission and life cycle appear likely to give rise to fragmentation and conflict. Organizations the work of which requires innovation and creativity face particular risks in this area. An absence of recognized technologies or procedures for achieving goals invites restricted groups within an organization to follow their own direction and challenge or ignore formal leadership. These conditions prevailed in mpc and are likely in any innovative community intervention. Success by innovative organizations depends on allowing individuals and subunits to experiment and follow strategies of their own making. It is natural to expect internal solidarity to develop in such contexts. Subcultures have values and make assumptions distinct from those of the mainstream, but they share the fundamental principles of the dominant culture; members of subcultures act in a manner consistent with the needs of the larger organization. Managers of new and innovative enterprises, therefore, must allow (or even promote) development of localized esprit de corps, but they

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must act to prevent the establishment of cultures that share too few elements with the mainstream. In enterprises combining the eﬀorts of diverse people and organizations, management thinking must include strategies to counteract risk of fragmentation. Such strategies must make establishment of mutually antagonistic cultures unlikely or their existence short-lived. The most eﬀective actions may be taken in a project’s earliest days. Governing boards need to talk through their basic assumptions and solidify their fundamental goals, values, and objectives before hiring permanent staﬀ. The project’s leadership must then ensure that values and assumptions inconsistent with the fundamental direction they have set do not develop and become widespread. Procedures of this nature include overseeing training activities and monitoring their content. The project’s leadership may choose to encourage development of creative subcultures and accommodate dissident employees and managers, but opportunities for accommodation must be oﬀered only to individuals and groups whose thinking and actions clearly contribute to achievement of the project’s goals.

REFERENCES McKnight, J. L. 1995. Careless Society: Community and Its Counterfeits. New York: Basic Books. Schein, E. H. 1985. Organizational Culture and Leadership. San Francisco: Jossey-Bass.

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CHAPTER 6

Project Outcomes

Despite the conﬂict that characterized the Mutual Partnerships Coalition’s (mpc) operations, signiﬁcant eﬀort was devoted to the project’s originally emphasized intervention: matching actually or potentially isolated elders. Findings from an outcome evaluation of the matching procedure are reported below. Evaluation of match outcomes focused principally on readily measured variables reﬂecting social ties with others in the community, personal health, and quality of life. A long tradition in research on individual social participation and well-being preceded mpc’s work. Several of the indicators developed by the social scientists who carried out these studies are used here. The outcome evaluation attempted to determine the speciﬁc areas in which the matching intervention showed greatest promise. Information of this kind has potential value in planning future programs designed to reduce isolation among elders and others facing similar risks. Changes in the lives of the people who were matched are not the only outcomes of importance in mpc. Changes evident among potentially isolated elders, however, receive the most attention. Such outcomes are the most readily measurable; they lend themselves to

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conventional research procedures and statistical analysis, to which most of this chapter is devoted. Outcome-related evaluation of this kind is necessary in today’s quantitatively and cost/beneﬁt-oriented world. Other outcomes, which do not lend themselves as readily to statistical treatment, are, of course, important as well. These are addressed in a more impressionistic fashion at the end of the chapter.

A REVIEW OF THE INTERVENTION

Community specialists, whose job duties are described in chapter 4, carried out the matching intervention. All had signiﬁcant social service and community outreach experience. One held a master of social work degree and had worked in several agencies. Another had signiﬁcant, recent experience in a city home-sharing project. The third, a former corporate executive studying for the clergy, had conducted pastoral work. In their early days with mpc, all received training from an in-house specialist on recognizing the gifts and capacities of people often thought of as dependent. Two attended a weeklong workshop led by John McKnight, who has spearheaded eﬀorts to change the traditional focus of social service professions from the presumed deﬁcits of the elderly, poor, and physically challenged to an emphasis on their assets and potential independence. The community specialists were salaried and remained with the project for its entire active life, continuing to make matches and report on their activities. The community specialists identiﬁed individuals who were isolated or at risk of isolation through community agencies, food banks, and the city housing authority. Criteria for risk of isolation included living alone, recent death of a spouse, or identiﬁcation by informants as homebound or reclusive. The “matching” procedure, carried out by the community specialists with isolated individuals who gave consent, was tailored to

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the individual needs of each elder. Where appropriate, the community specialist attempted to match the elder with a compatible individual in his or her neighborhood for the purpose of establishing a one-on-one relationship of mutual assistance. Individual-toindividual matching of this kind was attempted in instances in which the elder had a special interest or need that might be met by another individual known to the community specialist. Alternatively, elders were invited to participate in one or more group activities, such as a weekly tea at the neighborhood senior center, a block watch group, a community action meeting, and a tai chi class. The community specialist arranged transportation to group activities if needed and provided continuing support and encouragement for maintaining one-on-one relationships and group attendance. mpc’s activity took place in central and southeast Seattle, communities with high concentrations of elders and minorities. Community specialists usually attempted to match the elder with another individual and invited him or her to attend a group activity. The individual-to-group matching eﬀort was most often omitted for elders with debilitating illnesses or signiﬁcant mobility problems. Such limitations presented barriers to meeting attendance. Still, even people with serious mobility problems attended group activities when these took place in their buildings or transportation was available. Group activities to which the elders were invited were sometimes held within their residence facilities and sometimes elsewhere. Persons other than the community specialists organized and operated the groups, although community specialists frequently attended. The community specialists reported the establishment of a match according to a standard form, indicating that the party or parties matched had had at least two instances of face-to-face contact and specifying the objective of the match (e.g., practical assistance, mutual company). Additional details about procedures used for matching appear in chapter 4.

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E VA L U AT I O N M E T H O D S Research Design

The mpc research consultant used a longitudinal study design to assess the eﬀect of matching on a sample of elders. Data were collected through a baseline survey conducted in summer 1993 and a followup survey in summer and fall 1996. Principal outcome indicators included measures of socialization, health status, and quality of life.

Sample

The evaluation used lists of residents from eight facilities operated by the Seattle Housing Authority (sha) as a sampling frame. Although mpc recruited individuals for matching from throughout central and southeast Seattle, residents of sha buildings comprised an identiﬁable set of individuals for whom addresses and telephone numbers were available and who appeared likely to remain at these addresses and telephone numbers through the planned follow-up survey. A community specialist maintained an oﬃce in one of the sha buildings and concentrated her eﬀorts on matching people who resided in this and other sha facilities. Residents of sha buildings were reported to be at particularly high risk of isolation for several reasons. A high proportion were elderly and lived alone. Changing demographics within some sha buildings increased the risk of isolation among these elders. Recent agency policy changes had resulted in introduction of younger individuals into sha units, including persons with aids or histories of drug use. sha personnel observed that the presence of these younger individuals tended to frighten the elders and discourage them from leaving their apartments. New residents also included many Southeast Asian immigrants, whose language and culture tended to reduce opportunities for socialization with the historically predominant African American and white sha building residents. 148

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Baseline and Follow-up Surveys

The baseline survey was administered via telephone in summer 1993. During a one-month period, interviewers attempted to contact all individuals aged 62 or over whose names appeared on the resident lists and for whom a telephone number could be determined. Up to ﬁve call attempts were made to each potential respondent. Of 240 individuals (excluding non-English speakers who were dropped from the sampling frame), a total of 164 gave interviews yielding suﬃcient data for analysis, a completion rate of 68.3 percent. Inability to reach an elder via telephone proved the greatest problem in accrual. A total of 30 individuals successfully contacted refused to give interviews. Community specialists carried out the baseline data collection procedure. They received brief training, including monitored practice interviews of actual subjects. It was felt that participation by the community specialists in the evaluation would promote a shared understanding of the evaluation process. Because baseline interviewing took place at the beginning of the project, it was hoped that the procedure would promote early acquaintance by the community specialists with the lives of their future “clients.” A follow-up survey was conduced via telephone in summer and fall 1996. Interviewers attempted to contact all those interviewed in the baseline study. Interviews with suﬃcient data for analysis were completed for 87 individuals. Of the remainder, 24 refused to provide interviews and 28 were unreachable due to relocation, unavailability of a current telephone number, or for an unknown reason. Twenty-ﬁve were known to have died; excluding those, the research team obtained interviews from 62.1 percent of those responding to the baseline survey. The follow-up study was carried out by an employee of Group Health Cooperative who was not directly acquainted with the respondents. The three-year period that elapsed between the baseline and follow-up surveys enabled enough time to pass to (1) allow a suﬃcient number of respondents to the baseline survey to be approached Project Outcomes

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by community specialists and matched and (2) to assess the eﬀect of each match at least one year after it had been completed. Community specialists reported the matches made, including the names of the individuals and groups involved and the type of match, to the evaluation consultant, who used the information to compute the key independent variable (matched versus not matched).

Outcome Indicators

Interview schedules used in the baseline and follow-up surveys contained parallel items and sets of items designed to assess socialization, health, and quality of life.

Socialization

This dimension, the inverse of isolation, was assessed through four measures. Three of these were modeled after dimensions found to predict mortality in the famed Alameda County study, the investigation which originally informed the world of the importance of social ties for health and survival (Berkman 1978; Berkman and Syme 1979). The measures include: • Sociability. This multi-item indicator reﬂects the number of friends and relatives each respondent reported with whom he or she could talk freely about personal matters and the amount of recent contact the respondent had with individuals so identiﬁed. Higher magnitudes on a 3-degree scale reﬂected more social contact. This indicator corresponds to the “friends and relatives index” utilized by in the Alameda County study. • Network. This multi-item indicator denotes whether the respondent belonged to a social network of any kind. This index is based on four items, which asked the respondent 150

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whether he or she was currently married, belonged to a church, belonged to a club, or had friends or relatives whom he or she saw regularly. If the respondent gave a positive answer to any of these questions, he or she received a score of 1 on the network variable. If the respondent answered negatively to all these questions, he or she received a score of 0. • Group attendance. Based on a single interview item, this variable reﬂects the respondent’s ties to the community through groups rather than individual contacts. Respondents who indicated they had attended “meetings, functions, or gatherings of a social, recreational, community, or charitable group” during the past month received a score of 1 on the group attendance variable. Others received a score of 0. • Age isolation. This variable, also based on a single interview item, indicates not whether an individual is generally isolated but whether he or she is isolated from people outside his or her own age group. People who indicated they knew and regularly saw no one under 50 years of age received scores of 1 on the age isolation variable. People who knew at least one individual under 50 received scores of 0.

Health Status

Analysis of changes in health status used two variables based on single items in the interview. Studies of elderly populations in diverse locales identify health status as a positive consequence of active participation. Health status indicators include: • Self-perceived health. A single interview item asked respondents to rate their health on a 5-degree scale, from 1 (poor) to 5 (excellent). Because self-ratings such as this are reported to correlate strongly with objectively observed health status and risk of mortality (Mossey and Shapiro 1982), this item serves as Project Outcomes

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a good measure of an individual’s health within the constraints of a telephone interview. • Visits to healthcare providers. As a separate measure of ill health, respondents were asked the number of times in the past 12 months they had visited a doctor’s oﬃce, clinic, or emergency room. This item also reﬂects resources utilized by respondents as a consequence of ill health. Responses were ranked according to a 5-point scale, from 0 (no visits) to 4 (nine or more visits).

Quality of Life

Assessment of the possible eﬀect of matching on quality of life utilized two variables, measured by single-item indicators: • Satisfaction with life. Respondents indicated their level of satisfaction with life on a 4-degree scale: 1 (not satisﬁed at all), 2 (mostly dissatisﬁed), 3 (partly satisﬁed), and 4 (mostly satisﬁed). • Satisfaction with residence. Respondents indicated their level of satisfaction with the building in which they were living on a 4-degree scale: 1 (not satisﬁed at all), 2 (mostly dissatisﬁed), 3 (partly satisﬁed), and 4 (mostly satisﬁed). Although satisfaction with residence is a specialized dimension of satisfaction with life, it is particularly relevant here. Residence in the same type of facility was a common feature of all individuals sampled. The sha, moreover, had a particular interest in this area because of its mission of providing quality housing.

Data Analysis

All items required for the measures speciﬁed above were administered both at baseline and follow-up. The evaluation consultant ﬁrst 152

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compared distributions of responses to pertinent items and indices obtained at baseline with those obtained at follow-up to assess trends in socialization, health status, and quality of life within the sample as a whole. He then constructed contingency tables to assess whether baseline levels on these items and indices corresponded to eventual participation in the intervention. Findings in this area provide clues to possible selection bias. Multiple regression (ordinary least squares) constituted the principal method of outcome analysis. Equations were estimated predicting scores on outcome variables (e.g., sociability) obtained at follow-up on the basis of participation in the intervention (matching) and background variables measured at baseline, including sex, age, income, education, and race. Equations predicting a given outcome variable measured at follow-up also included the same variable as measured at baseline among the predictor variables. This resulted in adjustment of coeﬃcients on the variable indicating participation in the intervention for the respondent’s baseline score on socialization, health status, or self-reported quality of life.

FINDINGS Sample Characteristics

Survey respondents had the following demographic characteristics: • 31.4 percent were 80 years of age or older, 55.8 percent were between 70 and 79, and 12.8 percent were under 70; • 27.4 percent were male and 72.6 were female; • 12.6 percent were married and living with spouses, 75.8 percent were divorced, separated, or widowed, and 11.5 percent had never married; • 38.4 percent were African American, 44.2 percent were white, 9.3 percent were Asian/Paciﬁc Islander, 1.2 percent Project Outcomes

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were Hispanic, 2.3 percent were Native American, and 4.7 percent were “other”; and • 35.8 percent reported annual household income below $5,000, 56.7 percent between $5,000 and $9,999, and 7.4 percent $10,000 or more. Health status questions indicated that 50.5 percent felt their health was fair or poor and 56.3 percent indicated that they had cut down on activities over the past year due to illness or injury. Approximately 43.8 percent reported seeing two or fewer friends or relatives per month.

Trends in Socialization, Health Status, and Quality of Life

Comparison of scores on the socialization, health status, and quality of life indicators obtained at baseline and follow-up provided no evidence for consistently favorable or unfavorable trends on these dimensions. Within the area of socialization, for example, more respondents indicated a decrease on the sociability variable than an increase (23.5 versus 16.1 percent), while more indicated an increase in group attendance than a decrease (20.7 versus 16.0 percent). For all other indicators, pluralities of respondents indicated no change between baseline and follow-up.

Frequency and Patterns of Matching

Among the 87 individuals interviewed in both the baseline and follow-up surveys, 15 were matched during the project. Comparison of individuals matched with those not matched indicates a weak relationship between two socialization variables measured at baseline and later participation in a match. Among survey respondents receiving the lowest score on the sociability variable,

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which ranked individuals on a scale of 1 through 3, 7.4 percent were matched and 92.6 percent were not matched. Among the highest scorers on sociability, 16.7 percent were matched and 83.3 percent were not matched. Individuals who reported attendance at meetings, functions, or gatherings of a social, recreational, community, or charitable group during the past month, as reﬂected in the group attendance variable, were more likely to become involved in matches than those who did not (22.7 versus 11.6 percent). Neither of these relationships was statistically signiﬁcant.

Outcomes of Matching Socialization

Table 6.1 summarizes multiple regression equations predicting values on socialization variables observed in the follow-up survey. It should be noted that background variables in these equations include self-perceived health measured at baseline. The investigators added this variable to the equations summarized in Table 6.1 to account for the possibility that ill health might have a particularly strong eﬀect on sociability because it aﬀects the practical ability of people to see friends, attend group functions, talk, and write. In Table 6.1, the coeﬃcient on the intervention participation variable (“matched”) achieves signiﬁcance only in the equation predicting group attendance (p < .04). The positive sign on matched in this equation indicates that respondents who participated in the intervention had higher scores on the outcome variable measured at follow-up than those who did not participate, even after levels of group attendance prior to the intervention were taken into account. In the equation predicting age isolation, the coeﬃcient on participation in the intervention approaches signiﬁcance (p < .10). Self-perceived health predicts greater socialization in all equations and is a statistically signiﬁcant predictor of network.

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Table 6.1: Multiple Regression Coe;cients Predicting Socialization Variables at Follow-up

Predictor Variables Sex a Age b Self-perceived health c Income d Education e Race f Matched g

Sociability

Network

Group Attendance

.051 (.840) .001 (.009) .108 (.063) .070 (.040) .004 (.054) –.129 (.146) –.054 (.181)

.046 (.084) .000 (.005) .073 (.033) .007 (.022) –.004 (.027) –.010 (.079) .029 (.096)

.072 (.131) –.007 (.007) .045 (.052) .009 (.032) .075 (.043) .139 (.123) .324 (.151)

Age Isolation .157 (.094) .001 (.006) –.017 (.038) .001 (.023) –.033 (.030) .066 (.088) –.186 (.106)

Baseline Values: Sociability

.377 (.124)

Network

.404 (.123)

Group Attendance

.153 (.117)

Age Isolation R2 =

.22

.22

.21

.091 (.093) .11

Note: a—Sex: M = 1, F = 2; b—Age: years; c—Self-perceived health: 1 (poor) to 5 (excellent); d—Income: dollars in pervious year; e—Education: years completed; f—Race: nonwhite = 0, white = 1; g—Matched: 0 = not matched, 1= matched. Standard deviations appear in parentheses.

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Table 6.2: Multiple Regression Coe;cients Predicting Health Variables at Follow-up Predictor Variables

Self-Perceived Health

Provider Visits

Sex (M = 1, F = 2)

–.462 (.299) .031 (.017) .040 (.075) .106 (.097) .388 (.278) .457 (.340)

.126 (.387) –.024 (.022) .015 (.094) .003 (.126) .238 (.348) .432 (.432)

Age Income Education Race Matched (N = 0, Y = 1)

Baseline Values: Perceived Health

.562 (.119)

Provider Visits R2 =

.36

.328 (.136) .14

Health Status

Table 6.2 presents results from multiple regression equations predicting self-rated health and visits to healthcare providers (in the preceding 12 months). Except for self-perceived ill health at baseline, which predicts self-perceived ill health at follow-up, and visits to healthcare providers at baseline, which predicts visits to healthcare providers at follow-up, Table 6.2 presents no statistically signiﬁcant relationships.

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Table 6.3: Multiple Regression Coe;cients (sds) Predicting Quality of Life Variables Observed at Follow-up Predictor Variables

Satisfaction with Life

Satisfaction with Residence

Sex (M = 1, F = 2)

–.400 (.220) .002 (.014) –.069 (.057) –.026 (.073) .041 (.209) .017 (.260)

–.234 (.150) .010 (.009) –.097 (.038) .086 (.049) .173 (.140) .110 (.171)

Age Income Education Race Matched (N = 0, Y = 1)

Baseline Values: Satisfaction with Life

.633 (.158)

Satisfaction with Residence R2 =

.24

.211 (.080) .22

Quality of Life

Regression analysis of the relation between matching and quality of life indicators yielded no positive results (see Table 6.3). Coeﬃcients from an equation predicting life satisfaction at follow-up were nonsigniﬁcant except for the coeﬃcient on life satisfaction at baseline. The coeﬃcients in a regression equation predicting satisfaction with residence at follow-up included only two of statistical signiﬁcance: satisfaction with residence at baseline and income, which predicted a lower level of satisfaction with residence.

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S U M M A R Y O F Q U A N T I TAT I V E O U T C O M E S

The research reported here sought evidence that a deliberate intervention to reduce isolation among elders could favorably aﬀect socialization, health status, and quality of life. Findings presented above provide evidence that the Mutual Partnerships Coalition’s intervention improved socialization on one and perhaps two dimensions. Participation in group activities at follow-up was found to be higher among those who participated in the intervention than those who did not by a statistically signiﬁcant margin, even after several background variables were controlled. Isolation from nonelderly individuals was found to be marginally lower among those who participated in the intervention than among those who did not. The study detected no evidence that the intervention directly aﬀected quality of life or health status. Several sources of possible bias are apparent in the study design. Randomization of individuals into an intervention and a control group did not take place. Patterns of socialization, health status, and quality of life observed at baseline did not diﬀer strongly between those who later took part in the intervention and those who did not. Analysis of outcomes observed at follow-up controlled for socialization, health status, and quality of life at baseline, as well as background characteristics of the respondents. Still, undetected sources of bias could be present. Findings presented above are generalizable only to Seattle Housing Authority facility residents who spoke English and who survived three years after the intervention began. Unable to determine the vital status of individuals lost to follow-up and not known to have died, the researchers did not attempt a survival analysis. The followup sample obtained may have been biased against elders whose health at baseline predisposed them to near-term mortality. Findings on socialization are consistent with the content of the intervention. Nearly always, the intervention included an effort to interest individuals in joining social or volunteer groups or attending

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their functions. An increase (or reduction in decline) of group attendance among people who were matched is an expectable consequence of the intervention. Increased group attendance, moreover, seemed to continue well after the actual intervention, which, for all respondents, had preceded the follow-up study by at least one year. The researchers had hoped that individual-to-group matches would enable elders to make acquaintances and friends within the groups they attended; however, this outcome, which would have been indicated by a statistically signiﬁcant relationship between intervention participation and sociability, was not detected. These ﬁndings are consistent with several interpretations. First, and perhaps most likely, encouraging potentially isolated elders to join and attend groups appears consistent with their predilections. Attendance at group activities presents fewer emotional challenges to individuals than becoming acquainted with a person selected by a third party. Participating in group activities, moreover, appears consistent with a possible tendency among elders, both matched and not matched, to increase such attendance over time. Alternatively, it may be argued that more time must pass between an intervention of the kind described here and changes in an individual’s life measurable by the sociability variable. Only one year passed between entry of some individuals in the intervention and the follow-up interviews. An intervention speciﬁcally focused on fostering one-on-one ties, of course, might have been more eﬀective in promoting changes consistent with the sociability index. This study detected no eﬀects of the intervention on health status or quality of life. Again, several explanations are possible. Involvement in group activities may lack the intensity of social interaction required to aﬀect health and longevity. Findings from the Alameda County study (Berkman 1978; Berkman and Syme 1979) suggest that networks of intimate relationships are indeed the most eﬀective in preventing mortality. Alternatively, the study reported here did not identify individuals among whom matching appeared to have actually increased sociability, networks, or group participation and assessed whether these individuals experienced changes in 160

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health and quality of life more favorably than comparable others. The number of individuals matched in the sample obtained was too small to carry out such an exploration. At minimum, this study suggests that an intervention focused on matching elders with social, volunteer, and community groups can produce some of its desired outcomes. Longer-term follow-up of the sample studied here or of individuals participating in similar interventions may provide evidence of direct relationships between deliberate eﬀorts at matching and outcomes such as health status and quality of life. Interventions of a more intensive nature or with a more speciﬁc focus on establishing one-on-one relationships, moreover, may prove eﬀective in promoting the intimate ties that have thus far been linked with reductions in mortality.

WAS MPC A SUCCESS?

During the project’s active period, elders, community activists, social welfare agencies, and public oﬃcials were aware of its presence. The term “gifts and capacities” crept into the vocabulary of public oﬃcials and was heard at public forums. Local community newspapers reported on mpc’s activities. Periodic conferences, one keynoted by John McKnight, made the need to focus less on dependency and more on empowerment visible to people unfamiliar with the concepts. A limited number of community residents clearly beneﬁted from mpc. Lloyd, the inventor of “Linkage” (see chapter 5), drew encouragement from the project. He expanded his circle of social acquaintances and was given resources to carry out his work. It cannot be argued that mpc had a major, lasting eﬀect on individuals in Central Seattle or the community itself. As noted earlier, follow-up interviews revealed scant memory of mpc or its work by elders after the project’s active period ended. Outcomes of matching, as detailed in this chapter, were not found to include improved health or satisfaction with life. Project Outcomes

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Still, the W. K. Kellogg Foundation funded mpc as a demonstration project, the goal of which was to identify interventions of potential value in reducing isolation and rebuiding community. mpc was successful in determining attractive future directions and avoiding past error. mpc has yielded information of value for formulating interventions, organizing collaborative projects, and conducting evaluation.

Type of Intervention

Evidence from the quantitative outcome analysis suggests that individual-to-group matches were most eﬀective. Among elders followed in the longitudinal study, those matched were more likely to increase their group participation than those not matched. No other statistically signiﬁcant results were detected. This ﬁnding would prove encouraging to the community specialists who advocated for interventions other than the originally proposed individual-to-individual matches. The ﬁnding adds support to their contention that encouraging the natural processes of the community may be more eﬀective than introducing entirely new interventions. At the very least, it is clear that individual-to-group matches are easier to make than individual-to-individual, and hence capable of being made more economically and in larger volume.

Type of Organization

Chapter 5 can be read as an evaluation of mpc’s implementation. Observations made in the chapter include a disinclination of the steering committee, the project’s governing board, to take timely and forceful action. Cosupervision of personnel, an initially praised feature of mpc’s strucutre, proved a failure. Authority was diﬀused among their multiple supervisors and set the community specialists adrift. Future collaborative projects should emphasize the need 162

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to maintain accountability. Of equal importance, their leaders should do everything possible to create and maintain shared vision among diverse participants.

Type of Evaluation

Finally, the mpc experience raises questions for evaluation. Some limitations of the traditional type of evaluation summarized in this chapter have been acknowledged. Important outcomes may have occurred that were not detected. Chapter 7 examines issues regarding evaluation of collaborative projects focused on community wellbeing. Less traditional methods than the one illustrated here may be more appropriate.

REFERENCES Berkman, L. F. 1978. “Social Networks, Host Resistance, and Mortality: A Followup Study of Alameda County Residents.” Unpublished doctoral dissertation, University of California, Berkeley. Berkman, L. F., and L. Syme. 1979. “Social Networks, Host Resistance, and Mortality: A Nine-Year Follow-up Study of Alameda County Residents.” American Journal of Epidemiology 109: 186–204. Mossey, J. M., and E. Shapiro. 1982. ”Self-Rated Health: A Predictor of Mortality Among the Elderly.” American Journal of Public Health 72: 800–08.

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PART III

Lessons Learned

In its ﬁnal section, this book concentrates on lessons learned form the authors’ direct experience and the broad range of projects reviewed in the preceding pages. Few coalitions have achieved everything they sought; some, however, have enjoyed successes which few if any of their stakeholders expected. Most coalitions have found it necessary to revise their strategies and modify their objectives as they become more familiar with the tasks they face. Application of the coalition concept requires patience and ﬂexibility. This section concentrates ﬁrst on program evaluation. The topic of evaluation has appeared repeatedly in previous sections. Evaluation is focused on here because it constitutes a key means for determining the lessons that may be learned from a coalition’s efforts. The emphasis placed today on performance and accountability makes it necessary to pay close attention to the evaluation; this section provides readers with an understanding of the range of evaluation techniques available and the limits of each. Finally, part III summarizes lessons learned from speciﬁc programs and derived from the general overview made possible by this book. Speciﬁc directions and caveats are suggested.

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CHAPTER 7

Assessing Accomplishments: Traditional and Nontraditional Approaches to Evaluation

T H E C H A L L E N G E O F E VA L U AT I O N

Evaluating collaborative community programs in a manner broadly recognized as valuable represents one of the most diﬃcult challenges facing such enterprises. Familiarity with evaluation-related dilemmas and choices encountered by past collaborative programs suggests options for future eﬀorts, and selection of appropriate methods can do much to make evaluation eﬀorts worthwhile. Of potentially greater importance, the perceptions of individuals and relationships among them pertinent to evaluation can have a decisive impact on its value to everyone involved. Nearly every program referenced in the preceding chapters has included an eﬀort to assess success. Today, almost no organization mounts a health-related intervention without planning and budgeting resources for evaluation. Most agencies that sponsor interventions require that applications for support include an evaluation component. The mandate for evaluation, however, often creates diﬃculty for community interventions. Many program operators believe that resources expended for evaluation are wasted. Staﬀ and community

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residents frequently perceive evaluation personnel as outsiders, snooping on enterprises in which they have abiding faith. To many program staﬀ, the word evaluation has an uncomfortable ring, recalling school exams and tax audits. The level of discomfort induced by evaluation helps explain the negative dynamics associated with evaluation in community-based programs such as the Mutual Partnerships Coalition (mpc). As described in part II of this book, diﬀerences in world view among program personnel became visible in discussions and arguments regarding evaluation. Most community liaison personnel considered their functions personally fulﬁlling and saw their eﬀorts as part of a social movement. The project evaluator, who argued for the use of standardized procedures and data instruments, was perceived as challenging the legitimacy of activities to which others were emotionally committed. People involved in program delivery often have diﬃculty justifying evaluation expenditure based on the value it is perceived to add. Regularly, the sentiment surfaces that the money could be better spent hiring an additional nurse or social worker. Evaluation is perceived as a necessary evil in accepting funds from a foundation or government agency. Dismissive attitudes toward evaluation by program executives result in tight budgets and restricted access to information about program operations. This chapter aims to demonstrate how the diverse stakeholders involved in community partnerships can beneﬁt from evaluation. This requires, ﬁrst, that program staﬀ and evaluation specialists enter into a collaborative relationship. Evaluators are seldom able to do their best without cooperation from intervention staﬀ and the surrounding community. Program executives and staﬀ and community residents can obtain signiﬁcant value from evaluation if an atmosphere of collaboration rather than competition prevails. Second, meaningful evaluation requires appropriate evaluation techniques. Traditionally, program evaluators have borrowed methods from biomedical research and the social sciences in program assessment. Some evaluation projects have taken the form of social 168

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experiments, featuring before-after comparisons of community residents or comparison between communities exposed to a program and those not exposed. Program staﬀ and community residents regularly receive questionnaires and telephone interviews. The review of evaluation techniques presented in this chapter is not intended as an application-oriented guide. Many high-quality textbooks are available for this purpose. Rather, the review demonstrates options to readers unfamiliar with the technical features of evaluation and provides a review for those experienced in the ﬁeld. By now, social scientists have successively reﬁned traditional evaluation techniques over several generations. Yet, most evaluation studies fail to detect program impacts. Peter Rossi, a noted authority on evaluation techniques, has formulated an “iron law” to express this phenomenon. He has written, “If there is any empirical law that is emerging from the past decade of widespread evaluation research activities, it is that the expected value for any measured eﬀect of a social program is zero” (Moynihan 1996) Critics of traditional evaluation techniques, however, argue that the failure of evaluators to detect measurable outcomes depends not on the absence of outcomes, but the ability of traditional techniques to detect them.

T H E U S E S O F E VA L U AT I O N

That evaluation has a useful function for everyone involved should be a basic principle of evaluation in community settings. But by their very nature, coalitions include groups with diﬀerent orientations and goals. It is useful to review what each “stakeholder” in a collaborative project is likely to seek from evaluation. Some stakeholders have long recognized value in formal evaluation for their objectives. Among other stakeholders, this recognition has been slow. It is not necessary that all stakeholders seek the same objective via evaluation, but all stakeholders should be made aware that evaluation, when appropriately conducted, can serve as a key asset to them. Assessing Accomplishments

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The diversity of uses to which evaluation can be made is reﬂected in the thinking typical of two key stakeholders: the sponsors who support programs ﬁnancially and the staﬀ (both executive and ground level) who are responsible for program operations.

Evaluation and Program Sponsors

Program evaluation was born in the twentieth century, and the notion promises to increase in importance in the twenty-ﬁrst. At one time, social benefactors bestowed resources in the belief that resulting projects were of obvious public beneﬁt. The Rockefellers, Vanderbilts, and Carnegies, who endowed auditoriums and museums, never sought outcome assessments. Donations to the settlement houses of yesteryear were not followed by evaluation contractors. Some researchers and foundations continue to adhere to this view. Today, it is expected that the impact of every social intervention be measured and systematically analyzed. Community-based and other public health programs seldom receive funding from individual, wealthy donors. Typically, they get their dollars from businesses, foundations, and government agencies. These organizations view their funding decisions in a corporate rather than personal fashion. They seek visible indications of performance rather than feelings of personal gratiﬁcation or prestige.

Performance

Reasonably, sponsors desire to measure the performance of the organizations they fund. Agencies that provide funding seek to determine whether the interventions they support work. Agencies that fund community programs have many options about what to support. Evidence of eﬃcacy based on evaluation data supports arguments in favor of initial or continued funding. 170

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Assessment of performance has importance beyond funding decisions. Funding agencies today wish to see the organizations and processes they support improve over time. Realizing the limits of their resources, funding agencies seek to initiate a program for protecting health, increasing employment, or promoting public safety. Often, they hope to see a technique perfected under their funding and then spun oﬀ to government agencies or community groups. Development of interventions requires evaluation, so that more successful programs can be compared with others. Lessons are obtained from grantees that encounter challenges as well as those that clearly achieve their aims.

Accountability

Accountability constitutes a second rationale for evaluation. Funding agencies desire to see whether people receiving their support act in a manner consistent with their promises. This is particularly important for government agencies. The laws that enable them to make grants also require project monitoring. The term accountability connotes an element of suspicion; ﬁdelity to a proposed program cannot be taken for granted. Stories circulate among sponsors of programs whose staﬀs have never done what their grants mandated. An evaluator tells of a drug treatment program that never recruited or treated a single addict. Rogue grantees rent oﬃces and hire staﬀ but do not deliver the required service. Clearly, these stories in no way reﬂect the commitment to accountability that the vast majority of programs demonstrate, but exceptions do contribute to concerns.

The Program’s Perspective

People responsible for day-to-day program operations seldom consider evaluation as providing immediate value. The need of staﬀ Assessing Accomplishments

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members to meet concrete objectives and deal with crises requires considerable attention. The function of evaluators seems more abstract, and they are often viewed as outsiders. A more practical role seems to be developing. In some important projects, staﬀ have identiﬁed the output of evaluation eﬀorts as valuable for achievement of their objectives. Exploiting the beneﬁts available in evaluation eﬀorts makes sense for many more projects today than those which presently use them, but changing circumstances will likely motivate staﬀ of more and more projects to look to evaluation for assistance in their tasks. Several leadership and staﬀ functions will become more dependent on evaluation as competition for funding becomes more intense and the nature of community interventions themselves become more complex.

Program Planning

For program planners, evaluation has immediate applicability in helping deﬁne and reﬁne objectives. Many community-level interventions begin with aims that are highly abstract and general. Visible success, however, requires identifying manageable aspects of the community’s concern and adopting sequences of concrete actions to achieve progress. The 1990s saw the development of a trend in community interventions which made focusing on speciﬁc dimensions of community health more diﬃcult. As chapter 3 illustrates, programs designed to improve community health have operated in some form for hundreds of years. Many of today’s community health initiatives are comprehensive in nature. Foundations and public agencies award funds to communities for the general purpose of improving community health, a concept which includes not just disease control but improvement in areas such as employment, public safety, and civic participation. Overwhelmed with the breadth of such a mandate, communities run the risk of dissipating their resources and, after years of operation, showing no solid achievements. 172

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Procedures that are part of every evaluation design can enable community programs to achieve the focus necessary to enhance their eﬀectiveness. A systematic survey of community characteristics is a practical place to begin the process of focusing. Even interventions led by long-term community residents can often beneﬁt from systematic reviews of business trends, employment patterns, incidence of communicable disease, and demographic variables. Almost every evaluation eﬀort begins with collection of baseline data. Baseline data provide evaluators with information for making the later, before-after comparisons which nearly every evaluation procedure requires. They have direct beneﬁts for program planning as well.

Available Data

Evaluators sometimes draw on available data sources, obtaining information from agencies such as the U.S. Census and county and state vital statistics. Information of this kind can be obtained at low cost. It is particularly useful in evaluating projects with outcomes addressing pregnancy rates, preventable mortality, and the economic fortunes of a community. These same data can be used for program planning. They can help community leaders assess the magnitude of problems in the area they intend to serve. Baseline data can assist program planners in determining the priorities for their eﬀorts. They can also enable program planners to direct resources to segments of the community where they are most needed.

Baseline Surveys

Other baseline data need to be collected for the speciﬁc purposes of the intervention. Mail, telephone, and face-to-face interviews are Assessing Accomplishments

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among the most familiar techniques. Assessment of the prevalence of a problem is often the ﬁrst step in a public health intervention. Less familiar but of increasing importance today are key informant interviews. Traditionally, surveys ask respondents their personal opinions on a given subject. Key informant interviews, on the other hand, tap the respondent’s knowledge about the history, development, resources, and needs of his or her community. Key informant procedures make use of the observations of numerous, wellpositioned individuals in a program’s service area.

Implementation

If evaluation eﬀorts can be useful for planning a public health intervention, they can be invaluable for starting the machinery of a collaborative program. Implementation always involves embarking on a new venture. Startup tasks may include forging new working relationships between unfamiliar parts of the same community. Implementation of a project requires hiring new personnel and doing business with new suppliers. The startup situation exposes programs to uncertainty and potential conﬂict. Evaluation personnel can make an important contribution here. They can provide program staﬀ with external observations about the success of an implementation phase. Many large ﬁrms hire organizational development experts to assess working relationships and promote collaboration and productivity. When evaluation includes monitoring of implementation, the ﬁndings of evaluators can have immediate value for program staﬀ.

Sustainability

Evaluation helps community interventions achieve perhaps their most important objective: sustaining their operations beyond an

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initial cycle of funding. Most program sponsors see themselves as short-term partners. The desire is to help an innovative project begin its work and demonstrate its value. Once these objectives have been achieved, the project is presumed able to sustain itself without outside resources. In fact, few grant-funded projects ever become self-supporting. The functions of community programs—preventing teen parenthood and ﬁnding jobs for the chronically unemployed, for example—are seldom supported by the “market.” Individual consumers do not or cannot pay for such services. Community programs, therefore, are perennial seekers of grant and public-sector funding. As the end of a funding cycle nears, their attention turns to ﬁnding a new funding partner, either to continue in an established direction or toward a new service area. At this time, positive evaluation ﬁndings become crucial. Nothing can promote favorable decisions by prospective funding partners as well as documentation of successful performance on a previous eﬀort.

A COMMUNITY OF INTEREST

Too often, evaluation seems like a process imposed from outside on people dedicated to doing good things for the community. But evaluation should be seen as a function that unites all stakeholders: program staﬀ, funding agencies, community residents, and the broader public. Everyone has an interest in seeing evaluation done well. Some products of evaluation are of obvious value: those that enable program staﬀ to strengthen implementation and promote sustainability or that allow funding agencies to determine how well their mandates are being followed. Less traditional but of increasing importance is the role evaluation may play in demonstrating the value of a funding agency’s contributions to the community. Today, nonproﬁt organizations such as foundations and community

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hospitals are under often suspicious public scrutiny regarding their public service contributions. Well-conducted evaluation can demonstrate the value of a funding agency’s contributions to the public. In some instances, private foundations are mandated by regulatory bodies to contribute to a speciﬁc area of public well-being. Evaluation ﬁndings can contribute to the funding agency’s ability to demonstrate that it has fulﬁlled government requirements. The most important beneﬁciary of a well-conducted evaluation, however, is the community itself. The community-based interventions with which this book is concerned, after all, are conducted in the name of community residents. Communities have been recipients of well-meaning eﬀorts by outsiders for generations. Yet, many of the programs to which they have been subject have had little noticeable eﬀect. Repeated cycles of community programs which come and go are likely to foster cynicism among community members. The suspicious feelings are justiﬁed if evidence of progress in a form meaningful to them cannot be given to community residents. Evaluating community-based programs in a manner that actually fulﬁlls the functions speciﬁed above is not easy. The task of an evaluator in the community is more complex than that of a traditional scientiﬁc investigator. The community evaluator, for example, must meet the expectations not just of the scientiﬁc community but of several other stakeholders. Technically, community evaluation addresses questions that are highly complex, imprecisely measured, and often emotionally charged. Program interventions and objectives, moreover, must change over time. Evaluation of community programs can be conducted in a manner appropriate to its multiple uses. The most successful evaluations use a combination of traditional and nontraditional methods. Appropriate eﬀorts diﬀer from project to project. The pages to follow provide an overview of the approaches evaluation of community programs may take and guidelines for matching available techniques with individual program needs.

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Technical Approaches to Program Evaluation

The biomedical and social sciences provide a wide range of options for evaluation of community-level interventions. Each has positive and negative features for evaluation tasks. A mix of evaluation techniques can serve a community best. Any evaluation design must have a deﬁnite set of features, and these are speciﬁed at the end of this section. It is important to remember, however, that special considerations apply to community-based interventions. In addition, the manner in which evaluation design is formulated and executed can make the diﬀerence between failure and success.

BIOMEDICAL RESEARCH MODELS

People responsible for program evaluation often feel tempted to emulate biomedical research models. Models of this kind are familiar to every clinical professional and many administrators. People using biomedical research procedures have established the basis for many successful clinical interventions. Because of their renown for scientiﬁc validity and familiarity to people in the health ﬁeld, biomedical models should be considered highly valuable. Some community-based interventions may lend themselves to evaluation with these traditional techniques, and opportunities of this kind might be explored; generally, however, such techniques appear incompatible with the complexity, demands, and needs of community-based work.

Randomized Controlled Trials

The best-known traditional biomedical techniques, randomized clinical trials (rcts), represent the gold standard of research. This technique is frequently applied to test the eﬃcacy of medications.

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Under this procedure, the scientist randomly selects individuals for placement in two or more groups. Traditionally, one group, known as the “experimentals” would receive the medication to be tested, while the other group, the “controls,” would receive a placebo. Today’s rcts typically test several treatments simultaneously. The principle of the rct remains the same no matter how many treatments (or interventions) are tested: individuals are assigned to each group on a completely random basis. The rct technique derives its validity from random assignment of all subjects to speciﬁc interventions and controls. Distinct groups of individuals selected at random from the population at large should be identical. In rcts, therefore, the characteristics of people in all groups should be, on average, the same, except for the treatment they receive. Any diﬀerence perceived later can be unequivocally attributed to the treatment, and not diﬀerences among the subjects. Of all research methods in use, rcts have the greatest validity. A research method’s validity is high if the relationship it ﬁnds between two variables cannot be potentially explained by a third variable. An rct, for example, may indicate that cancer patients who receive the experimental drug experience a decrease in their tumor size, while those who receive the placebo experience no such decrease. Critics of the experiment cannot claim that the diﬀerence in tumor development occurred because the experimentals and controls had diﬀerent biological or social characteristics. This is because participants in the experiment were randomly assigned to the experimental and control groups, ensuring identical average characteristics within the two groups, if numbers of subjects are suﬃciently high. To strengthen the validity of rcts still further, biomedical researchers often ensure secrecy regarding which subjects are experimental and which are controls. In such procedures, subjects are not told whether they are receiving a drug or a placebo. This is done to counteract the well-known “placebo eﬀect,” in which people who receive even treatments known to be ineﬀective report improvement

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because of the mere expectation that something beneﬁcial has been done to them. In the ideal design, the experimenter as well as the subjects are kept ignorant of who is in the experimental versus the control group. This procedure is known as a “double blind” study.

Dose-Response Designs

Attractive as they are, rcts are not always feasible and do not always provide the most valuable data. Scientists cannot always randomly assign people to experimental and control groups. Often, people strongly desire to be in the group receiving the positive intervention. Researchers cannot legally withhold eﬀective treatment from anyone when one is available. In these instances, scientists may utilize a dose-response procedure. Subjects are divided into groups, all of which receive the same medication, but in diﬀerent amounts. If the treatment is eﬃcacious, it is reasoned, subjects receiving the largest doses will demonstrate the most change (presumably in the direction of improved health). The dose-response technique can also provide information on the point at which undesirable side eﬀects start to occur. In medicine, researchers seek to establish the dosages at which health effects are greatest but before which risk of side eﬀects becomes considerable. Crossover design represents a useful reﬁnement in both rct and dose-response methodology. At the midpoint of the procedure, the experimenter switches the group receiving presumably eﬀective treatment and the group receiving the placebo. It is expected that desirable eﬀects observed earlier in the experimental group will decline, while those in the group originally given the placebo will improve. Crossover design can present convincing evidence when the initial similarity between experimentals and controls is in dispute.

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Observational Studies

Biomedical scientists refer to a broad range of research approaches as observational studies. Such studies lack the feature of an intervention that is deliberately given or withheld to a distinct group of individuals. Biomedical researchers often use observational methods for public health or epidemiological studies. They use this procedure to identify risk factors associated with a particular illness. This method may also be used to assess the eﬃcacy of an intervention when no randomized control group is available. An observational study may take the form of a survey. Under this procedure, researchers may seek to identify common characteristics among individuals with diseases such as arthritis or diabetes. Surveys may be conducted at successive time points to determine causes of health and illness. Several famous investigations, for example, have identiﬁed strength of social ties as a cause of longevity. At a baseline point, people were asked how often and with how many people they interacted intensely. Several years later, it was determined whether these people were alive or dead (Berkman 1978; Berkman and Symes 1979). The case control study is a widely used example of an observational investigation. In case control studies, researchers may identify individuals with a particular illness or health history. These individuals are the “cases.” Then the researchers search medical records to ﬁnd people who have demographic characteristics like the cases, but without the disease or health history. These are the controls. The diﬀerences between the cases and controls provide clues to the causes of disease and the eﬃcacy of interventions. A well-known example was published in the early 1980s, when scientists sought to determine whether coﬀee consumption caused pancreatic cancer. Patients being treated for pancreatic cancer were given a battery of questions designed to assess their dietary history. Then, individuals identiﬁed in clinical settings but free of pancreatic cancer were given the same battery of questions. Data were analyzed to determine how dietary patterns diﬀered. It was initially 180

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determined that the subjects with pancreatic cancer had consumed more coﬀee (MacMahan et al. 1981).

METHODS FROM THE SOCIAL SCIENCES Sources of Data

A research design, employed for a program evaluation or any other purpose, is only as good as the data analyzed in it. Biomedical data tend to be straightforward. They include information obtained from laboratory analysis of blood and other body products, as well as clinical observations. Data used by social sciences are based less on directly observable phenomena. Some of the most widely used methods for data gathering in social research include surveys, focus groups, and unobtrusive information collection.

Surveys

Due to their visibility, surveys are the best-known data collection method of the social sciences. Basic procedures include identifying a sample representative of the population of interest, contacting the individuals in the sample, and obtaining responses to questions regarding the issue of interest. In past years, large research organizations such as Louis Harris Associates and the National Opinion Research Center maintained networks of interviewers who came to the subject’s door and asked questions. Today, this method has been largely supplanted by telephone interviewing. Many more interviews can be obtained per hour via telephone. In addition, selection of interviewees via telephone can be done in a more reliable manner through techniques such as random digit dialing (rdd). In a modern survey research operation, interviewers are put in contact with respondents via automatic dialing mechanisms and administer scripts appearing on Assessing Accomplishments

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computer screens. Responses to survey questions are typed onto keyboards and are immediately available for machine analysis. Surveys used for market research and political polling are most familiar to the public. This technique can also be used in program evaluation. It is most useful for evaluation of interventions intended to raise the public’s level of awareness regarding a health issue or attitude regarding physical or social surroundings. Surveys of this kind might ﬁrst ask people if they are aware of the intervention (perhaps a publicity campaign), and then, how they feel about the issue of interest. Comparison can then be made of responses given by those reporting awareness of the intervention and those not aware of it. When readministered over time, surveys provide indications of changes in general public consciousness. Changes of this nature may reﬂect the inﬂuence of comprehensive interventions aimed at broadly aﬀecting the community. Although large survey organizations use sophisticated hardware and software to conduct surveys, good results can be obtained without access to such involved machinery. With adequate knowledge of the technique, survey researchers armed only with pencil, paper, a telephone, and a well-conceived randomizing device can achieve creditable results. The randomizing device can be as simple as a table of four-digit random numbers. Each four-digit number can be matched with three-digit exchange numbers corresponding to the intervention’s target area.

Focus Groups

Focus groups represent a more exploratory method used by social scientists. Typically, a focus group comprises a dozen or so individuals seated around a table and presented with open-ended questions. A facilitator presents the questions and encourages participants to respond. He or she uses a protocol containing questions developed in advance by research specialists. Employed extensively in market

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research, focus groups can serve as venues for presentation of product logos and advertising copy to potential consumers. Practical procedures for focus group–based information gathering begin with recruiting individuals who represent the program’s or product’s target population. Comfortable surroundings and a warm, conversational atmosphere promote good results. Like surveys, focus groups can be conducted at great or little expensive. Contractors with ample resources recruit participants through rdd telephoning. This enables the researcher to select people who match the description of the very consumer or neighborhood resident in which he or she is most interested. Researchers working for corporate America usually pay subjects for their participation. They hold the groups in special rooms with two-way mirrors, allowing executives to observe, and sound and video recording equipment making later study possible. Good focus group results can be obtained with fewer material resources, however. In communities, many residents will participate for free. A skilled note-taker can substitute for recording equipment. Essential to all focus group procedures is a well-constructed set of questions reﬂecting issues pertinent to program implementation and outcomes.

Unobtrusive Information Collection

“Unobtrusive” information includes all data that can be obtained without directly asking an individual for it. Unlike surveys or focus groups, unobtrusive data gathering does not depend on the willingness of people to answer questions or provide truthful information. Unobtrusive methods rely on the researchers’ eyes rather than his or her ears. Unobtrusive sources of information include documents (from a community organization, government agency, etc.) or things observable in day-to-day life. The potential for use of unobtrusively

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obtained data is just being recognized in evaluation research. Records of state legislatures and city councils can be reviewed to determine if health-related measures have been passed, an objective of an increasing number of community coalitions. The rate at which billboards advertising unhealthy products (such as alcohol and tobacco) are found in the community can be monitored. The introduction of healthful items such as sugar-free soft drinks on convenience store shelves can be tracked. Neither surveys, focus groups, nor unobtrusively obtained information constitute actual evaluation designs. Rather, they are tools for collecting information. To use information obtained from surveys, focus groups, or documents for evaluation purposes, researchers must employ the information obtained in designs such as case controls, discussed above, or several of the procedures outlined below. People concerned with high-quality evaluation should always ensure that data collection eﬀorts are not being undertaken in the absence of an accompanying evaluation design.

Research and Evaluation Designs

Two of the most frequently encountered designs for social research and evaluation are quasi-experimental procedures and case studies. Many diﬀerent designs and procedures are carried out under these two labels. The designs listed below constitute illustrative examples.

Quasi-Experimental Procedures

While admiring the validity of rcts, social scientists seldom have opportunities to apply this technique in their own work. Human beings resist randomization. Biomedical scientists obtain compliance with such procedures by holding out the possibility of improved treatment to potential subjects. But few people if any would seem

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willing to consent to arbitrary assignment to situations reﬂecting variables of interest to social scientists. It is unthinkable, for instance, to randomly assign people to lifelong membership in speciﬁc social classes or residence in designated neighborhoods. Many entities studied by social scientists, moreover, are stationary and enduring, such as corporations, religions, and entire societies. Social scientists can do little other than make passive comparisons among such entities. Social scientists, then, have developed procedures intended to capture some of the advantages of rcts but requiring considerably less control over the people or groups studied. Quasi-experimental designs have been developed which have some features of rcts but are better adapted to the study of social issues. Exercising signiﬁcant creativity, social scientists have devised designs such as the following: • Time series. In time series studies, scientists measure the phenomenon of interest at repeated intervals. A change in the frequency of a particular form of behavior or occurrences in a community is interpreted as evidence for program eﬃcacy. In evaluating a program to lower teen pregnancy, for example, evaluators would monitor the number of births to teen mothers divided by the female teen population in the target community. Rates would be calculated every month. A sharp drop in the number of teen mothers following the program’s implementation would constitute evidence that the program had been eﬀective. • Nonequivalent control groups. Several quasi-experimental designs mimic rcts by comparing experimental with control groups. In such designs, an evaluator ﬁnds a locale similar to the community in which the intervention is taking place, but without the intervention. Evaluation studies are often conducted by identifying a comparison community after the intervention has been initiated. Selection of a comparison

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community after the intervention has begun is an expedient frequently used by evaluators who receive their assignments after a program has been implemented. Much publicly available data can be used in selecting a comparison community. Evaluators may, for example, seek comparison communities with similar age and racial makeups to the community in which the intervention is being conducted. Control groups selected in this manner, however, must still be considered nonequivalent with respect to the intervention community. The evaluator necessarily matches communities using only a small number of characteristics. It is virtually certain that the communities will diﬀer according to other dimensions that the evaluator has not investigated. • Mixed designs. Mixed designs represent an important set of options for program evaluators, providing stronger tests of program outcomes. Multiple rather than single time series designs represent one such option. In multiple time series designs, evaluators observe outcomes in multiple communities, some with intervention and some without. If the intervention were having a genuine impact, it would be observed in the communities in which the intervention was active but not in others. In the example cited above, teen pregnancy would be observed to drop in a community with the relevant program but not in a community without this or a similar intervention. Evaluation designs using nonequivalent control groups may also include the dimension of comparison over time. The evaluator may compare variables of interest observed in the intervention and control communities before and after the intervention has taken place. Change scores may be calculated reﬂecting degrees of reduction or increase (for example, of teen pregnancy rates). Change scores are more likely to reﬂect eﬀects of an intervention than observation of outcomes across communities at a single point in time. Many factors, perhaps most unobserved, can determine community characteristics 186

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such as teen pregnancy rates at given points in time, but rates of change, in the absence of a deliberate intervention, are ordinarily uniform from community to community. It should be recognized that quasi-experimental designs do not duplicate the validity of rcts. The quasi-experimental methodology cannot exclude the possibility that factors other than the intervention account for observed outcomes. At best, quasi-experimental designs help build a case.

Case Studies

Case studies represent perhaps the most widely used techniques of program evaluation. Borrowed initially from anthropology and ethnography, case study methodology has the advantage of accumulating rich and complex material from the ﬁeld. Its less sophisticated versions require little formal training and no mathematical analysis, as do techniques that produce numerical results. Three types of case studies illustrate the tools available to evaluators: 1. Impressionistic. As the name implies, impressionistic case studies gather impressions about a program’s implementation and outcomes. Observers spend considerable time monitoring the project from close range. They become familiar with staﬀ and community members. Although some impressionistic case studies utilize observation guides to focus observers on particular subject matter, the evaluator’s powers of personal observation and assessment are the key research instruments in this approach. The evaluator develops vignettes, examples, and extended stories to document his or her conclusions. 2. Interpretive. Interpretive case studies impose more structure on the observation technique. The evaluator makes his or her observations with deﬁnite theories and constructs in mind. He or she has often worked out ideas about what successful Assessing Accomplishments

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implementation or outcomes should look like. Concrete standards for success may have been developed in advance, against which observations are compared. 3. Logic model. Logic model case studies represent the most sophisticated stage of the methodology. In them, both observation and interpretation are guided by a logic model or theory of action, which comprise series of postulated steps leading from program intervention to achievement of outcomes. Observation must take place throughout the intervention’s life cycle. Conclusions are drawn by comparing the sequence of events observed with the sequence suggested by the logic model. Unlike other types of case studies, logic models provide arguments that observed outcomes can be directly traced to the intervention. Evaluators using this methodology determine whether a sought-after outcome has taken place, but they do not attribute these outcomes to the intervention unless evidence is also available to indicate that the intervention was implemented as planned. Lower rates of teen pregnancy, for example, may be observed in a community in which a teen pregnancy program has been started. Program staﬀ may rejoice in the observation, but if the intervention was not fully implemented before teen pregnancy started to drop or service delivery began, the program cannot take credit for the favorable development.

C R I T E R I A F O R E VA L U AT I O N D E S I G N

As shown by the examples above, most if not all of the research methods traditionally utilized in the biomedical and social sciences can be applied in evaluation of community-based programs. Some lend themselves better to this application than others, as discussed below. Approaches to evaluation other than those presented here exist and more are likely to be developed in the future. For good 188

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reason, many program evaluators utilize a mix of techniques, capturing diﬀerent aspects of the program with each methodology. Whether a stand-alone procedure or an item in a mix, every evaluation design requires a set of basic properties. People formulating evaluation strategies should use the items appearing below as a checklist. Agencies contracting for program evaluation should ensure that all these criteria are met as an assurance of competence and quality.

Systematic Inquiry

Every evaluation design should have an information-gathering component systematically focused on speciﬁc evaluation questions. Observation may take place through devices as concrete as survey forms or as ﬂexible as instructions to ﬁeld staﬀ carrying out impressionistic case studies. All survey questions or instructions to ﬁeld researchers in case studies should reﬂect three concerns: • Has the intervention been implemented as proposed? • Have the expected outcomes been achieved? • In view of a program’s challenges, what innovations and lessons may be obtained for the future?

Objective Measurement

High-quality evaluation requires concrete criteria reﬂecting the degree to which programs have been implemented and outcomes have been achieved. Increasingly, both biomedical and social scientists have formulated numeric scales. Scales of this kind include multiple questions administered to program participants or outside informants. They generate an achievement score in a speciﬁc area of interest. Dimensions measured by scales range from physical function of an individual to social capital in a community. Assessing Accomplishments

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Objective measurement, however, does not require numerical instruments. Criteria may be formulated to specify the level of achievement expected of a program. For example, program evaluators have formulated stages of maturity for community organizations operating programs. The stage reached by a community program is not determined numerically, but by the presence of one or more observable functions taking place in it. An example of measurement in this fashion occurred in the Community Care Networks (ccn) program in the 1990s. Funded by the W. K. Kellogg Foundation and the Health Research and Educational Trust (hret), the initiative sought to establish working coalitions between healthcare organizations and public sector and community-based agencies. Evaluation researchers observed these coalitions over time and classiﬁed their degree of development based on formal, although nonnumerical, criteria. A measure is not objective because it is numerical. Rather, objectivity corresponds to standards for assessing a program’s development or achievements likely to be accepted among people with diﬀering orientations and values.

Adequate Observation

Attempts at obtaining understanding of physical or social phenomena often fail because information of insuﬃcient volume or range is accumulated. Survey researchers must collect suﬃcient numbers of cases to compute statistically signiﬁcant relationships among the variables in which they are interested. Otherwise, readers may consider their conclusions unconvincing. The same logic applies to program evaluators. Assessment must take place over a long enough time to allow full implementation to take place and outcomes to appear. Program evaluation must observe an adequate range of program functions and participants. Attendance at leadership meetings alone cannot provide information about what is

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happening on the ground. Interviews of staﬀ provide important perspectives, but community residents and potentially critical observers outside the project must be contacted as well. Clearly, an evaluation in which researchers merely make an occasional visit can seldom provide a true assessment of implementation, achievements, and challenges.

Capacity for Comparison

All evaluation planning should explore the possibility of making comparisons: one neighborhood with another, for example, or one intervention with another. Comparison is an essential feature of both experimental and quasi-experimental designs. Although evaluators cannot randomly assign individuals to diﬀerent neighborhoods, they can compare neighborhoods as they already exist. Comparison may be made between a community as it was before and after intervention. Without the capacity for comparison, assessing outcomes or determining the interventions that work best is difﬁcult. Again, comparison need not be made on a numerical basis. Postulated phases of development may serve as a yardstick. Wellconstructed case studies may also provide a basis for comparison. Generally, an acceptable evaluation design must have intersubjectivity. That is, its results must be convincing to people with diﬀering backgrounds and expectations regarding the program’s likely outcome. Procedures used in a good evaluation design must produce results acceptable both to the program’s critics and supporters. To people with experience in biomedical, social, or evaluation research, these principles amount to statements of the obvious. But evaluation eﬀorts that conform to none of the approaches described here are still carried out today. It is not uncommon, for example, for supporters of a program to base an evaluation on anecdotes.

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Anecdotes and stories are useful if positive and negative instances are collected systematically and analyzed and reported in a disinterested manner. Despite the views of traditional science, they have great value in community contexts. Systematically collected and well-selected stories can have great value in expressing the community’s experience and communicating outcomes and lessons learned to community members.

E VA L U AT I O N I N P R A C T I C E

Numerous examples of the techniques described above can be found in published reports of program evaluation. The project summaries that follow represent only a few illustrations selected from the many that have been carried out.

Randomized Controlled Trials

Although the rtc’s usual venue is remote from community settings, this technique has been applied in evaluation of some very important social and coalition-based initiatives. An intervention designed by an English social work agency combined the resources of heathcare providers, community groups, and government bodies concerned with social welfare. Spearheaded by the Leichester Royal Inﬁrmary, the intervention was intended to reduce isolation and its consequences among elders in the town of Melton Mawbray (Clarke, Clarke, and Jagger 1992). Five separate techniques were employed: arranging visits and social groups for isolated individuals, providing help with ﬁnancial management, installing safety devices in dwellings, delivering home nursing services, and linking individuals with patient advocates. Of 523 elders, approximately half were assigned to one or more of these interventions, the other half to none of them. Both the experimentals and controls completed instruments designed to measure function and quality 192

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of life. Measurement of these variables was again taken after three years and the two groups compared. The Henry J. Kaiser Family Foundation Community Health Promotion Program, one of the most extensive multisite community interventions ever conducted, applied an expertly planned rct evaluation approach. Entire communities were randomly designated as experimental and control groups. Outcomes were measured over a period of six years in both the experimental and control communities and comparisons made. An elaborate procedure was used to carry out assignment of some communities as experimentals and others as controls. As indicated above, 11 communities were eventually designated as “intervention” sites (Wagner et al. 1991). These communities received funding under the program for the purpose of developing and carrying out health promotion procedures focused on speciﬁc health risks. Of hundreds of communities that originally expressed interest in the program, 18 were eventually determined to potentially merit funding. Four applicants were determined to be especially meritorious and were awarded grants. The remaining 14 were believed to be equally likely to succeed in achieving the program’s objectives. Among the 14 “qualiﬁed” communities, 7 were randomly selected as intervention sites. The remaining 7 were designated as controls. The Kaiser Program’s random assignment of communities to experimental versus control groups directly parallels the randomization procedure in clinical trials. In the Kaiser Program evaluation, however, additional steps were taken to ensure that both the experimental and control pools in fact included communities that were comparable to each other. A special procedure was used to ensure that both the experimental and control groups included urban communities, communities located in suburban or rural areas, and Native American reservations. In addition to the seven randomly selected control sites, four control communities were selected from outside the pool of communities that had applied for funding and been deemed eligible. The evaluators felt these additional controls were necessary for Assessing Accomplishments

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representation of communities which may not have had the high levels of organization and resources likely to prevail among those submitting outstanding applications for funding under the Kaiser Program. Inclusion of the four additional control communities brought the total number of communities involved in the Kaiser Program evaluation to 22. Data collection for evaluation of the Kaiser Program was as innovative and elaborate as the experimental design. Both independently collected and available data were used, and successive observations were made using these data. Successive observations enabled the evaluators to make before-after comparisons as the program progressed. Multiple surveys, requiring repeated cycles of questioning in successive years, were carried out in all communities. Surveys were conducted in all 22 communities, for example, to assess levels of community activation. Community activation, reﬂecting areas such as strength of leadership and interagency collaboration in health promotion, was regarded as a key resource for achieving program goals. Surveys were conducted of both adults and young people to determine beliefs and behavior patterns pertinent to the health concerns of each community. In communities to which objective availability of tobacco, alcohol, and healthy diet were pertinent, the contents of grocery store shelves and the oﬀerings of restaurants were surveyed. In addition, the evaluators made extensive use of available data. Data collected such as vital statistics, hospitalizations, and behavioral risk survey ﬁndings from public agencies were used to track incidence of disease and changes in mortality rates before and after the program began.

Dose-Response Studies

Dose-response studies are most familiar in biomedical science, where they are used to test new medications, but they are useful in program

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evaluation as well. The dose-response method makes comparing experimental with control groups unnecessary. Evaluation of a tobacco program directed at youths in the 1990s illustrates use of the dose response method. The program was known as “Youth Takin’ On Tobacco” (Greenwald et al. under review). Conducted in California under state funding, the program southt to build coalitions of youths who, with a high degree of independence, would formulate educational programs designed to prevent their peers from beginning use of tobacco. It was hoped that membership in the coalition itself would reinforce the commitment of participants to refrain from tobacco use. Participation in the groups or activities that emerged from them was voluntary, so young people could not be compelled to participate or not to participate. Borrowing from the biomedical sciences, the evaluators considered the number of times a youth attended a meeting or function to constitute a “dose” of the program’s inﬂuence. The evaluators determined the number of meetings and functions each youth had attended and assessed the relationship between these totals and the youth’s later thinking and behavior regarding tobacco.

Observational Studies

The study described in chapter 6, which assessed outcomes of the Mutual Partnerships Coalition (mpc), conforms to the basic features of case-control studies in biomedical sciences. The evaluators were unable to assign some elders to the intervention and others to a placebo situation, but at the conclusion of the program, the evaluators obtained a list of individuals who had not participated. They sought out people with characteristics similar to the program participants by surveying housing facilities in which the participants lived. In analyzing data from the surveys, the evaluators attempted to compensate statistically for diﬀerences in personal characteristics

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of those who had participated in the program and those who had not.

Quasi-Experimental Design

Quasi-experimental designs are widely used in program evaluation, compensating for the fact that evaluation researchers cannot normally assign people to experimental versus control groups. In using a quasi-experimental design, an evaluator selects control groups that he or she knows are likely to diﬀer from those exposed to the intervention. Evaluation of the 1 Percent or Less Campaign, detailed in chapter 2, represents an example of a quasi-experimental design. Before publicity for the campaign was released, evaluators conducted surveys in the community to be exposed and a nearby comparison community. The surveys focused on milk-drinking habits and personal characteristics of respondents. After the campaign, individuals in both communities were again surveyed and changes in milk-buying and consumption patterns compared. The evaluators tested the expectation that more change in the hoped-for direction (consumption of low-fat rather than regular milk) would be observed in the community exposed to the intervention (Reger, Wootan, and Booth-Butterﬁeld 1998). Another procedure used by evaluators of the 1 Percent or Less Campaign utilized records obtained from grocery stores of milk sales, separately reporting sales of low fat and regular milk. This represents use of an unobtrusive measure of program outcomes. Data on milk sales in the experimental and control community, before and after the publicity campaign, were compared, as were data obtained from the surveys. The carteens project, also described in chapter 2, is also quasiexperimental in nature. Surveys were conducted of participants before and after they were exposed to the intervention. In contrast to

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the nonequivalent control group used in the 1 Percent or Less Campaign evaluation, the evaluation in carteens dispenses with use of control groups altogether.

Case Studies

As its title indicates, the investigation of mpc’s implementation summarized in chapter 5 constitutes an example of a case study. Evaluators “lived with” the project, took notes at meetings and other events, interviewed participants, held focus groups, summarized conversations, and studied documents. Findings were based on a mental synthesis of all these data. No attempt was made to quantify the observations made. Of the case studies discussed earlier in this chapter, the one summarized in chapter 5 (mpc) should be considered an interpretive case study. Throughout the observation period, the evaluators were guided by theories and concepts about human organization and conﬂict resolution. These theories and concepts focused the evaluators’ attention on speciﬁc events and issues. Development of mpc and ensuing conﬂicts were then interpreted in terms of organizational culture.

L I M I TAT I O N S O F E VA L U AT I O N T E C H N I Q U E S

This chapter began with observations regarding human values and potential conﬂict associated with evaluation. The chapter’s substance has concentrated on prevailing practice in program evaluation. To suppose that diﬃculties facing evaluators arise only from human disagreement would be a mistake. All of the technical approaches to evaluation discussed here have limitations, either logically identiﬁable or readily perceived in use. Review of the major techniques covered here illustrates expectable limitations in evaluation designs.

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Randomized Controlled Trials

Although the gold standard in biomedical research, rtcs are almost impossible to utilize for evaluating community programs. Biomedical researchers typically have the power to assign people randomly to various treatment groups, but people cannot be randomly assigned to diﬀerent neighborhoods, school systems, or work organizations. When properly designed, rtcs oﬀer researchers a means of arguing that favorable outcomes are attributable to the intervention. Detection of outcomes, however, represents a challenge to the rtc. Reliable measures of the desired outcomes must be available. In addition, the trial must continue long enough for the expected eﬀect to become apparent. Finally, the ﬁnancial resources required for such designs are rarely available. Even when such resources are available, community coalitions have diﬃculty justifying their expenditure in resource-constrained situations.

Quasi-Experimental Designs

Quasi-experimental designs appear to oﬀer a reasonable alternative to rcts, but this type of evaluation method faces challenges of its own. First, identifying an appropriate control community against which to compare an intervention community is diﬃcult. Diﬀerences appear likely between an intervention community and any nonequivalent control. Researchers can never be sure about the respects in which an intervention and control community may in fact diﬀer, even if no diﬀerences are visible. The validity of quasi-experimental designs is subject to several sources of compromise. First, conditions in the environment may be responsible for any favorable outcomes that are observed. Apparent success in a smoking cessation program may be due not to the intervention applied, but to growing consciousness on the part of people everywhere that smoking represents a health hazard. It can 198

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be argued, furthermore, that both an individual community’s intervention and the conditions prevailing within that community are unique; no comparison between two communities would be valid if this were true. Like rcts, quasi-experimental methods may suﬀer from limitations due to measurement. An evaluation design cannot produce useful information unless it is accompanied by accurate measurement of outcomes. The more complex the outcomes desired in an interventions are, the more diﬃcult they are to measure.

Case Studies

Although case studies have an honored place in the world of research and evaluation, producing unchallenged results using this technique is diﬃcult. Most case studies are of the impressionistic variety, lacking deﬁnite data collection protocols and outcome measures. Memorable case studies have appeared over the years, as talented observers have returned from the ﬁeld with convincing stories. While illustrating important features of life in the community, however, stories represent the experience of only one observer. Another observer might return from the ﬁeld with quite a diﬀerent story. Material from case studies is nearly impossible to replicate. Authorities on evaluation and research methods question the reliability of case studies. That is, they raise doubts about whether diﬀerent case study researchers may reach the same conclusions or whether an individual investigator would obtain the same ﬁndings upon repeated observations of the same community.

Nontechnical Challenges

Over and above the technical problems with any evaluation design, people involved in community-based interventions are unlikely to consent to being passive “subjects.” The rationale behind Assessing Accomplishments

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community-based programs is, after all, active participation in planning and learning from evaluation activities. Without suﬃcient collaboration, no true evaluation is possible. Under these conditions, staﬀ will be reluctant to share information about challenges. Community residents will not come forward. Documents will prove diﬃcult to obtain. To carry out successful evaluation of community programs, evaluators must deal with technical issues in an eclectic and creative manner. They must pick and choose among available sources of data and make the most of opportunities for comparison. Multiple techniques must be used to supplement and cross-check each other. This use of multiple techniques in an atmosphere of collaboration with program staﬀ and community residents ﬁts best with requirements for high-quality evaluation of community programs. This chapter concludes with an illustration of an evaluation eﬀort of this kind.

E VA L U AT I N G C O M M U N I T Y P R O G R A M S : A NEW BALANCE

Appropriate evaluation of collaborative community programs does not require invention of new techniques for gathering and analyzing information. Rather, evaluation of these programs produces best results through achieving an appropriate balance of several factors. The ﬁrst set of factors is technical in nature. Appropriate weight needs to be given to qualitative and quantitative techniques. The correct balance must be achieved regarding attention to process and outcomes, and among outcomes, to those that are short and long term in nature. An appropriate balance must be struck among the interests of program leaders, staﬀ providing services, community residents, and funding agencies. An atmosphere of openness and ﬂexibility must prevail. In addition, the design must be compatible with the program in scope, signiﬁcance, funding, and eﬀort. An evaluation eﬀort consciously committed to achieving this balance occurred in the Health Improvement Initiative (hii). This 200

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initiative embodies key features of the comprehensive, communitybased initiative that has become so important for promoting health and improving quality of life among America’s disadvantaged. Application of the methods adopted in an atmosphere of collaboration presented challenges likely to be widely experienced among evaluators. Evaluation of hii has been spearheaded by members of the evaluation team at the Group Health Community Foundation (ghcf) in Seattle and California. Among programs conducted recently, hii perhaps best exempliﬁes a trend toward open-ended, community-driven approaches in collaborative programs. A multisite program operating throughout California, hii’s principal funding supported nine highly independent community partnerships. These features make evaluation particularly diﬃcult. Key health outcomes to be measured are often unknown at the beginning of the initiative, complicating the establishment of baseline measures.

Technical Features of the Evaluation Logic Model Case Study

A logic model case study served as the technical core of the hii evaluation. As introduced above, the case study concept is widely familiar to social scientists and evaluation specialists. When properly conducted, case studies have the capacity to demonstrate relationships between interventions and outcomes in unique situations. Case studies have been known to be successful in complex demonstration projects and ﬁeld experiments. The most familiar case studies are descriptive in nature. These are familiar to every undergraduate who has taken an anthropology course in which the ways of aboriginal societies are described. Much of the case study–oriented work in the hii evaluation was descriptive. This activity had value to the funding agency for keeping track of health partnership developments and changing conditions within Assessing Accomplishments

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the community. Much of the hii evaluation’s work has focused on documenting health partnership implementation and activities as a series of descriptive case studies. hii lent itself to more analytical application of case study principles as well. Case studies can be used to build an argument for attribution. Case studies of this kind are sometimes called “analytical” or “logic model” case studies. In analytical or logic model case studies, observers compare observed events and their sequences with a previously developed logic model. The logic model is based on a theory or the principles of an intervention program. Actual events (content and sequence) are compared with the logic model. A close correspondence of observed with expected events constitutes substantiation of the theory or eﬃcacy of the program. In hii, the logic model used was known as the hii Theory of Action. The Theory of Action comprises a logical sequence of steps, beginning with initial funding and concluding with increased community health. Intermediate steps are postulated to include development of community action plans and systems change. Actual observation of development of action plans, followed by systems change, followed in turn by improvements in community health, would constitute evidence of the initiative’s success. Data and Instruments. Collection of information required to test the logic model in hii included both qualitative and quantitative procedures. Details of these procedures are speciﬁed elsewhere. Brieﬂy, they include: • Key informant interviews. The evaluation team contacted key informants via telephone and used structured protocols for interviewing. Informants included staﬀ employed by the health partnership, active and less active participants in activities of the partnerships, and members of local communities knowledgeable about local issues but not directly involved in the work of the partnerships.

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• Governance surveys. Self-administered survey instruments were distributed annually to health partnership members to assess partnership decision-making processes, staﬀ-member relations, growth in capacity, eﬀorts to achieve work plan objectives, and satisfaction with partnership activities and progress. • Weekly program logs. Logs were completed by the directors of individual health partnerships to document major events and activities, the number and type of direct prevention services provided to the target populations, additional resources the health partnership received, and technical assistance the partnership received or provided to others. • Progress reports. These reports, submitted to the funding agency semi-annually by the health partnerships, documented progress in implementing partnership work plans and progress in governance, systems change, population health measurement, and direct services. • Site visits and participant observation. Visits were conducted to develop a comprehensive understanding of the community context in which each health partnership operates and of coalition dynamics. In the site visits, evaluation team members use a structured protocol to interview the partnership project coordinators and other staﬀ. • Technical support surveys. Semi-annual telephone surveys were used to assess the satisfaction, utility, and perceived impact of the technical assistance provided by the funder to each partnership. Technical support was given in such areas as planning the partnership’s program, building communication skills, inﬂuencing policy, and conducting locally planned evaluation eﬀorts. • Polling data. Periodic telephone surveys were conducted on random samples of residents within each health partnership community. These surveys were conducted through collaborative eﬀorts of The Field Institute, Louis Harris and Associates, and the Center for Health Improvement,

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a health think tank in California. The instrument consists of closed-ended questions about local community health priorities, satisfaction with local eﬀorts to improve health, and satisfaction with health-related expenditures and the balance between spending on prevention issues versus chronic illness issues. • Secondary data. Secondary data were examined to assess long-term health outcomes. Sources included the California Behavioral Risk Factor Survey, the California Oﬃce of Statewide Health Planning and Development hospital discharge ﬁle, and selected vital statistics from the California’s birth and death master ﬁles. • Measurement of variables. While acknowledging that each health partnership had unique features, the research team devised scales to measure variables of importance within all partnerships. Scales devised include population health measurement and systems change. Each degree of the scales was matched with criteria applicable to a wide range of achievements within a health partnership. Ordinal in nature, the scales were not intended to be of suﬃcient precision to locate an individual partnership on a broad continuum. Successive degrees on the scales were intended to indicate whether a partnership had progressed beyond a starting point, to intermediate levels of achievement, or, ﬁnally, to a broadly deﬁned highend category. The highest category was conceived as a level that all partnerships might attain in time.

Participatory Orientation

Evaluation of hii emphasized a participatory orientation, ﬁrst, to obtain information of the breadth and detail required for the logic model case study evaluation design. Second, a participatory approach was needed to ensure that health partnership staﬀ and supporters would make concrete use of the evaluation ﬁndings. 204

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Collaboration of Evaluators and Health Partnerships

The evaluation team carried out several steps intended to reduce the distance between program implementers and evaluators and ensure that the activities of the evaluation team and the partnerships mere mutually supportive. Speciﬁc measures included: • Evaluation goal setting. On the most basic level, the evaluation team and the health partnerships collaborated in setting evaluation goals. All members of the evaluation team met with key staﬀ from all partnerships during the initiative’s ﬁrst weeks of operation. Personal relationships were formed and perspectives shared. • Evaluation question development. Health partnerships were involved in development of every data collection instrument. Development of the survey instruments for community-level polls constitutes a key example. The Field Institute and Louis Harris and Associates sought input from each partnership regarding questionnaire items of potential use to the partnership in its planning and self-evaluation. Another example included the governance survey. Partnership staﬀ was invited to help develop questions to ensure their usefulness to the partnerships. Partnerships were also invited to critique the weekly program logs. • Implementation. Health partnership involvement was most apparent in the implementation of the evaluation design. Partnerships implemented several of the data collection procedures. Partnership staﬀ, for example, distributed and collected the governance survey instruments. Partnership staﬀ were required to submit material for the weekly logs, a process the evaluation team supported by establishing an internet linkage for submission. The progress report routines were implemented entirely by the partnerships. Formats for questioning during the site visits were revised several times in response to partnership requests and in collaboration with the partnerships. Assessing Accomplishments

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• Analysis. Health partnerships were invited to help set objectives for analysis of many forms of data collected in the hii evaluation. One example includes the governance survey. Special reports were developed consistent with the partnerships’ interests. Reports from the polling activities were also produced to the partnerships’ speciﬁcations. The evaluation team conducted several analyses of secondary data at the request of partnerships. • Reporting. Members of the evaluation team continuously reported data and results of analysis back to the health partnerships. Members of the evaluation team, for example, made presentations on results from the governance and key informant surveys to partnership staﬀ and at full partnership meetings. This reporting was intended as formative feedback to the partnerships, aiming at facilitating their planning, implementation, and assessment of the outcomes of their work plans. • Building technical capacity. Building technical capacity constituted an important part of the collaborative structure of the evaluation. The evaluation team’s objectives included helping the partnerships become able to perform their own evaluations, a capacity which, it was hoped, would be maintained after the expiration of funding from hii. In pursuit of this objective, the evaluation held a series of technical workshops for partnership staﬀ, which reviewed techniques and features of their application within hii. Evaluation team members also helped increase evaluation capacity in one-on-one discussions with partnership staﬀ.

The Local Evaluator’s Role

Special mention needs to be made of a unique feature of hii intended to promote responsiveness of evaluators to local health partnership needs. Each health partnership received funding for the 206

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hiring of a local individual or ﬁrm to evaluate its work on the local level. The local evaluator worked under direct supervision of partnership staﬀ and responded directly to the partnership’s needs. The local evaluators met regularly with the ghcf evaluation team, sharing impressions and seeking ways in which they could collaborate to improve the evaluation overall.

PRACTICAL CHALLENGE

Several features of the hii evaluation proved feasible and eﬀective as approaches to the challenges posed by community-based interventions. The evaluation team, however, failed to anticipate several issues in implementing the evaluation strategy. The unexpectedly encountered challenges provide lessons for future evaluation eﬀorts. Major lessons learned in the process of ﬁeld work included the following: • Interest in evaluation varies among partnerships • Capacity for contributing to evaluation varies among communities • Fit of evaluation with operations is crucial

Interest in Evaluation Varies Among Partnerships

In the course of the evaluation, the evaluation team came to realize that interest in evaluation varied among partnerships. A few partnerships showed considerable interest in evaluation and were enthusiastic collaborators in devising evaluation questions and administering data collection instruments. Level of interest among the remaining partnerships varied from dutiful willingness to collaborate to ignoring requests for needed input and information. Among the partnerships that collaborated enthusiastically, a high level of understanding of evaluation appeared to prevail. Where low Assessing Accomplishments

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levels of enthusiasm were encountered, signiﬁcant cultural diﬀerences between operations and evaluation seemed to exist. Among personnel operating the interventions, understanding of the abstract language and objectives associated with evaluation was highly limited.

Capacity for Contributing to Evaluation Varies Among Communities

In the course of the evaluation, it became clear that the level of experience and expertise varied among communities. Some communities, having carried out previous interventions similar to hii, had developed evaluation data collection and evaluation expertise of their own. These communities often retained personnel with data collection and evaluation skills that were quite high. In other communities, such expertise was absent. Levels of expertise and experience often seemed to be reﬂected in the choice of a local evaluator. Some communities hired local evaluators who were clearly well-trained and spent enough time with the partnership to do an outstanding job. At the other end of the spectrum, one partnership hired a succession of evaluators in the early years of the initiative, never settling on a single contractor responsible for local evaluation.

Fit of Evaluation with Operations Is Crucial

The need to adjust collaborative evaluation requirements to existing community capacity became clear as the evaluation progressed. The evaluation team’s low level of success with one data collection instrument illustrates this principle. The weekly log of partnership activity was ultimately acknowledged to be a failure and was abandoned. Only two of the nine partnerships completed the logs in

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a complete and timely manner. At the other extreme, at least two partnerships were consistently several months behind in their reporting. The evaluation team acknowledged that the instrument poorly ﬁt the orientations and staﬀ capacities of most partnerships. Many did not have the time to report the required volume of data. In at least one case, a personal aversion to paperwork and reporting deterred the project director from ﬁlling out the logs. Problems of this nature persisted even after an Internet-based, user-friendly mechanism for reporting log data was developed and deployed.

LESSONS FROM THE FIELD

Although evaluation was still in progress when this chapter was written, it appeared at that time that the hii evaluation had achieved successes in some areas and encountered diﬃcult challenges in others.

Successes

Several of the evaluation team’s successes occurred in technical parts of the evaluation. Identiﬁcation of the logic model case study design and substantiation of its validity in the research literature provided an appropriate evaluation framework. Development of scales of population health measurement and systems change enabled the team to report on the intervention’s achievements yet not characterize any individual health partnership as unproductive. Successes in relationships with the health partnerships were also notable. The evaluation team established regular, reliable routines of communications with most if not all of the health partnerships. Most partnerships appear to have had conﬁdence in the evaluation team, viewing it as an ally and resource in accomplishing their

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objectives. In an eﬀort to serve these functions, the evaluation team revised procedures in response to health partnership comments and changing conditions. In an eﬀort to serve and be seen as a resource rather than a nuisance, the evaluation team provided regular feedback to the health partnership through a variety of mechanisms.

Challenges

Several challenges persisted throughout the evaluation eﬀort. Because the evaluation design focused on intermediate outcomes, for example, it was not possible to collect data of the outcomes of broadest importance: long-term health improvement. This was appropriate in view of the short time frame in which hii has operated. Ultimate health impact, however, is of greatest signiﬁcance for community residents. A second challenge resulted from the continuously changing nature of communities. Through the techniques utilized in the hii evaluation, evaluators cannot be assured of accurately measuring change. Observed changes may have taken place in the absence of the initiative, such as events occurring in the community which inﬂuence health in the direction opposite to that sough by the health partnership. In the latter case, the impact of the partnership may erroneously appear to be nonexistent. Any changes actually observed, moreover, are diﬃcult if not impossible to attribute to the initiative. Many social forces simultaneously aﬀect a community. An initiative such as hii is likely to be small in its inﬂuence compared with long-term social trends and historic forces. Today, communities often are the focus of initiatives from several diﬀerent foundations or agencies, compounding the diﬃculty of attributing observed change to any single, deliberate inﬂuence. Use of the case-study approach, while appropriate in the present context, nevertheless has drawbacks. The evaluation team conducted

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case studies of nine separate health partnerships. The team experienced considerable diﬃculty in determining how, and how extensively, to merge information about the diverse cases, a process required for assessing the impact of the initiative as a whole. Finally, the evaluation team encountered diﬃculties in providing health partnerships with the data they needed to plan and evaluate their own eﬀorts. This diﬃculty stemmed in part from the fact that data available from public sources are not the kind, or do not exist in a form, which is directly useful to individual communities. Data from the U.S. Census constitute an example. Community boundaries are not coterminous with those of census tracts. Thus, census and much public health data are applicable to a community only in an approximate fashion. The same is true of telephone exchange preﬁxes within which random telephone numbers are generated for survey research purposes.

E F F E C T I V E E VA L U AT I O N S T R AT E G I E S

Several formal lessons may be learned from the principles and cases cited in this chapter. These lessons are summarized in chapter 8. Generally, however, evaluators of community programs must select wisely among research techniques available from the biomedical and social sciences. A mix of techniques appears most likely to capture program accomplishments. Nothing may better illustrate this point than the Health Improvement Initiative evaluation, which utilized techniques as informal as observation of meeting and service delivery, and as conventional as analysis of survey and census data. Perhaps most important, it should be emphasized that no large-scale evaluation can be conducted without collaboration from local program leadership and staﬀ. The best way to ensure this collaboration is to (1) use evaluation procedures to produce ﬁndings pertinent to local program planning and operations, and (2) provide timely and relevant feedback to the local program.

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Finally, it is important to acknowledge the limitations of evaluation when applied to collaborative community programs. Evaluation eﬀorts have obtained evidence of measurable health outcomes in few if any of the programs and initiatives cited in this and earlier chapters. It is possible that the problems community programs address are too long-standing or complex to be solved in the time these interventions typically last. Alternatively, the evaluation ﬁeld is yet to develop suﬃciently sensitive procedures and measures. At this time, evaluation may contribute most to documenting the implementation of programs with recognized long-term promise and providing program leaders and staﬀ with feedback applicable to their practical tasks.

REFERENCES Berkman, L. F. 1978. “Social Networks, Host Resistance, and Mortality: A Followup Study of Alameda County Residents.” Unpublished doctoral dissertation, University of California, Berkeley. Berkman, L. F., and L. Syme. 1979. “Social Networks, Host Resistance, and Mortality: A Nine-Year Follow-up Study of Alameda County Residents.” American Journal of Epidemiology 109: 186–204. Clarke, M., J. S. Clarke, and C. Jagger. 1992. “Social Interventions and the Elderly: A Randomized Controlled Trial.” American Journal of Epidemiology 136: 1517–23. Greenwald, H. P., S. Senter, D. Pearson, et al. “Youth Development and Tobacco Avoidance: Measures and E=ects.” Under review. MacMahon, B. S., et al. 1981. “Co=ee and Cancer of the Pancreas.” New England Journal of Medicine 304: 630–33. Moynihan, D. P. 1996. “Congress Builds Itself a Co;n.” New York Review of Books, January 11, pp. 33–36. Reger, B., M. G. Wootan, and S. Booth-Butterfield. 1998. “1% Or Less: A Community-based Nutrition Campaign.” Public Health Reports 113: 410–19. Wagner, E. H., T. D. Koepsell, C. Anderman, et al. 1991. “The Evaluation of the Henry J. Kaiser Family Foundation’s Community Health Promotion Grant Program: Design.” Journal of Clinical Epidemiology 44: 685–99.

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CHAPTER 8

Collaborative Intervention: Challenges and Triumphs

T H E E X P E R I E N C E O F C O L L A B O R AT I O N : A R E - E X A M I N AT I O N

Over the last two decades, collaborative techniques received increasing attention as approaches to improving health and quality of life in American communities. This is not unique to the health ﬁeld. As noted in chapter 1, collaborative techniques have been used to facilitate community policing and to help determine the utilization of public lands. The collaborative approach may date back to agricultural extension service activity by state universities, which used farmers’ groups as a venue for promoting adoption of hybrid seed corn. This chapter reviews material covered in the preceding chapters for the purpose of answering the following questions: • What goals can reasonably be pursued through collaborative community interventions? • Within communities, what capacities must be recognized and what limitations must be acknowledged? • When a collaborative strategy is adopted, what practical considerations must be applied in its implementation?

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• What errors should providers avoid in considering collaborative strategies, working with communities, or seeking resources? • What triumphs have collaborative community interventions achieved that are worthy of wide emulation? Generally, the collaborative community intervention model draws its strength from two sources. First, the concept is consistent with basic psychological principles. It is easiest to obtain the assistance of others in a project if they are directly involved in decision making. Similarly, an individual’s behavior is most readily changed by exposing him or her to a consensus of thinking among his or her peers. Second, the collaborative community interventions are compatible with the values of American democracy, which mandate involvement of people in the decisions that shape their lives and celebrate local community initiative and participation. In observing community collaboration, however, challenges and potential limitations emerge which cannot be ignored. Hoped-for outcomes in collaborative community interventions have seldom been clearly demonstrated. Of the programs reviewed in chapter 2, most appear to have resulted in activity of a desirable kind: coalitions have been established, meetings held, and services provided. But in most of the truly collaborative programs, no evidence is presented that improved community health has resulted from the interventions. The most concrete results, in fact, are visible in the more traditional programs. Consumers in Wheeling, West Virginia, are more likely to drink nonfat milk because of the public education campaign. Evidence was gathered during Project Immunize Virginia (piv) indicating that youths in Virginia are more likely to be vaccinated for inﬂuenza and hepatitis b after than before the intervention of piv. Still, no strong argument can be made that the intervention was responsible for this outcome. The less traditional programs—those marked by strong collaboration and broadly deﬁned goals—can be credited with some notable achievements. Bethel New Life can claim impressive 214

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accomplishments. Skeptics might argue that the job training and placement the program has carried out has not dented the long-term unemployment rate among minorities on Chicago’s South Side. At the very least, however, Bethel New Life serves as a symbol of hope and civic pride to many. The Mutual Partnership Coalition’s numerous interventions did not result in measurable health improvement, but at least a few of the elders reached by the program received encouragement to attend group activity, perhaps improving the quality of life for some of them. Still, some of the most extensive programs designed to foster collaborative community intervention have produced scant outcomes. The Kaiser Family Foundation Community Health Promotion Grants Program (chpgp), described in chapter 2, operated for the better part of a decade and cost many millions of dollars. E. H. Wagner, T. M. Wickizer, and their colleagues (Wagner et al. 2000) evaluated the program using perhaps the most sophisticated techniques ever applied to collaborative community interventions. They could only conclude: “The chpgp, like other prominent community-based initiatives, generally failed to produce measurable change in targeted health outcomes.” The inability of evaluators to detect measurable outcomes in collaborative community interventions may not be due to true absence of signiﬁcant results. Diﬀuse results of comprehensive interventions are simply diﬃcult to measure. Observers have correctly noted that improvement of community health in troubled neighborhoods should not be expected in the short term. Consequently, evaluation should focus on implementation of a program (development of the coalition, identiﬁcation of goals, etc.) rather than ﬁnal outcomes. The logic of this approach, however, will leave the skeptic unconvinced. Signiﬁcant faith is required to make the connection between a program’s implementation and possible future outcomes. A second series of challenges concerns implementation and operation of collaborative community programs. These programs require expenditure of signiﬁcant time, eﬀort, and patience to bring them into operation. In all true collaborative ventures, people unfamiliar Collaborative Intervention

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with each other must learn to work together. They must overcome often long-term histories of suspicion and competition. The requirement that people from mainstream organizations work as equals with community-based organization (cbo) personnel and that people from diﬀerent ethnic and socioeconomic backgrounds must learn to work together creates challenges that must be overcome. In collaborative eﬀorts with comprehensive goals, no interventions can be formulated before concrete objectives are determined. Often, this task constitutes one of the most delicate and time-consuming tasks faced by a coalition. The risk of conﬂict is by nature present in collaborative community interventions. The example provided in chapter 5 in the Mutual Partnerships Coalition may appear extreme. Doubtlessly, the personality clashes occurred because of the participating individuals themselves, but basic features of the collaborative community intervention make it prone to conﬂict. The need of mutually unfamiliar individuals to work together can create discomfort. Diﬀering outlooks and cultures contribute to conﬂict and make its resolution more diﬃcult. The newness of organizations carrying out collaborative community interventions fosters confusion over individual responsibilities and roles. The indeﬁniteness of objectives makes evaluation of individual performance diﬃcult. Disputes over resources inﬂame human relationships, particularly in instances where aims and commitments exceed—as they do in many collaborative community interventions—the money and time available. The preceding chapters have reviewed the concepts and convictions surrounding collaborative community interventions, providing an overview of typical collaborative interventions and, in one instance, an in-depth analysis. The book has recapitulated standard and nonstandard techniques for evaluating collaborative community interventions. In sum, this material supports four conclusions: 1. Although compelling for their potential, collaborative community interventions require signiﬁcant time and other resources to implement. 216

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2. Because of the newness of organizations carrying out collaborative interventions, mutual unfamiliarity of participants, and diﬀerences in the background and culture of personnel, collaborative community interventions may become prone to conﬂict and other management problems. 3. Collaborative community interventions, particularly those that adopt comprehensive aims, tend not to produce measurable outcomes. 4. Organizations, individuals, and grantmakers should initiate and support collaborative community interventions only if (a) they can accept the need for long and resource-intensive startup periods, (b) they believe that intermediate achievements likely to be observable within a few years will eventually produce desired ﬁnal outcomes, and (c) they are willing to work with people whose experiences and ideas about society may diﬀer from their own. The remainder of this chapter concentrates on speciﬁc principles valuable in promoting success in initiating, operating, and assessing collaborative community interventions.

PRINCIPLES FOR SUCCESSFUL PROGRAMS Apply Reasonable Expectations

Too often, communities engaging in collaborative interventions encounter expectations that are unreasonable. Participants in the programs often believe that major changes in the community, if not society itself, will result from the enterprise. Foundations and other funding partners charge collaboratives with transforming entities as signiﬁcant as decision-making processes in cities, delivery of healthcare, and norms of behavior. It is important to remember, however, that the assignments given (and accepted) by community programs often reﬂect problems that Collaborative Intervention

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have stood unsolved within the larger society for generations. Community residents have lived for a century under governments that have given them only small consideration. Habits that are hazardous to health have found acceptance if not encouragement in society for hundreds of years: tobacco is the prime example. Some of the most powerful interests in the United States, including President Bill Clinton, have tried to change the healthcare system. Success in meeting these challenges has been evasive. Often, it seems that collaborative community interventions are expected to solve problems that the United States has tried for generations to solve, and repeatedly failed in the attempt. Although sometimes well funded, community interventions by no means command the resources of a major executive agency in federal or state government. Seriously expecting any single collaborative community intervention to remedy major social or economic problems in its locale—and particularly within a few years’ time—amounts to setting a community up for failure.

Accept Di=erences in Readiness

Communities diﬀer in their readiness for carrying out collaborative programs. Some communities enjoy high levels of social capital and consensus. Others lack strong traditions of community organization, meeting attendance, and mutual assistance. Of more direct relevance, cbos, which are often the lead agencies in collaborative community interventions, diﬀer among each other in their readiness for implementing and managing an intervention. Some cbos are well established in their communities, such as churches, clinics, and social service agencies that have operated for generations. Others may be of recent vintage, reﬂecting migration of new groups into a neighborhood or newly emerging concerns. Still others may form in response to availability of public support or foundation funds.

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In none of these cases are cbos likely to have more than adequate in-house resources. Community organizations are likely to be understaﬀed. Among staﬀ members, individuals may be unfamiliar with routine oﬃce procedures like business letter writing and computer operation. Principles of ﬁscal management may be poorly understood. Communities at every stage of development deserve support. Observers and participants in collaborations, however, should recognize that expectations regarding outcomes should diﬀer among communities. In some communities, establishment of a single, recognized, and self-sustaining cbo may be a worthwhile objective for a collaboration. In other communities, operation of a childcare center, running a senior center, or articulating a neighborhood policy agenda should be recognized as constituting continuation of routine activities and established traditions. Although establishment of a cbo, community service center, or network of ties among residents may seem insigniﬁcant, it can be quite important given a community’s level of readiness. Collaborations in which the participants have not traditionally engaged in common enterprises may be in a low state of readiness for commencing operations. The experience of a Washington State program aimed at comprehensive community health promotion provides an example. Under this program, two central city neighborhoods and an Indian reservation were linked in one collaborative structure. Articulation of common objectives was not achieved during the course of the project. Receipt of funds from the supporting foundation proved divisive, giving rise to intense competition over pieces of the pie.

Long-Term, Abstract Goals Are Often Counterproductive

Collaborative interventions beneﬁt from articulation of longterm goals; these may be considered, in fact, essential for strategic

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planning and organization. Still, abstract terminology tends to alienate community members. Program planners are often attracted to words and phrases such as “social capital” and “structural change.” The word “policy” seems to be one of the most popular in program communications. But these terms are meaningless to people who are not professional academics or grantsmen and -women. Use of these terms places program managers apart from community members who often face serious challenges in their day-to-day lives. Their attention is captured by concrete plans for progress: improving police protection, cleaning up graﬃti, ﬁxing a pothole. Abstract ideas certainly have their place. It makes sense to argue that every collaborative community program should have a “theory of action.” As discussed in chapter 7, a theory of action comprises series of postulated steps leading from components in program intervention to achievement of outcomes. Thus, the collaboration should be planned around a “logic model,” which speciﬁes a problem, a rationale for intervention, steps in an intervention, contributors to the intervention, intermediate outcomes, and ﬁnal outcomes. Community members are likely to pay most attention to the steps in the intervention and intermediate outcomes. This line of reasoning should not be interpreted to indicate that community members are simply less sophisticated than academics or project professionals. Communities, particularly disadvantaged ones, have been approached with promising ideas, catchwords, and slogans for generations. Even if not conventionally articulate, people in communities exercise a healthy skepticism surrounding such abstractions. Concepts in an intervention logic model become meaningful when connected with concrete achievements that improve the lives of community members. Inﬂuence on policy may have the most important impact on quality of life in the community, but concrete action alone lays the groundwork for the widespread involvement of community members in policy debate and agitation.

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Resident Involvement Should Be Real

Most collaborative community interventions place emphasis on involvement of community residents. Such involvement is a key criterion for establishment of a program in which citizen control prevails. As noted earlier, the philosophy behind community collaboration is one of participatory democracy. Traditional programs, such as those identiﬁed in chapter 2 as therapy or informing, attempt to aid the community in a top-down fashion. Interventions that, according to this schema, amount to manipulation or placation seek to use the community for outside purposes or to remove the community from active participation in events and deliberations that shape its future. True resident involvement constitutes the greatest challenge for many collaborative interventions. Of the programs summarized in chapter 2, only Bethel New Life appears to come close to true citizen control. Church members provided broad-based support for the program from its very beginning. The degree to which decision making in the fully developed program involves “ordinary” citizens—those for whom politics and program operations is not a fulltime job—is not known. Most programs in fact operate on a partnership basis. They are collaborative in that several diﬀerent organizations sit on a governing board, contribute to the program’s operations and decision making, and give or receive assets from it. Individual members of the community are believed to be represented in this manner. Moving to citizen control represents a major step. Conscientious eﬀorts to make this happen have been frustrated in several collaborative interventions. Conditions of daily life in the community can constitute barriers to resident participation, as people devote their attention to personal, day-to-day concerns. The Mutual Partnerships Coalition provides an illustration of challenges to resident participation in governance. The project was strongly committed to involvement of residents. Of particular

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relevance was participation by young people and elders, reﬂecting the project’s focus. A succession of young and elderly individuals was in fact recruited for membership on the project’s governing board. Young people, however, found board meetings boring, ﬁlled as they were with discussion of budgets, personnel issues, procedures, and forms. The youths, moreover, had diﬃculty attending meetings because of school responsibilities. Some of the very hazards the program was designed to address interfered with resident participation on the board. At least one elder suﬀered from severe diabetes and had trouble traveling to meetings. One of the youths became pregnant, which ended her participation. Community interventions might seek to formulate methods of involving residents other than having them sit on governing boards. Youths might be invited to participate in groups of their own age to formulate interventions and make suggestions. This procedure was used in a California tobacco-control program, in which young people were recruited into peer groups for planning, and later carried out the interventions they had devised. Similarly, elders might be asked to join senior caucuses meeting at places convenient to them and charged with generating input on issues concretely meaningful to their age group.

Interventions Must Be Appropriately Sta=ed

Few community collaborative interventions have staﬃng comparable to that of mainstream institutions such as public health departments or businesses. Inadequate staﬀ prevents programs from achieving their potential. Issues regarding staﬀ training and capabilities have been identiﬁed above. The simple presence of paid staﬀ, however, is a more basic consideration. A common denominator of all the programs outlined in chapter 2 has been the presence of paid staﬀ.

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Although valuable, volunteers do not compensate for the absence of core, paid staﬀ. Even the most dedicated volunteers now and then ﬁnds himself or herself drawn away by personal needs. Paid staﬀ are more likely to make the program their top priority. It has often been said that the management of volunteers requires the presence of a paid staﬀer. Volunteers must be scheduled, instructed, and made to feel that their services are important and appreciated. The challenges facing collaborative community interventions are diﬃcult ones. People who dedicate years of their lives to making these programs successful deserve payment as deﬁnitely as do professionals and businesspeople who often carry out much more routine functions. Paid staﬀ, moreover, have a natural motivation to build programs that are self-sustaining. Collaborative interventions often live from grant to grant, contract to contract. A paid staﬀer’s job depends on the continual receipt of new funding. Thus, the presence of paid staﬀ promotes a conscientious, sustained focus on identifying and pursuing new material resources.

BASIC DILEMMAS FOR PROGRAMS

Collaborative community interventions are resource-intensive ventures. Community members devote time. Organizations lend staﬀ. Foundations and government agencies provide funds. For all these contributors, many alternative needs vie for attention. In determining whether to support a collaborative community intervention, questions must be asked regarding balance in three areas.

Established Versus Emergent Agency

Many diﬀerent entities can serve as the lead agency in a collaborative community program. Funders and others providing support must determine whether it is better to work with an established

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agency or a newly emerging cbo-type entity. The new cbo is likely to have fresh ideas. The interventions it mounts are likely to be innovative. The older agency, however, is likely to be more stable. Its staﬀ is better able to resolve personnel problems and keep ﬁnancial and other records. Organizationally, it is less likely to suﬀer from the pathologies described in the discussion of the Mutual Partnerships Coalition. A strong argument can be made that the best choice is a newer agency, with its mandates and leadership still in ﬂux, but with a suﬃcient track record to ensure adequate focus and management.

Theory Versus Practice

Agencies taking the lead in collaborative community intervention may tend to emphasize long-term, abstract goals; others may place emphasis on concrete and immediate purpose. Vision is an essential feature of a successful collaboration. But, as discussed above, too much emphasis on abstract concepts and distant goals alienate the community. The course most likely to result in success strikes a balance between the ultimate dream and day-to-day advances.

Categorical Versus Comprehensive Interventions

Finally, a trend has taken place in recent years toward collaborative community interventions that are comprehensive in nature. Categorical programs dominated collaborative community interventions in their early days. Programs such as these formulated objectives regarding a single health risk, such as heart disease or diabetes. Today, the programs that attract the most interest seem to be those with the most general focus. Communities are given resources and instructed to formulate their own objectives and strategies.

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The review of programs presented in chapter 2, however, suggests that the programs with the most speciﬁc aims provide the clearest evidence of favorable outcomes. Increases in vaccination rates and reductions in consumption of whole milk are easier to measure than structural change. Nevertheless, the concept of community health is consistent with broad goals. The program most likely to achieve both measurable and meaningful success appears to be one with a balance between concrete, focused objectives and longer-term, general goals.

AN UNEXPECTED SUCCESS

This chapter, and perhaps this book as a whole, has focused on challenges to the success of collaborative community interventions. Much has been made of lack of adequate staﬀ, appropriate measures of success, and stability of organization. All in all, measurable outcomes of collaborative community interventions, particularly when large-scale and comprehensive in nature, must be considered scant. But collaborative community programs have the ability to surprise the “experts.” Successes occur of a kind only capable of being achieved by communities. Ultimately, the mixing of established and unconventional thinking creates value that justiﬁes the expenditure of resources in the programs that are the subject of this book. An example of this kind was provided by an Indian tribe that participated in one of the comprehensive health promotion initiatives described here. A coastal people, the tribe’s lore harked back to times a century earlier when brave people set forth in sea-going canoes to ﬁsh and to engage in sporting competition. At the end of a bitter dispute over division of funds, the tribe obtained money to build replicas of the boats used by their forefathers and a shed for storage of the craft. At ﬁrst the venture met with skepticism and occasional ridicule. What relevance did the canoes have to health promotion? Shortly,

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however, the tribe’s wisdom became apparent. As boatbuilding proceeded, rowing competitions sprang up among the youth. Annual “canoe-pulling” events became enthusiastically anticipated festivals. Championship in the competitions was coveted. In the language of public health, the tribe’s young men had been at elevated risk of illness. Tobacco and alcohol use was widespread. Sedentary lifestyle prevailed. At least for some, canoe-pulling worked a transformation. Young people in training realized that success required leading a healthy life. The tribe had achieved eﬀective health promotion while celebrating its cultural heritage. Just as canoe-pullers work together to propel their racing vessels, organizations, groups, and individuals everywhere should recognize that they, too, can advance the vehicle which has brought prosperity, fulﬁllment, and safety to human beings through the ages: the community.

REFERENCE Wagner, E. H., T. M. Wickizer, A. Cheadle, et al. 2000. “The Kaiser Family Foundation Community Health Promotion Grants Program: Findings from an Outcome Evaluation.” Health Services Research 35: 561–89.

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APPENDIX A

Resources to Help Implement and Evaluate Community Partnerships

TOOL KITS/MANUALS:

Assessment Protocol for Excellence in Public Health (APEXPH) (1991, updated in 1998) The Assessment Protocol for Excellence in Public Health (APEXPH) project, funded by a cooperative agreement from the Centers for Disease Control and Prevention (CDC) to the National Association for County and City Public Health Oﬃcials (NACCHO), was developed to be used voluntarily by local health oﬃcials to assess the organization and management of the health department, provide a framework for working with community members and other organizations in assessing the health status of the community, and establish the leadership role of the health department in the community. The APEXPH workbook guides health oﬃcials in three areas: • Part I: Organizational Capacity Assessment is an internal self-assessment process designed to aid local health departments in assessing and improving their organizational capacity. • Part II: The Community Process assists an organization in working with the community to identify health problems of greatest concern, set health status goals and programmatic objectives, and identify community resources that can be utilized in meeting these objectives. • Part III: Completing the Cycle provides a framework to ensure that the Organizational Action Plan and the Community Health Plan developed in Parts I and II are eﬀectively carried out and evaluated. Part III also

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includes a discussion of the policy development and assurance functions of a local health department and its policy board. Resources have been developed to assist APEXPH users in their implementation of the process. These resources include: • • • • • •

APEXPH Workbook APEXPH in Practice: A Supplement to the APEXPH Workbook APEXPH Part I Worksheets on disk APEXPH Part II Worksheets on disk, and the APEXPH Slide Show (31 slides with a corresponding script) APEXPH ’98, Software for the APEXPH Process

For more information, contact by e-mail at [email protected], or see the web site, www.naccho.org/tools.cfm. Also see MAPP, Mobilizing for Action through Planning and Partnerships (2000) Built on lessons learned from NACCHO’s Assessment Protocol for Excellence in Public Health (APEXPH), MAPP is a community wide strategic planning tool for improving community health. Facilitated by public health leadership, this tool assists communities in prioritizing public health issues and identifying resources for addressing them. Each section of the MAPP tool includes: overview and guidance, tools, case vignettes, and references and resources. For more information, contact National Association of County and City Health Oﬃcials (NACCHO), www.naccho.org/tools.cfm. The Community Partnership Tool Kit This is an online tool kit developed by the W. K. Kellogg Foundation for building and maintaining partnerships to strengthen communities. The tool kit is available at www.wkkf.org/Documents/cct/secd/cptoolkit. Collaboration Handbook: Creating, Sustaining, and Enjoying the Journey Michael Winer and Karen Ray. A guide to putting together a collaboration: how to initiate a collaboration, deﬁne the results, determine individuals roles, create an action plan, and evaluate results. Includes a case study, worksheets, and special sidebars with tips such as what to do at your ﬁrst meeting. For more information, contact The Wilder Foundation, www.wilder.org/pubs /index.html#Collaboration.

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Collaboration. What Makes It Work (2000) Paul Mattessich, Ph.D., Marta Murray-Close, B.A., and Barbara Monsey, M.P.H. Addresses what makes the diﬀerence between a collaboration’s failure or success with an up-to-date and in-depth review of collaboration research. The new edition also includes The Wilder Collaboration Factors Inventory. For more information, contact The Wilder Foundation, www.wilder .org/pubs/index.html#Collaboration. Community Building: Coming of Age James O. Gibson, Thomas Kingsley, and Joseph B. McNeely. Community building diﬀers from the narrow neighborhood-based programs of the past. This book explains how and why this change has occurred and what is needed to make community building successful today. The book takes an in-depth look at seven themes of today’s community building and why they are important. It also includes ﬁve case studies and other examples. For more information, contact The Wilder Foundation, www.wilder.org/pubs/index.html #Collaboration. Community Building: What Makes It Work (1997) Paul Mattessich, Ph.D., and Barbara Monsey, M.P.H. Examines 28 factors inﬂuencing the success of community building initiatives. This book oﬀers a synthesis of the ﬁndings of numerous studies on community building. Each of the 28 factors includes a description, examples, and practical applications to help community builders assess their work and diagnose what is needed. The book also contains a glossary of community building terms, a list of resources and technical support for community builders, and a bibliography listing over 75 studies. For more information, contact The Wilder Foundation, www.wilder.org/pubs/index.html#Collaboration. The Community Tool Box An online tool kit to guide community building eﬀorts. Key modules include: • Understanding Community Context (e.g., assessing community assets and needs) • Collaborative Planning (e.g., developing a vision, mission, objectives, strategies, and action plans) • Developing Leadership and Enhancing Participation (e.g., building relationships, recruiting participants)

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• Community Action and Intervention (e.g., designing interventions, advocacy) • Evaluating Community Initiatives (e.g., program evaluation, documentation of community and systems change) • Promoting and Sustaining the Initiative (e.g., social marketing, obtaining grants) The tool kit was developed by researchers at the University of Kansas and is currently supported by grants from the Robert Wood Johnson Foundation, the John D. and Catherine T. MacArthur Foundation, the Kansas Health Foundation and the Work Group on Health Promotion and Community Development, University of Kansas. It can be found at http://ctb.lsi .ukans.edu. The Compass Framework An assessment, planning, and evaluation tool developed by AtKisson + Associates, Inc. The tool starts with a symbol of a compass to help clarify goals and objectives. The system converts the four compass points—N, E, S, W— into the four elements of sustainability: nature, the economy, society, and human well-being. This framework helps select indicators of success for a city, a region, a community, or an enterprise. After indicators are selected and researched, the system helps develop a consensus-based performance scale (100 = “sustainability,” 0 = “unsustainable or unacceptable”). The compass helps communities see where they are and where they are going. To view an example of a report see: The Legacy Report, produced by the Healthy Communities Initiative of Orlando, Florida (www.hciﬂorida.org/HCI%20LYout.pdf ). For more information, contact AtKisson + Associates, [email protected] or at www.atkisson.com. Facilitating Community Change A step-by-step resource for community members and leaders designing, organizing and implementing community partnerships. Includes tools, resources and approaches based on lessons emerging from the healthy communities movement. It oﬀers an approach to harnessing the values, assets, and aspirations of a community. This guide provides a summary of “what works,” based on extensive real-life experience with dozens of communities throughout the world. The guide contains sections covering:

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• • • • • •

Assessing the readiness of the community Preparing and energizing leadership Groundwork Mobilizing and activating the community Focusing and thinking outside of the box Implementing and maintaining change

For more information, contact Community Initiatives, Inc at www.communityinitiatives.com. EMPOWER: Enabling Methods of Planning and Organizing Within Everyone’s Reach (1998) Robert S. Gold and Lawrence W. Green ($39.95). EMPOWER is a computerized software program tailored to assist health educators teaching community health courses and practitioners in their eﬀorts to plan and implement community health programs. Using a knowledge base from experts in health promotion planning and mammography screening, and the PRECEEDPROCEDE process of planning, EMPOWER illustrates how the models and interventions for health promotion or community health programs can be integrated systematically. It uses breast cancer prevention and control programming to demonstrate the steps. CDs provide technical guidance and assistance to those involved in planning and implementing community-level prevention and control interventions. To order, contact Jones and Bartlett, www.jbpub.com. Evaluation Handbook—W. K. Kellogg Foundation. A handbook that provides a framework for project evaluation, describes diﬀerent levels of evaluation, and provides a blueprint to guide project-level evaluations. Case studies and examples are provided throughout the handbook: www.wkkf.org. FROM THE GROUND UP! A Workbook on Coalition Building and Community Development David Chavis, Stephen Fawcett, Vincent Francisco, David Foster, Gillian Kaye, Beth Rosenthal, and Tom Wolﬀ. This workbook is a tool box for building community-wide processes. It includes ﬁeld ideas, frameworks, and exercises that have evolved from the authors’ work in communities across the country. Chapter titles include:

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• • • • •

Barriers to Coalition Building and Strategies to Overcome Them Involving and Mobilizing the Grassroots Dealing with Conﬂict in Coalitions Community Assessment: A Key Tool for Mobilization and Involvement Monitoring and Evaluation of Coalition Activities and Success

For more information, contact AHEC/Community Partners, www.ahecpartners.org/hcm. Healthy People 2010 Tool Kit: A Field Guide to Health Planning A resource made available by the federal government, the tool kit provides guidance, technical tools, and resources to develop and promote successful state-speciﬁc Healthy People 2010 plans. It is organized around seven major “action areas”: • • • • •

Building the Foundation: Leadership and Structure Identifying and Securing Resources Identifying and Engaging Community Partners Setting Health Priorities and Establishing Objectives Obtaining Baseline Measures, Setting Targets, and Measuring Progress • Managing and Sustaining the Process • Communicating Health Goals and Objectives Found at www.health.gov/healthypeople/state/toolkit/default.htm. Innonet Internet-based tool for program planning, evaluation, budget plans, and grant writing. Nonproﬁt agencies, regardless of location, size or funding status, can use the website to research information, use evaluation tools, learn more about data collection and analysis, and create program, evaluation, and budget plans. Technical assistance is also available. For more information, contact Innovation Network, Inc., www.innonet.org. The Outcomes Tool Kit The Outcomes tool kit is an online planning, collaboration, action, and analysis tool that provides a comprehensive approach to planning and evaluating cross-sector community initiatives. It includes templates for deﬁning and tracking performance and outcomes goals, a database of key indicators for

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health and well-being, and a portal to share strategies and practices with local and state leaders across the nation. For more information, contact The Health Forum at www.act-toolkit.com. PATCH: Planned Approach for Community Health The Planned Approach to Community Health (PATCH), developed by the Centers for Disease Control and Prevention (CDC) and its partners, is a model for planning, conducting, and evaluating community health promotion and disease prevention programs. It has been used to address a variety of health concerns such as cardiovascular disease, HIV, injuries, teenage pregnancy, and access to healthcare. The PATCH Guide is designed to be used by the local coordinator and contains “how to” information on things to consider when adapting the process to communities. Sample overheads and handout materials are provided. For more information, contact National Center for Chronic Disease Prevention and Health Promotion, www.cdc.gov /nccdphp/patch. Practical Evaluation of Public Health Programs (1998) This two-part video course, designed for nonstatisticians, enables participants to learn why program evaluation and building commitment for it are important; and how to design and conduct program evaluation in a team environment. Learners are introduced to a CDC evaluation framework, work through the framework in terms of a case study, and see videotaped interaction with experts from state and local health departments, schools of public health, and CDC. The course was developed by the School of Public Health, University of Texas–Houston Health Science Center, Texas Department of Health, the Association of Schools of Public Health, and the Centers for Disease Control and Prevention. The program contains two videotapes and one 70-page workbook. Contact www.cdc.gov/phtn/catalog/vc0017.htm. A Program Evaluation Tool Kit: A Blueprint for Public Health Management The tool kit is a ﬁve-step guide to planning, doing, and using evaluation. It is presented in a series of short modules with explanations and tools. It is presented in a three-ring binder so that it can be updated and expanded. The tool kit presents a decision-oriented model of program evaluation. The tool kit is a guide to small-scale, in-house evaluation of existing programs focusing on process and short-term outcomes. For more information, contact Public Health Research, Education and Development Program, Regional

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Municipality of Ottawa Carleton Health Department and the Population Health Service, Public Health Branch, Ontario Ministry of Health, www .uottawa.ca/academic/med/epid/toolkit.htm. We Did It Ourselves: Guidelines for Successful Community Collaboration (2000) A three-volume set of guidebooks written by the Sierra Health Foundation, the Center for Collaborative Planning, and SRI International. Each guide book illustrates step-by-step approaches communities in the Community Partnership for Healthy Children’s program took to develop a vision for children’s health, identify and mobilize local assets, engage communities to reach their goals, and learn from their successes and challenges. Components include: • Book One, entitled We Did It Ourselves, A Guide Book to Improve the Well-Being of Children Through Community Development, walks the reader through an asset-based approach to community engagement, planning, and action for the health and well-being of children, families, and communities. • Book Two, entitled We Did It Ourselves, An Evaluation Guide Book, is a lay person’s guide to the complex methodology of evaluating community building and development eﬀorts. This guide book takes the reader through the stages of assessing and measuring communitybased eﬀorts. • Book Three entitled, If We Speak They Will Listen, The Importance of Communication Activities in Collaborative Building and Planning, is a guide for successful communication and focuses on a menu of communication tools and methods a community collaborative can use to get its message to the people who need to hear it. For more information, contact The Sierra Health Foundation, www.sierrahealth.org/library/special.html.

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APPENDIX B

Other Resources for Community Collaboration

BOOKS AND ARTICLES

Basics of Qualitative Research: Grounded Theory Procedures and Techniques, Second Edition Anselm Strauss and Juliet Corbin (1990), Sage Publications. The second edition of this text oﬀers the advice and technical expertise that assists researchers in making sense of their collected data. Basics of Qualitative Research, Second Edition presents methods that allow researchers to analyze and interpret their data ultimately building theory from it. The authors provide a step-by-step guide from the formation of the research question, through several approaches to coding and analysis, to reporting on the research. The book concludes with chapters that present criteria for evaluating a study, as well as responses to common questions posed by students of qualitative research. Benchmarking Christine W. Letts, William P. Ryan, and Allen Grossman, “Benchmarking: How Non-Proﬁts Are Adapting a Business Planning Tool for Enhanced Performance.” The Grantsmanship Center Magazine, Winter 1999. How the private sector practice of performance benchmarking is being adopted in the non-proﬁt sector. Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets. J. P. Kretzmann and J. L. McKnight (1993). Evanston, IL: Center for Urban

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Aﬀairs and Policy Research. More resources available through the Asset-Based Community Development Institute, Institute for Policy Research, Northwestern University. This guide to what the authors call “asset-based community development” summarizes lessons learned by studying successful community-building initiatives in hundreds of neighborhoods across the United States. It outlines in simple, “neighborhood-friendly” terms what local communities can do to start their own journey down the path of asset-based development. This book will be helpful to local community leaders, leaders of local associations and institutions, government oﬃcials, and leaders in the philanthropic and business communities who wish to support eﬀective community-building strategies. See www.northwestern.edu/IPR/abcd.html. Case Study Research: Design and Methods (2nd Edition) Robert K. Yin. Applied Social Research Methods Series, Volume 5. Sage Publications. 1994. This best-selling book has been revised, updated, and expanded. New materials include discussion of the debate in evaluation between qualitative and quantitative research (chapter 1), more on the role of theory in doing good case studies (chapter 2), more discussion of triangulation as a rationale for multiple sources of evidence (chapter 4), and inclusion of program logic models as another analytic option (chapter 5). The text has updated examples, including ones dealing with international trade and world economy. In addition to these enhancements, the second edition of this volume still retains virtually all of the features and coverage of the original text. Choosing Eﬀective Evaluation Methods Frances Butterfoss, Vincent Francisco, and Ellen Capwell. Health Promotion Practice. October 2000. Volume 1, No. 4, 307–13. The many possible methodologies for evaluating programs make it diﬃcult to decide how to evaluate a program. This article identiﬁes the basic types of data gathering strategies, strengths and weaknesses of each, and variables to consider in making choices. Community-Based Public Health: A Partnership Model Edited by Thomas A. Bruce, M.D., and Steven Uranga McKane, D.M.D. (2000). Copublished by the W. K. Kellogg Foundation and the American Public Health Association. Developing meaningful partnerships with the communities served is crucial to the success of institutions, nonproﬁt organization and corporations. This book focuses on public health practice in

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communities, the education and training of public health professionals at colleges and universities, and public health research and scholarly practice within academic institutions. The experiences shared provide a model for philanthropic organizations. See www.apha.org/media. Community Health Report Cards: Results of a National Survey Jonathan Peilding, Carol Sutherland, and Neal Halfon. American Journal of Preventative Medicine 1999; 17 (1). Results from a study examining community report card development and use. Evaluation: A Systematic Approach (6th Edition) Peter Rossi, Howard Freeman, and Mark Lipsey. Sage. 1999. New edition of a standard text ﬁrst published in 1979 that discusses the range of research activities used in appraising the design, implementation, and utility of social programs. New chapters cover topics on identifying issues and formulating questions, program theory, tailoring an evaluation, needs assessment, and outcome monitoring and performance measurement. Evaluating Comprehensive Community Change Report from the Annie E. Casey Foundation’s March 1997 Research and Evaluation Conference. http://www.aecf.org/publications/evaluation/index.htm. An Evaluation Framework for Community Health Programs (June 2000) Based on “Framework for Program Evaluation in Public Health” (Centers for Disease Control and Prevention) and the “Community Tool Box” (University of Kansas). Produced by the Center for the Advancement of Community Based Public Health. www.cdc.gov/eval/evalcbph.pdf. Finding the Best Outcome Evaluation Approach for Your Community Programs A brief guide for evaluating community-based programs produced by the Seattle Community Evaluation Network. Available at http://depts.washington.edu/hprc/CRC/biblio.htm. Framework for Program Evaluation in Public Health (CDC) Eﬀective program evaluation is a systematic way to improve and account for public health actions by involving procedures that are useful, feasible, ethical, and accurate. The framework guides public health professionals in their use

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of program evaluation. It is a tool designed to summarize and organize essential elements of program evaluation. The framework comprises steps in program evaluation practice and standards for eﬀective program evaluation. This report presents a framework for understanding program evaluation and facilitating integration of evaluation throughout the public health system. Source: Morbidity and Mortality Weekly Report Sept. 17, 1999 / Vol. 48 / No. RR-11. Making Outcomes Matter Findings from a conference on “evaluating community-based health initiatives: dilemmas, puzzles, innovations, and promising directions.” The working conference brought together 100 participants from the practice, funding and evaluation communities. The publication is available through www.ghcfoundation.org. Getting to Yes: Negotiating Agreement Without Giving In Roger Fisher, William Ury, and Bruce Patton. Boston: Houghton Miﬄin, 1991. Oﬀers a step-by-step strategy to coming to mutually acceptable agreements in every sort of conﬂict, whether it involves parents and children, neighbors, bosses and employees, customers or corporations, tenants or diplomats. Based on the work of the Harvard Negotiation Project, a group that deals continually with all levels of negotiation and conﬂict resolution domestically and internationally. Lessons from the Field Written by the Community Anti-Drug Coalitions of America (CADCA) (2000), this document provides analytic insights into the organization, operation, sustainability, and impact of community antidrug coalitions across the United States. This volume involved in-depth case studies of eight highly eﬀective community coalitions and a cross-site analysis that examines characteristics shared among them, such as leadership, outcomes, planning, institutionalization, and diversiﬁcation of funding sources. www.aecf.org/publications/Lessons.pdf. New Approaches to Evaluating Community Initiatives (1995) Edited by Connell, Kubisch, Schorr, Weis. The Aspen Institute. The papers in this volume explore key dilemmas in the evaluation of comprehensive community initiatives (CCIs). Collectively, the papers suggest that CCIs are diﬃcult to evaluate for reasons that relate both to the design of the initiatives

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themselves and the state of evaluation methods and measures. They also suggest that work can be done on both fronts that will enhance the ﬁeld’s ability to judge the eﬀectiveness of CCIs and, ultimately, other social welfare interventions. www.aspenroundtable.org/vol1/index.htm. A Participatory Evaluation Model for Healthier Communities: Developing Indicators for New Mexico Nina Wallerstein. Public Health Reports. March/April and May/June 2000. Volume 115. 199–206. A participatory evaluation models that invite community coalitions to take an active role in developing evaluations of their programs are a natural ﬁt with Healthy Communities initiatives. The author describes the development of a participatory evaluation model for New Mexico’s Healthier Communities program. She describes evaluation principles, research questions, and baseline ﬁndings. The evaluation model shows the links between process, community-level system impacts, and population health changes. The Practice of Health Program Evaluation D. Grembowski. Thousand Oaks, CA: Sage Publications, 2001. This text presents major concepts, methods, and issues of evaluating health programs, and explains how to navigate the political terrain so as to work more eﬀectively with decision makers and other groups when developing evaluation questions. Covers methods for selecting among evaluation designs, and discusses the use of answers by decision makers, looking at methods for developing formal dissemination plans, factors that inﬂuence whether evaluation ﬁndings are used, and major challenges facing the discipline in the next decade. Principles for Evaluating Comprehensive Community Initiatives (June 2001) This document was produced by ASDC on behalf of the National Funding Collaborative on Violence Prevention for evaluators and practitioners (i.e., program implementers, technical assistance providers, and trainers) who are involved in comprehensive community initiatives (CCIs). It provides practical guidance on how to approach the evaluation of CCIs. The principles are presented in the hope that readers will build upon the ideas in their own work and share them with others. The principles demonstrate that evaluation can be responsive to community needs and help educate community program staﬀ without losing its scientiﬁc rigor. http://www.capablecommunity.com/asdc /pubs.html.

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Philosophy and History of Community Partnerships Public Health Reports, March/April and May/June 2000. Volume 115, Issue 2 Devoted to community partnerships, it discusses the philosophy and history of the Healthy Communities Movement, making collaborations and coalitions work, assessment and evaluation partnerships, as well as several case examples. The Teamnet Factor: Bringing the Power of Boundary Crossing into the Heart of Your Business Jessica Lipnack and Jeﬀrey Stamps (1995). A detailed description of how today’s forward-looking companies can put boundary crossing to work for them. Explains why boundary crossing shakes up stodgy thinking, opens up pathways to new ideas, and creates unexpected opportunities. The TeamNet factor is an innovative, proven approach to renewing a company’s ability to thrive in today’s competitive environment. Although this is a book written for the for-proﬁt world, it contains insights and practical information for nonproﬁts and public agencies. Improving Stakeholder Collaboration A special report on the evaluation of community-based eﬀorts available through www.ghcfoundation.org. Twenty-ﬁve initiatives came together to share information and lessons learned regarding community-based collaboratives and their evaluation. This publication is a summary of presentations, discussions, and background documents. Using Case Studies to do Program Evaluation Edith Balbach. March 1999. California Department of Health Services. This guide will help evaluations assess whether to use a case study evaluation approach and how to do a case study. http://www.dhs.cahwnet.gov/tobacco /html/Evaluation_Resources.htm.

WEB SITES

AHEC/Community Partners: www.ahecpartners.org/index.shtml This organization specializes in developing, promoting, and sustaining community-based eﬀorts across Massachusetts. Its goals are to increase collaboration within and between communities, build citizen participation, and improve community quality of life. Programs focus on expanding healthcare access and creating healthy communities.

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Annie E. Casey Foundation: www.aecf.org The Annie E. Casey Foundation seeks ways to build better futures for disadvantaged children and their families in the United States. Its mission is to foster public policies, human service reforms, and community supports that more eﬀectively meet the needs of today’s vulnerable children and families. Working with neighborhoods and state and local governments, the Foundation provides grants to public and nonproﬁt organizations to strengthen the support services, social networks, physical infrastructure, employment, selfdetermination, and economic vitality of distressed communities. The Asset-Based Community Development Institute (ABCD): www.northwestern.edu/IPR/abcd.html Established in 1995 by the Community Development Program at Northwestern University’s Institute for Policy Research, this agency is built upon three decades of community development research by John Kretzmann and John L. McKnight. The ABCD Institute spreads its ﬁndings on capacitybuilding community development in two ways: (1) through extensive and substantial interactions with community builders, and (2) by producing practical resources and tools for community builders to identify, nurture, and mobilize neighborhood assets. The ABCD Institute is funded by the Chicago Community Trust in consultation with the Kinship Foundation. The Change Project: www.well.com/user/bbear This project oﬀers information about coping with change, with a section about change in healthcare. The site contains case studies of projects done in health systems and features a section on healthy communities. Civic Practice Network (CPN): www.cpn.org The Civic Practice Network (CPN) is a collaborative and nonpartisan project dedicated to bringing practical tools for public problem solving into community and institutional settings across the United States. Their web site contains case studies on collaboration as well as manuals and guides. Civic Democracy Movement: www.ncl.org and www.ncl.org/anr/index.htm The Civic Democracy Movement oﬀers assistance to people working collaboratively to develop civil society and to revitalize their communities. Its work emphasizes developing democratic processes and institutions which are inclusive and supportive of individual freedom, social justice, and the

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strengthening of broad based civic indicators. The National Civic League and the Alliance for National Renewal are the primary players. Coalition for Healthier Cities and Communities: http://www.healthycommunities.org A web site for individuals involved in Healthy Communities Projects. Site contains the history of the movement, a catalog of communities and countries involved in the Health Communities Movement, and links to other resources. Community Care Network (CCN): www.communitycare.org The Community Care Network (CCN) demonstration program is an eﬀort to learn about how cross-sectoral partnerships approach the task of improving the health—broadly deﬁned—of their communities. The CCN demonstration has a special interest in the role of major healthcare providers in working with other community partners to transform the healthcare delivery system. This demonstration features partnerships from across the country, from all kinds of communities. Community Building Movement: www.ncbn.org The Community Building Movement works to reduce poverty and create social and economic opportunity through comprehensive community building strategies. In addition, this Movement works to achieve social and economic equity for all children and families. Community builders work on physical and economic community development, but also focus on promoting strong social networks among community residents. Community Initiatives: www.communityinitiatives.com Community Initiatives helps organizations, corporations, and community collaborations shape change and accelerate results. It is an alliance of professionals dedicated to creating healthy and sustainable communities wherever people live, work and play. The Community Research Center (CRC): http://depts.washington.edu/hprc The Community Research Center provides technical assistance to nonproﬁt community based and grassroots organizations in central, southeast, and southwest Seattle. The CRC assists in writing grants, evaluating programs, and carrying out community-based research projects.

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Creating Healthier Communities Fellowship Program: www.healthforum.com/HFEducation/asp/chc.asp The Creating Healthier Communities Fellowship Program oﬀers an opportunity for healthcare professionals, business leaders, and community change agents who are interested in improving health status, while increasing the business performance of their organization, through a year-long intensive learning collaborative. CDC Evaluation Working Group: www.cdc.gov/eval/resources.htm or www.cdc.gov/eval/index.htm The CDC Evaluation Working Group has put together listings of resources about evaluations and how to conduct an evaluation project. The Enterprise Foundation: www.enterprisefoundation.org The Enterprise Foundation rebuilds communities. They work with partners to provide low-income people with aﬀordable housing, safer streets and access to jobs and child care. They also help strengthen nonproﬁt organizations working in community development. The Health Forum: www.healthforum.com The Health Forum provides communications, information, education, and research products and services that advance leadership for health. These services oﬀer healthcare providers, suppliers, payers, and consumers with knowledge and learning toward the advancement of organizational leadership, market leadership, clinical and medical leadership and community leadership. The Health Forum was created in 1998 through the union of The Healthcare Forum and the American Hospital Association’s publishing and data and information subsidiaries. Healthy People 2010: www.health.gov/healthypeople/default.htm Healthy People 2010 is the prevention agenda for the nation. It is a statement of national health objectives designed to identify the most signiﬁcant preventable threats to health and to establish national goals to reduce these threats. The Sierra Health Foundation: www.sierrahealth.org The Sierra Health Foundation is a private, independent philanthropy supporting health and health-related activities in a 26-county region of northern

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California. Foundation programs address a wide range of health issues aﬀecting individuals, families and communities. The Foundation is committed to collaboration, promoting communication, and sharing successful strategies. Through partnerships with other foundations, nonproﬁt organizations, public agencies, and community leaders, Sierra Health Foundation works to leverage existing resources and ensure eﬀective results. United Way Outcome Measurement Resource Network: http://national.unitedway.org/outcomes The Network provides United Way of America and other organizations with outcome measurement resources and learnings. The website contains an online resource library. University of Wisconsin Extension: Program Development and Evaluation: http://www.uwex.edu/ces/pdande contains guides and worksheets on program evaluation. The Washington Health Foundation: www.whf.org The Washington Health Foundation has sponsored a variety of collaborations projects with communities. They also produce workbooks, guides, and other resources. The Wilder Foundation: www.wilder.org The Wilder Foundation is a nonproﬁt health and human services organization that has served the greater Saint Paul, Minnesota, area since 1906. The Foundation operates more than 110 programs that serve people of all ages and backgrounds, with a focus on low-income individuals and families, people needing support during critical times in their lives, and Saint Paul’s central neighborhoods and communities. Their website contains a variety of resources, links, and case examples. W. K. Kellogg Foundation: www.wkkf.org The W. K. Kellogg Foundation’s mission is “To help people help themselves through the practical application of knowledge and resources to improve their quality of life and that of future generations.” The W. K. Kellogg Foundation is a nonproﬁt organization whose mission is to apply knowledge to solve the problems of people. Its founder, W. K. Kellogg, the cereal industry pioneer,

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established the Foundation in 1930. Since its beginning the Foundation has focused on building the capacity of individuals, communities, and institutions to solve their own problems. For resources, search “Resources” in the “Knowledgebase.”

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APPENDIX C:

Key Foundations Involved with Community Collaboration

Foundation

Priority Areas

The Annie E. Casey Foundation www.aecf.org

Improving major systems serving disadvantaged children and families Transforming neighborhoods Promoting accountability and innovation

The California Endowment www.calendow.org

Access to healthcare Health and well-being Multicultural health

The California Wellness Foundation www.tcwf.org

Diversity in health professions Environmental health Healthy aging Mental health Teenage pregnancy prevention Violence prevention Women’s health Work and health

The Colorado Trust www.coloradotrust.org

Within the state of Colorado: • Accessible and aﬀordable healthcare programs • Strengthening of families

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Dorothy Rider Pool Health Care Trust www.pooltrust.com

Priority given within the Lehigh Valley of Pennsylvania. Program areas: • Education • Health and welfare • Culture and art • Community development

The Group Health Community Foundation www.ghcfoundation.org

Within Group Health Cooperative’s service area. Program areas: • Children’s and adolescent health • Health promotion and disease prevention • Clinical innovation and sharing of best practices • Research

The Henry J. Kaiser Family Foundation www.kﬀ.org

Health policy Media and public education Health and development in South Africa

Kansas Health Foundation www.kansashealth.org

Within the state of Kansas. Program areas: • Children’s health • Leadership • Public health

The Robert Wood Johnson Foundation www.rwjf.org

Programs that broadly aﬀect health and healthcare Exploratory projects in areas of emerging importance, such as genetics

The Sierra Health Foundation www.sierrahealth.org

Community Partnerships for Healthy Children: a 10-year eﬀort to improve the health of children from birth through age eight. Twenty-one communities in 14 northern California counties participate in CPHC, which emphasizes a collaborative, community-driven approach to addressing children’s health issues. Bright Smiles is a funding opportunity that addresses dental health projects.

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The Wilder Foundation Serving the greater Saint Paul, Minnesota, area. www.wilder.org Programs and services: • Healthy, resilient youth • Support for older adults • Community and neighborhood services • Aﬀordable housing • Employment and life skills counseling • Support across cultures • Working to end violence W.K. Kellogg Foundation www.wkkf.org

Access to healthcare Philanthropy and volunteerism Food systems and rural development Youth and education Greater Battle Creek area

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APPENDIX D:

Further Reading for Chapter 2

Lasker, R., A. Abramson, and G. Freedman. 1998. Pocket Guide to Cases of Medicine and Public Health Collaboration. New York: Center for the Advancement of Collaborative Strategies in Health, the New York Academy of Medicine.

1 PERCENT OR LESS MILK CAMPAIGN

Reger, B., M. G. Wootan, and S. Booth-Butterﬁeld. 1999. “Using Mass Media to Promote Healthy Eating: A Community-based Demonstration Project.” Preventative Medicine 29 (5): 414–21. ———. 1998. “1% or Less: A Community-based Nutrition Campaign.” Public Health Report 113 (5): 410–19. Additional information provided by Margo Wooton.

BETHEL NEW LIFE

Web site for Bethel New Life: www.bethelnewlife.org. Program proﬁle of Bethel New Life by Enterprise Institute: www.enterprisefoundation.org/model%20documents/1272.pdf.

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University of Illinois at Chicago Center for Urban Economic Development and Bethel New Life. 1999. “Lessons Learned: Community-based Organizations and Career Ladder Training. Moving from Dependency to Work and Living Wage Jobs.” November. Enterprise Foundation. 2000. “On the Ground with Comprehensive Community Initiatives.” Columbia, MD: Enterprise Foundation. Flowers, J. “Bethel New Life, Chicago. A Case Study of Community Transformation.” HealthCare Forum: Leadership Strategies for Healthcare. http://www.well.com/user/bbear/bethel.html.

BOSTON SMALLPOX EPIDEMIC

Kohn, G. C. (ed.). 1995. "South Bend, IN Area Genealogical Society, April 1996." In Encyclopedia of Plague and Pestilence, edited by George C. Kohn. New York: Facts On File, Inc., and The Family Education Network. Barquet, N., and P. Domingo. 1997. “Smallpox: The Triumph over the Most Terrible of the Ministers of Death.” Annals of Internal Medicine 15 (127): 635–42. http://www.acponline.org/journals/annals/15oct97/smallpox.htm. Albert, M. R., K. G. Ostheimer, and J. G. Breman. 2001. “The Last Smallpox Epidemic in Boston and the Vaccination Controversy, 1901–1903.” The New England Journal of Medicine 344 (5). http://www .anthrax.osd.mil/Site_Files/articles/INDEXgeneral_interest /OccasionalNotes.htm. http://www.news.harvard.edu/gazette/1999/05.20/waterhouse.html.

CARTEENS

Safrit, D., J. King, R. Schmiesing, J. Villard, and B. Wells. “Assessing the Impact of Youth Service Delivered Though University Engagement.” Uunpublished article. Columbus, OH: The Ohio State University.

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Marshall, C., and G. B. Rossman. 1989. Designing Qualitative Research. Thousand Oaks, CA: Sage Publications. Cropper, R. J. 1999. “Ohio 4-H CARTEENS: Peer Intervention Safety Program.” J-ext. United States, 37 (2). Extension Journal, Inc. Interview with Becky Cropper (CARTEENS), OSU Extension Agent. Interview with Ryan Schmiesing (Teen BRIDGES). Ohio 4-H. 1999. “Programs of Excellence.” http://www.reeusda.gov/4h /excellence/1999/ls_healthy.htm. “Ohio Teen Bridges Year 3 Renewal Proposal Narrative.” 1998. AmeriCorps 3-year renewal application.

C O M M U N I T Y H E A LT H P R O M O T I O N G R A N T P R O G R A M

Wagner, E. H., T. M. Wickizer, A. Cheadle, B. M. Psaty, T. D. Koepsell, P. Diehr, S. J. Curry, M. Von Korﬀ, C. Anderman, W. L. Beery, D. C. Pearson, and E. B. Perrin. 2000. “The Kaiser Family Foundation Community Health Promotion Grants Program: Findings from an Outcome Evaluation.” Health Services Research 35 (3): 561–89. Cheadle, A., B. M. Psaty, P. Diehr, T. Koepsell, E. Wagner, S. Curry, and A. Kristal. 1995. “Evaluating Community-based Nutrition Programs: Comparing Grocery Store and Individual-level Survey Measures of Program Impact.” Preventive Medicine 24 (1): 71–79. Wagner, E. H., T. D. Koepsell, C. Anderman, A. Cheadle, S. G. Curry, B. M. Psaty, M. Von Korﬀ, T. M. Wickizer, W. L. Beery, P. K. Diehr, et al. 1991. “The Evaluation of the Henry J. Kaiser Family Foundation’s Community Health Promotion Grant Program: Design.” Journal of Clinical Epidemiology 44 (7): 685–99. Wickizer, T. M., E. H. Wagner, A. Cheadle, D. C. Pearson, W. L. Beery, J. Maeser, B. M. Psaty, M. Von Korﬀ, T. D. Koepsell, P. Diehr, and E. B. Perrin. 1998. “Implementation of the Henry J. Kaiser Family Foundation’s Community Health Promotion Grant Program: A Process Evaluation.” The Milbank Quarterly 76 (1).

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H E A LT H Y C O M M U N I T I E S I N I T I AT I V E O F G R E AT E R ORLANDO

Health Communities Initiative of Greater Orlando web site: www.hciﬂorida.org. Flowers, J. “Orlando, Florida: A Case Study of Community Transformation.” The Change Project: Orlando, Florida. http://www.well.com/user/bbear/orlando.html. Interviews with Sarah Stack, community building coordinator, and Ray Larson, executive director, Healthy Communities Initiative of Orlando.

PROJECT IMMUNIZE VIRGINIA

Information about Project Immunize Virginia was taken from an executive summary and from an interview with Clint Crews, project coordinator.

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About the Authors

Howard P. Greenwald, Ph.D., is professor of management and policy at the University of Southern California School of Policy, Planning, and Development, and clinical professor at the University of Washington School of Public Health. He is a specialist in research on major social issues, with an emphasis on health and communities. He holds a Ph.D. in sociology from the University of California at Berkeley. He has served as a faculty member at the University of Chicago Graduate School of Business, research scientist at Battelle Memorial Institute, chairman of the Network for Healthcare Management, and director of the Health Services Administration Program at the University of Southern California. William L. Beery, M.P.H., is vice president of the Programs of the Group Health Community Foundation and professor (aﬃliate) with the School of Public Health and Community Medicine, University of Washington. His career has focused on the planning, implementation, and evaluation of community-based programs to improve health. He has worked in government, academic, and managed care settings and directed major evaluation efforts for the W. K. Kellogg Foundation, The California Wellness Foundation, The California Endowment, the Centers for Disease Control and Prevention, and other local, state, and federal agencies. Earlier, he served in West Africa and Southeast Asia as a Peace Corps volunteer and health program director. He is active in his community and has a special interest in reducing violence and aiding the homeless.

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Additional community health strategies from Health Administration Press These products are the result of a three-year collaborative research project between the American College of Healthcare Executives and the American Hospital Association. The project was designed to uncover the practices put in place by hospitals that have been recognized for their efforts to improve community health. This project was funded in part by the W.K. Kellogg Foundation. Achieving Success Through Community Leadership Peter A. Weil, Ph.D., FACHE; Richard J. Bogue, Ph.D.; and Reed L. Morton, Ph.D., FACHE This handbook provides real-life examples of the 25 practices discovered during site visits at leading hospitals recognized for their community leadership. It includes various forms and tips to help you implement the practices at your organization. It is a great tool for stepping up your community initiatives, as well as an ideal supplement to the discussion video. Order No. BKCO-1136, $35 Softbound, 150 pp, 2001 ISBN 1-56793-166-9

Rekindling the Flame: Achieving Success Through Community Leadership Discussion Video In this 61-minute video, executives from leading hospitals explain the practices they are using to build community relationships. Ideal for board and management retreats, the video comes with a booklet of discussion questions pertaining to each strategy covered in the video. Order No. BKCO-V1136, $300 Running time: Approximately 61 minutes

For quick and easy ordering, call the ACHE/HAP Order Fulfillment Center at (301) 362-6905. Order online at www.ache.org/hap.cfm. Prices are subject to change.