Chapter 6: Applications of PRECEDE-PROCEED in Communities

1. Chapter 6: Applications of PRECEDE-PROCEED in Communities

2. Community: Definition and Aspects • Common place, interest or cause • Mutual trust • Based on equal opportunity, openness • Assumption of interdependency • Reciprocity • Sense of community • Community in action, community-based • Active partnerships • Planning, implementing, evaluating

3. Community Interventions • The epidemiological case for community-wide • The arithmetic of moving the middle of the curve • Small changes in large numbers = large effects • The social-psychological case • Normative influence of large numbers of people changing their behavior • Reinforcing effect of denormalizing old behavior • The economic case • The political case *Green & Kreuter (2005). Health Program Planning, 4th ed. NY: McGraw-Hill.

4. “Community partners refer to…”* • volunteers • partner agencies who may be: • local area offices of government • voluntary agencies • local hospital(s), professional associations • self-help groups • networks such as local inter-agency councils; • educators; health care providers; rec groups • private sector; foundations; others... *Ontario Ministry of Health: Heart Health Application Guidelines, 1997.

5. The Compelling Logic for Partnerships and Coalitions* • The complexity of the health determinants and community problems • The limited resources of any one agency • The limited mandate of any one agency • The limited reach of any one agency • The limited credibility of any one agency • The need for shared commitment and planning to ensure sustainability of the program • The need for shared monitoring and evaluation to ensure joint accountability *Green & Kreuter (2005). Health Program Planning, 4th ed. NY: McGraw-Hill.

6. The Lenses of Health Professionals and Lay People Subjective Indicators of Health Professional Layperson “Objective” Indicators of Health Adapted from Yukon Bureau of Statistics, Whitehorse, Yukon Territory, Canada, 1995; UBC, IHPR, 1997.

7. Ecological Models* • Individual-Family-Organizational • Environmental-Cultural-Societal Health resources: Social environment, norms Healthful food in workplaces Fitness facilities in inner city Child care at work Smoke-free environments Mandated health curriculum Restaurant menu programs Other governmental policies Other organizational policies *Green LW, Richard L, Potvin L. “Ecological Foundations of Health Promotion,” AJHP, 1995.

8. Some other Benefits of Partnerships* • Relative freedom from individual organizations allows some to explore new ideas, challenges, situations. • Enables some to become involved in issues without having the sole responsibility for them. • Can generate greater public awareness and support • Can create a “critical mass” for action • Can minimize duplication of effort & resources • Can act as “strategic devices” to mobilize and leverage resources *F. Butterfoos et al. (1993) Health Education Research 8:315-330.

9. Re-examine the Community-Based Results & Strategy • Were the trials truly community-based? • Did they truly add much to the individual behavior-change models of previous work? • How to account for the secular trends that were so pervasive during the trials? • Did they continue long enough? • Would some population aggregate other than local community serve better

10. Of Marathons, Milestones & Methodological Metaphors* • The trials captured a series of snapshots in the early sprints of what must be understood as the marathon of community & population changes, which unfold slowly. • The communities that might not finish the race run just as fast during these early heats, making the experimental communities look lackluster in comparison with their controls. *Green LW. American Journal of Preventive Medicine, July-Aug.1997.

11. Question the Advantages & Motives • If partnership is to gain resources, must also consider the loss of control over resources • Two or more organizations partner when they perceive mutual benefits from interacting, or when at least one is motivated to establish a relationship and powerful enough to compel the others to interact. • If the main motivation for partnering is the lure of external resources, must hurry to replace that motivation with something more intrinsic Green LW (2000). Caveats on Coalitions; In Praise of Partnerships. J H Prom Prac 1(1).

12. Some Inherent Limitations* • 3rd Law: Expansion means complexity; and complexity decay. • 4th Law: The number of people in any working group tends to increase regardless of the amount of work to be done. • 5th Law: If there is a way to delay an important decision, the good bureaucracy, public or private, will find it. • Axiom: An official wants to multiply subordinates, not rivals. *C.Northcott Parkinson, Parkinson's Law. Boston: Houghton-Mifflin, 1969

13. Principles of Good Partnerships* • Partners agree on mission, goals, outcomes • Mutual trust, respect, genuineness, commitment • Builds on identified strengths and assets • Clear & accessible communication among partners, making clarity of a common language a priority • Partnerships evolve; using feedback to, among and from all partners [Is technology helping with this?] • Roles, norms and processes for the partnership are evolved from input and agreement of all partners... *Community-Campus Partnerships for Health (Univ. California, 1997)

14. Components of Successful Community Partnerships* • Contact with local political leaders and funders • Going beyond the community self-determination and ownership of problems to building consensus on priorities, resources and specific actions • Focusing on commonplace, easily identifiable, solvable “publicly owned” problems in order for citizens to feel competent in resolving them; • Use of existing structures to incorporate solutions into their mission; or the creation of new ones. *Adapted from Heller K (1992). Am J Community Psychol 20:143-61.

15. “Actual needs” Public’s perceived needs, priorities C A A D B Resources, feasibilities, policy Community Action & Sustainability are where Three World Views Overlap Phase I Social Diagnosis Phases II-III: Epidemiological, Behavioural, Ecological & Motivational Assessments Health Impact Assessment; Risk-benefit Assessment; Cost-benefit evaluation; Quality-of-life evaluation E Phase IV: Administrative, Policy & Implementation Assessments Green MW & Kreuter MW. (2005). Health Program Planning, 4th ed. NY: McGraw-Hill.

16. Strategies to Reconcile Perceived & Actual Needs, & Resources Participatory Research A A Health Education (advocacy) Community mobilization & organizational development Green LW, Kreuter MW, Health Promotion Planning, 3rd ed. Mayfield, 1999.

17. Maxims for Building Partnerships* • Groups enter into partnerships to gain maximum power while expending minimum resources • Once a partnership receives power, rewards are distributed among allies in proportion to the amount of power & resources each brought to partnership • An excess of members or resources in a community partnership may produce a disappointing payoff • Agreement on a common goal increases in difficulty in proportion to the number of partners *Levine & Daneberg (1984). Alliances & Coalitions. NY: McGraw-Hill.

18. Maxims for Building Partnerships • A clear success early in the partnership’s efforts can enhance the chances of unity in the long run. • The closer the ideology of those trying to form a partnership, the greater the possibility of forming a successful partnership or coalition. • Partnerships will tend to disintegrate over time; defections are least among those who perceive that their power is rooted in membership in the partnership or coalition. [Issues of sustainability] *Levine & Daneberg (1984). Alliances & Coalitions. NY: McGraw-Hill.

19. Institutionalization>Sustainability: A Proposed Hierarchy of Indicators • The program has been made a line item in the recurring budget of a government agency • By legislative mandate as a priority • By legislation but not necessarily with high priority • Added to budget from director’s discretionary funds • Added from program head’s discretionary funds • Rebudgeting within existing programs • Program’s functions distributed to other organizations in the community

20. Sustainability Level 4 • New grants or donated funds added to agency budget permitting continuation on “soft” money • From special (one-time) legislative appropriation • From headquarters incentive grant • From director’s institutional “seed money” • From other organizations in community • From organizations outside the community

21. Sustainability Levels 5-8 • People trained and inspired by the program representing a developed human resource • Increased change of behavior in the public=norms • Increased public awareness, interest, or support = precursors to institutionalization or norms • Increased community organization, cooperation, participation of people previously unaware of the issue

22. Caveats on Coalitions • Most organizations will resist giving up resources, credit, visibility or autonomy. • Not everyone insists on being the coordinator, but nobody wishes to be the coordinatee. • So much goes into maintaining the coalition that little is left for program. • Who comes to the coalition meetings? • Those who were good at initiating not necessarily those best at implementing Green LW & Ottoson JM. Community & Population Health 8th ed. McGraw-Hill, 1999.

23. Noah’s Ark Principle of Partnering “Go forth two-by-two” After the initial consensus on vision and goals that a larger coalition of multiple partners can usefully forge, the best implementing strategy is to assign tasks to single or pairs of organizations that can work effectively and efficiently toward accomplishing those tasks. Green LW. Caveats on Coalitions; In Praise of Partnerships…J Health Promotion Practice. 1(1), 2000.

24. A Vision for Diversity in Shaping Community Action • A world in which the special knowledge and perspective of each relevant profession, agency discipline and social role can contribute to the development of understanding, better practice, services, policies, and outcomes. • Communities in which the solutions to social problems are pursued collaboratively among relevant disciplines and community groups who have a stake in the issue.

25. Social Organizational Capital* • Mutual trust • Based on equal opportunity, openness • Assumption of common goals , interdependency • Reciprocity • Sense of community • Complementarity • Shared access to essential information • Information technologies • Participatory research *Adapted from Kreuter, Marshall W. See footnote to Table 6-2.

26. The Social Reconnaissance Strategy of Grantmaking • Funding agencies send staff or consultants into the setting proposed for a program • Funding agency representatives assess whether key stakeholders are included in the planning of the programs • Funding agency uses its convening powers to bring key stakeholders together to work through collaborative agreements • Cf., however, “caveats on coalitions” Felix M, Green LW. Kaiser Family Foundation. Menlo Park, CA, 1989-91.

27. Recommendations for Community Prevention Programs* • Base planning and evaluation on explicit theory or logic model • Theory should be contextualized with understanding of local circumstances • The research process should embrace the involvement of the community affected • Prevention programs must be of adequate duration to have population effect *Daniel, M. & Green LW (1999). “Community-based prevention…” Dis. Mngt. & Health Outcomes 6,185-194.

28. Recommendations (concluded) • Interventions should vary across levels of implementation and stages of program • Assure intensity of intervention effort, and appropriate adaptation at each phase, in each subpopulation • Sample size and statistical power should be assured before evaluation begins • Design, analysis, & funding should address issues unique to community trials. *Daniel M, Green LW: “Community-based prevention…” Dis Mngt & Health Outcomes, 1999

29. THEORY RESEARCH P O L I C Y P R A C T I C E BRIDGING CONCEPT & CONTEXT Contained studies---------------->Taken to Scale (e.g., Clinical Epidemiology ----------------->Population policies) Protocols----------------------------> Real Time (e.g., Community trials------>Community-based programs) “Controlled” data--------->Participatory research (University control---->Shared control)

30. Definition of Participatory Research--for Health • Systematic investigation... • Actively involving people in a learning process... • For the purpose of social action (new services, resource allocation, regulation or policy) conducive to their health or quality of life. Green, L.W., et al. (1995). Study of Participatory Research in Health Promotion: Review and Recommendations for the Development of Participatory Research in Health Promotion in Canada. Ottawa: Royal Society of Canada, 1995.

31. Participatory Action Research (PAR) Action Research Participative Research Conscientizing Research (Paulo Friere) Policy-oriented Action Research Empowerment Evaluation Dialectical Research Collaborative Inquiry Emancipatory Research Participatory Action Learning Research Participatory Rural Appraisal (PRA) Participatory Research in Other Incarnations

32. Basic & applied------> Action research--------------> PAR in practice-------------------------> PAR on health needs of patients, families-----------------------> PAR on other needs---------------------> Layers of Collaboration in Participatory Research Practitioners, Service providers Traditionally defined researchers Patients, Families, Public Green, L.W., Mercer, S.L. (2001). Community-based participatory research: Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? American Journal of Public Health 91(12):1926-1929.

33. The big questions remaining • Local community as “center of gravity” for health promotion, or as a grassroots starting point for bottom-up influence on state, national, and global change? • Local community as a progressive or a conservative force for change? • How to operationalize the principle of participation in the new age of information technology and people’s new orientations?

34. Stakeholder Criteria used by stakeholder to asses our performance Our judgment of our performance according to these criteria 1. 2. 3. 1. 2. 3. 1. 2. 3. Stakeholders’ Analysis Worksheet

35. Objective: Action Steps Accountability Schedule Resources Feedback Mechanism Primary Others Start Complete Money Time Action Plan Format

36. Current Status Action: Who and When OK Need N/A Preplanning Factors Planning Process Model Planning Roles Clarified CEO & Senior Management Team Unit President Planning Facilitator Tactical Planning Key Results Areas Critical Issue Analysis Key Performance Indicators Objectives & Action Plans Plan Review Process Additional Considerations Cross-Functional Coordination Unit Mission Statements & Tactical Plans Training Plan Documentation & Communication Planning Assessment Checklist

37. Connecting the Dots Public Health Research Surveillanceand Evaluation Practice Policy Programs Monitoring Needs Assessment How to measure effects Identify research-practice gaps Dissemination Translation Participation and Collaboration Planning, Assessing Uptake and Quality