Community Toolbox Overview Modules 1-8

Lesson 1.5 and 2.0 What is a community asset (or resource)?

1.5 An asset (or resource) refers broadly to those people or things that can be used to improve the quality of community life. Assets can include: - People (e.g., a youth who has experience with an issue, community residents) - Organizations or associations of people (e.g., a local non-profit, a neighborhood association) - A physical structure or place (e.g., a school or library) - A business (e.g., a local grocery store)

Writing a Community Description

Once you determine what geographic boundaries your assessment will include, and what data you may draw upon to inform your assessment, it is important to create a community description. 1..3, 3.0

What is a community health assessment?

- Collection and interpretation of information to assess the community - Enables communities to prioritize, plan, and act upon unmet health needs to improve quality of life - Uses a collaborative approach and seeks community ownership of the process - Engages community members and stakeholders from different sectors - Helps identify community assets for health improvement efforts - Assesses community readiness and promising approaches to addressing community health problems and goals Module

A/an________ statement is a statement that reflects the groups' dreams for their community e.g., "Health and safety for all".

1 assessement

What content might not be appropriate for a community description?

1 assessement

Three common survey types include: Community Toolbox 3.0

1. Census surveys are given to every member of the population you want to learn about. These give the most accurate information about a group, but may not be very practical to administer to large groups. 2. Sample surveys ask a smaller portion or percentage of a group to reply to your questions. For the sample results to accurately reflect the results you would have gotten by surveying the entire group, the survey sample must be carefully chosen. Given good sampling choices, this will usually prove to be a more practical and cost-effective option than a census survey. 3. Case study surveys collect information from a part of a group or community without trying to select for overall representation of the larger population. You may need to conduct several of these before you get a sense of how the larger community would respond to your survey. Case study surveys only provide specific information about the individuals studied, and as such are less generalizable to larger populations.

1.6

2. Needs assessment surveys are a way of asking group or community members what they see as the most important needs of that group or community. The results of the survey then help prioritize future action. A needs assessment can be as informal as "asking around" with people you know in your community or as formal as a professionally written survey that is mailed to a large sample. A needs assessment survey has other advantages: - It helps us become aware of possible needs that we may not have seen as particularly important - or that we never even knew existed - It provides documentation of needs, as is required in many applications for funding, and can be helpful in advocating for the initiative's cause - It helps ensure that any actions the initiative gets involved with are in line with needs that are expressed by the community - It improves community support for the initiative's actions because local people will have stated the need for that action

What makes a logic model effective? Community Toolbox 5.0

A model's usefulness is its ultimate measure of success. A logic model should: » Logically link activities and intended effects » Lay out concepts in a visual way » Provoke questions about what works and under what conditions » Name factors known to influence desired outcomes

Which of the following are examples of the kinds of data that should be collected through a community health assessment?

A. Issues and concerns of importance to community members B. Leading causes of death and disability C. Behavioral and environmental risk factors associated with these health outcomes D. Social determinants of health E. B and C F. All of the above

Which of the following are possible uses of a community description?

A. To guide your community health improvement efforts B. To share with others working in the community C. As background information for the media D. As part of the justification for a grant proposal or request for funding E. A, B, and D F. All of the above

What is the meaning of community?

Although we traditionally think of a community as the people in a given geographical location, it can mean a group that has one or more things in common. "Community" refers to people who share a common: - Place (e.g., city: San Diego, neighborhood: the Westside or local school district: USD 66) - Experience (e.g., shared experience with health disparities) - Interest (e.g., a community's concern about poverty issues, or caring for the environment)

What is an action plan? Community Toolbox 6.0

An action plan describes what will be done (by whom, and by when) to implement the initiative's activities and strategies. The action plan often refers to: a.) Specific activities to be implemented or community/ system changes to be sought, b.) Specific action steps necessary to implement or bring about changes in the relevant sectors of the community.

Establish a structure for making decisions, managing, and supporting the work Community Toolbox 8.0

Be sure to establish rules for decision making. Clarify when representatives can speak for their organizations, and when they need to obtain approval from more senior leadership. Establish a management team and a coordinator role. Assure, when needed, technical support from consultants or University partners. The organizational structure for the community health initiative might include action committees for each priority issue, and an overall Community Advisory Board that includes representation from each action committee. The Board should have diverse membership, including leadership from the hospital, local health department, United Way, local coalition(s), service providers, and community members.

What does "collaboration" mean in community health? Community toolbox 8.0

Collaboration, literally a form of "co-labor," involves people and organizations working together to create conditions to improve the community's health. Practically, it involves sharing resources and responsibilities to implement the action plan. Collaboration should take place among diverse stakeholders from multiple sectors of the community, including but not limited to government, business, education, health, human services, community organizations, and the faith community.

Once best practices have been identified, specify the core components and elements to be included in the intervention C

Core components are approaches intended to bring about change in behavior and improvement in outcomes. A comprehensive intervention will include multiple components that reflect strategies for behavior change For instance, to promote physical activity in a community, in addition to providing information about its value for health, we would improve access to safe places to walk and play, modify school policies to assure more time for physical activity, and so on.

Before you get started developing an intervention Community toolbox 7.0

Engage key stakeholders and community members in assessment and planning? » Assess the level of community problems and identify priority health issues? » Analyze issues to be addressed, using end-users' input about potential causes? » Describe those whom the intervention should benefit and engage? » Set priority goals and objectives? » Identify the changes in communities and systems that should occur? » Identify the behavioral and community-level indicators that should improve? If you have completed these steps, you have a solid foundation with which to plan an intervention.

4. Using interviews as part of a community health assessment Community Toolbox 3.0

Interviews are often defined as conversations with a purpose. - They provide depth of perspective and help you tap into experiential knowledge, or information about how people experience a situation - They give texture and meaning to issues - Interviews can also provide in-depth information on a particular topic from someone who has technical expertise with an issue - Excellent results are achieved when trained interviewers listen well to what is said and can also discern and ask questions about what is often left unsaid Using an interview is the best way to have an accurate and thorough communication of ideas between you and the person from whom you're gathering information. Interviews can be used to gather information from different individuals, but are more expensive and time-consuming than surveys.

Applying key questions in evaluating potential solutions (approaches, strategies): Community Toolbox 4.0

It is finally time to decide which ideas for solutions are best suited to your group's effort. Simply evaluating the solutions that were plugged into the chart above is an excellent first step. Evidence-based or brainstormed (experience-based) solutions that could not be matched to identified factors can be set aside for future use. Those that appear promising can be evaluated more thoroughly. The following approach will help you evaluate potential solutions: 1. Judge each solution and its components independently. List on separate pieces of paper: » What does the evidence and experience suggest will work » What seems right to do in our context » What feels right for our group to take on » What are the likely intended and unintended consequences

Why use a comprehensive intervention? Community toolbox 7.0

Multiple factors affect health issues. It is unlikely that any single program or change in policy will be sufficient to improve health outcomes at the community level. Comprehensive interventions are multi-component efforts intended to achieve changes in outcomes. Comprehensive interventions include new or modified community programs, policies, and practices delivered through different community sectors.

The Springfield community is examining the issue of high rates of tobacco use among youth. This community has a high school district that draws from several smaller surrounding communities. The geographic area served by the hospital in the community is the city of Springfield and these surrounding communities. Recommend the scope or geographic area that will define "community" in this community health assessment. Community Toolbox 3.0 - Activity 3

Possible Answer: The scope or geographic area that will define "community" for Springfield's community health assessment will include the city of Springfield and surrounding smaller communities: - Specify a county or city, hospital service area, etc. - Rural context: we will include multiple counties with targeted assessments for towns with health disparities - Urban context: we might include one city, with targeted assessments for neighborhoods/census tracts with health disparities

Identify human and financial resources needed to implement priority strategies and secure commitments: Community Toolbox 8.0

Secure financial commitments from partners for needed implementation, coordination, and data collection. Is a coordinator needed to facilitate engagement and follow up on agreed-upon actions? » Apply for additional funding, if appropriate, to support implementation. » Engage community leaders who have trusting relationships with communities with health disparities in implementation efforts.

5. Identify clear roles and responsibilities for community members

Specify community members' opportunities for: - Roles (e.g., advice, review of plans, decision making) - Responsibilities (e.g., attending monthly community advisory board meetings, chairing sub-committees, providing voice about relevance to community concerns)

What are strategies?

Strategies refer to how the initiative will reach its objectives. Generally, organizations will have a wide variety of strategies such as forming coalitions or public awareness campaigns. These aim to engage people from different sectors, or relevant parts, of the community. These strategies range from broad approaches that encompass many different people and organizations from multiple sectors of the community (such as a coalition or partnership strategy) to very specific activities that take place on a much more focused level (such as a training program for particular groups, or an advocacy campaign for a particular policy change).

How-to steps in developing a strategic (and action) plan: Community Toolbox 6.0

The first phases of this process involve articulating the broad view: vision and mission statements and objectives. This is followed by developing strategies and an action plan for implementing them. 1. Convene community members and groups who have a stake in the community health improvement effort. Indicate how you will bring together a group of individuals and organizations from various sectors of the community who are affected by the problem or goal and/or who are in a position to address it. State the mission (what and why) for the community health improvement initiative. Here is an example: Promoting healthy families [the "why"] through parent training and community support [the "what"]. a.) Develop a mission statement that includes what is to be done and why: » Describe the essential "what" of the initiative by reviewing its core functions and current programs and activities » Explain the essential "why" of the organization or initiative by reviewing the vision statements » Frame the mission statement as a single sentence that captures the common purpose (the essential "what" and "why") b.) The mission statement should be: » Clear, regarding what is to be done and why » Concise, usually one sentence » Outcome oriented » Robust, leaving open a variety of possible means » Inclusive, reflecting the voices of all people who are involved. State the objectives of the initiative (how much you hope to accomplish by when): a.) Create objectives by identifying and specifying intended changes/improvements: » Identify the changes/improvements to be made in: ο Activities to be implemented ο Community/system changes to be brought about ο Behaviors related to the problem/goal ο Longer-term health outcomes » Specify how much or what by when for each objective for your initiative 4. State the objectives of the initiative: c.) Ensure objectives are "SMART + C": » Specific » Measurable, at least potentially » Achievable » Relevant, to the mission » Timed, with date for attainment » Challenging, requiring extraordinary effort Be flexible with deadlines in creating objectives; for instance, if the objective is important but may not happen right away, keep it but extend the timeline for attainment. Defining objectives is a process; it may require second and third versions for clarity and completeness. 4. State the objectives of the initiative: c.) Ensure objectives are "SMART + C": » Specific » Measurable, at least potentially » Achievable » Relevant, to the mission » Timed, with date for attainment » Challenging, requiring extraordinary effort Be flexible with deadlines in creating objectives; for instance, if the objective is important but may not happen right away, keep it but extend the timeline for attainment. Defining objectives is a process; it may require second and third versions for clarity and completeness. 5. Identify the strategies (how things will be accomplished). a.) Consider the personal and environmental factors that affect the likelihood of the problem/goal and should be addressed by the activities/strategies: » Personal factors may include: knowledge, beliefs, skills, education and training, social status, experience, cultural norms and practices, cognitive or physical abilities, gender, age, and genetic predisposition. » Environmental factors may include: social support and ties, available resources and services, barriers (including financial, physical, and communication), social approval, incentives and disincentives, policies, environmental hazards, living conditions, poverty and other social disparities 5. Identify the strategies (how things will be accomplished). b.) Consider those who can most benefit and contribute and how they can be reached or involved in the effort: » Targets of change - how will we reach those who may be at particular risk for the issue » Agents of change - how will we engage those who may be in a position to implement priority activities/changes (often includes targets of change) » Community sectors through which targets and agents of change can be reached or involved When developing strategies, identify: » The levels to be targeted (e.g., individuals and families, organizations and sectors, whole community, and/or broader system) » Whether the strategy/approach will be: ο Universal, such as all children and youth. ο Targeted, such as youth who have greater risk for the problem. e.) For each strategy, consider what community programs, policies, and/or practices should be created or modified. Consider "best practices" or intervention approaches for which there is evidence of effectiveness. Make a list of strategies to use, keeping in mind how they work together to address the problem or goal. f.) Review the strategies for: » Whether they are likely to be effective in achieving results » Consistency with the overall vision, mission, and objectives » Goodness of fit with the resources and context » Anticipated resistance and barriers and how they can be minimized » Whether those who are affected are reached g.) Report potential strategies to the group, and revise based on feedback .) Convene the planning/ community stakeholder group to design the action plan. The group should be inclusive of a variety of individuals and groups including: » Influential people from all groups affected » People directly involved in the problem or goal » Members of key organizations » Members of groups facing health disparities » Different sectors of the community (e.g., government, business) Develop an action plan for implementing each priority activity/strategy implemented or community/system change to be sought. b.) Identify priority activities/strategies to be implemented and community/system changes to be sought. (Consider "best practices" or approaches for which there is evidence of effectiveness, especially if results were achieved in similar contexts.) » After compiling a list of potential strategy/changes, review each candidate and consider its: 1) Importance to the mission and 2) Feasibility » Secure a formal decision from the group on what strategy/interventions/community changes will be implemented or sought.

7. Determine who will find the information

The right person or persons for this task may vary, depending on the types of additional information that need to be included. Brainstorm what staff and volunteers within the partner organizations have the most experience in collecting these types of data, and identify who might be interested in and willing to do so.

Which of the following is not an example of prime use of identified assets and resources?

To publish a list or map of the assets identified To highlight the value of partner organizations To use asset patterns to target a particular place or group for development efforts To see progress in building community assets

Conditions to help ensure that "what works" can actually work in the community community toolbox 7.0

Use of sound practices that are well developed through systematic research and experience » Knowledge and skill of local implementers and local leadership » A clear sense of mission or belonging to something greater » Access to people who have successfully implemented the program previously » Technical assistance that recognizes there are new things to be discovered. Adaptation of the best practices to reflect the context » Local involvement in initial planning, finding and choosing among best practices, and implementing and adapting the intervention » Adequate resources: people, money, supplies, and time to achieve your goals » Documentation and feedback on implementation of core intervention components and community and systems changes » Outcomes matter when judging success of the effortgnizes there are new things to be discovered

Identify key stakeholders across multiple sectors whose organizations can contribute to addressing priority community issues: Community Toolbox 8.0

» Engage the leadership or boards from relevant groups including the local hospital, the health department, United Way and other human service agencies, and the community health coalition » Engage community members, including those most affected by the issues » Engage university or consultant organizations and others needed to support the community health improvement effort

Assess the fit of the proposed health issues and approaches for implementation with other current/emerging efforts to address related community health concerns. Community toolbox 4.0

» Note the overlap/gap between the proposed priority issues and approaches for implementation with other current/emerging efforts » Look to adjust, coordinate, and integrate efforts for maximum community benefit at lowest cost 8. Engage the community advisory board in making a formal decision about priority goal areas and approaches for implementation 9. Indicate how the priority approaches will be implemented fully and sustained long enough to achieve community health improvement

1.5 and 2.0 When should you identify community assets?

Identifying and engaging community assets should take place continually. Pay attention to resources and how they might be called upon to be part of a solution to identified health issues. Some situations in which identifying community assets may be especially desirable: - When the problem seems overwhelming, or you don't know what the assets are - When people's valuable skills are underused - When you want to encourage residents to own local concerns and improvements - When you want to strengthen relationships that will promote community health and development - When you want a collaborative approach to addressing community issues and goals

What is a community description?

A community description is a written analysis that describes the people and situation of a community. It usually includes information about geography, demographics, historical, social and cultural characteristics, and a summary of the community's problems and strengths. This information is gathered from secondary (existing) data sources (e.g., archival records) as well as through primary data collection (e.g., using direct observations, surveys, interviews, focus groups). 1.3, 3.0

1.6 and 3.0 Using focus groups as part of a community health assessment

A focus group is a small group discussion guided by a trained leader, used to learn more about a designated topic, and then to guide future action. Focus groups differ from other groups in three basic ways: - The group is given a pre-determined, focused discussion topic, such as ways to reduce risk for HIV/AIDS or assure quality care for children. - The group has a trained leader or facilitator who keeps the group on course. - The group's composition, such as people at risk for HIV/AIDS or young parents, is carefully planned to create a non-threatening environment for speaking openly. Members are encouraged to express their own opinions and also respond to other members, as well as to questions posed by the leader. Because focus groups are structured and directed, but also expressive, they yield a lot of specific information in a relatively short time.

What is a framework? What is a logic model? Community Toolbox 5.0

A framework is a structure used to give shape to something. Like the frame of a house, a framework for a community health initiative supports and connects the parts of that effort. A model is a representation of how things will work. Like an architect's model of a building, a model of change depicts visually how what is done produces the intended effects. What does the term logic mean in this context? For these purposes, "logic" is a sense of how things will work. It describes systems and relationships among inputs (e.g., funding) and outputs (e.g., new programs or policies, people served) intended to affect outcomes (e.g., widespread behavior change, lower rates of problems).

What is a community need?

A need can be defined as the gap between what a situation is and what it should be. Examples include the need for access to affordable nutritious food or clean water, opportunities for physical activity, and long-term negative health consequences of living in a place with high levels of environmental contaminants. A need can be felt by an individual, a group, or an entire community. 1.4 and 2.o

How-to steps for analyzing problems or goals: Community Toolbox 4.0

1. Ask questions about the problem or goal to identify key behaviors, actors, and consequences. a.) What behaviors contribute to the problem or goal? » What specific behaviors need to change, in which specific groups of people? » Whose behavior needs to change to transform the conditions that contribute to the problem or goal? ) Who is affected by the problem or goal? » What groups of people are most affected? » How many people are affected? » In what places do they live? c.) How are people affected by the problem or goal? » What are the consequences of the problem or goal for those affected? » How often does the problem occur? » For what amount of time are people affected? » How severe (socially significant) are the effects? » How important is the problem or goal perceived to be? By community members? By outside experts? When and where did the condition or behavior first occur, or when did it become significant? » Is the problem new or old? Is it increasing or decreasing? » In which places or groups does it occur more often? Why? Identify relationships among the identified community problems or goals. a.) State your priority problems or goals and how they may be linked to other related issues. b.) Draw a map or diagram of possible links between the priority problems or goals and other related issues. Use arrows (pointing one or both directions) to show how these issues may be related to each other. c.) How does this picture of interrelationships among problems/goals influence how we would address the problem or goal? When we analyze a particular problem, we ask questions of the situation, gather information, and examine available evidence. This probe seeks both depth and breadth for additional information about the problem. We then use logic to interpret that information and draw conclusions that can lead us to more effective solutions. Herein lies the value of analysis; it helps us see elements of a potentially effective solution.

5. Using surveys as part of a community health assessment Community Toolbox 3.0

A survey is a way of collecting information that you hope represents the views of the whole community or the group in which you are interested. It attempts to collect information in as uniform a manner as possible. It may include questions that call for a specified response: a "yes/ no/ don't know" choice, or categorical choices like family size of 1, 2, 3, 4, 5, 6 or more. In a behavioral survey, people are asked to report on their behavior during a specified time period (e.g., "During the past week, how many times did you walk, run, or engage in any other moderate physical activity for 20 minutes or more?"). Sometimes surveys also provide a space for open-ended responses in which more qualitative, descriptive information can be provided. However, surveys generally collect quantitative data. (The U.S. Centers for Disease Control and Prevention (CDC) offers a variety of behavioral survey modules through its Behavior Risk Factor Surveillance System [BRFSS] and Youth Risk Behavior Survey [YRBS].) Surveys can be administered by phone or in person, by mail, email, through websites, or at a particular location, such as a community center, that people frequently visit.

What is a vision statement? Community Toolbox 6.0

A vision statement for a community health initiative conveys what the group believes are the ideal conditions for your community. It communicates what success would look like. Having a clear vision has a number of advantages. It can: draw people to common work, encourage stakeholder buy-in, help articulate the group's work to others, and provide a basis for other important elements of planning. The vision statement should contain brief phrases that convey the community's dreams for the future. Examples include: healthy children, active adults, caring parents, safe neighborhoods, access to opportunity, health for all.

Adapting for differences in culture or context Community toolbox 7.0

Adaptation requires that when community members have identified a best practice that has been effective elsewhere, they must also be aware of the differences in context between their organization or community and that of the situation in which the best practice was identified. » Is your targeted group different from the original situation? In what ways (poverty, ethnicity, age, religion, cultural practices)? » What components of the intervention, such as skill training or modifying access, are necessary to preserve the intervention's effectiveness? » How might this difference affect implementation of the key components in your community? » What kinds of changes in the intervention would take advantage of your organization or community's strengths and resources? In cases where differences in culture or context exist, the importance of appropriate adaptation cannot be overstated. A well-adapted intervention will: » Show respect for the community and its diverse cultures, values, and identities » Improve your ability to connect with the community » Increase the relevance of your activities and interventions » Decrease the possibility of resistance or unwanted surprises » Increase the involvement of members of the community and its cultural groups » Increase support for your program or intervention » Increase the chances for success of your intervention

Who are agents of change? Community Toolbox 4.0

Agents of change are the people who can help reach the identified goals, or prevent or reduce identified problems. They are people who can influence those who are at risk, the targets of change, or the conditions that contribute to the problem or goal. Agents of change may include a variety of individuals, groups, or organizations - including those from communities that are most affected by the concern.

When should you analyze a community problem/goal? Community Toolbox 4.0

Almost always, however there are some conditions when analysis is especially important: » When the community problem or goal is not clearly defined » When little is known about the problem or goal, causes, or consequences » When people are jumping to "solutions" too soon » When you need to identify actions to address the problem or goal, and learn what people or groups could best collaborate to take action

Consider whether the conditions that affect success are present (or can be created) in your community

Alone, or in combination, will the "best practices" be sufficient to achieve the desired outcomes? » Is it feasible for us to implement the intervention in our community? Can we afford the potential costs, including financial costs, time, and political costs? » Can we assure the required amount ("dose") of the intervention for the required time ("duration") to produce the desired results? » Can we assure that important factors affecting success, such as the knowledge and skill of implementers, leadership, technical support, time and other resources, will be present in our community? » Are the effects likely to generalize to people and conditions in our community? Community toolbox 7.0

HELP TOOL Assess the readiness of key partners to fulfill their implementation responsibilities, and provide needed training: community Toolbox 8.0

Although community partners have agreed to work together, it is important to build capacity to work together across diverse sectors. Plan for needed training, coaching, and practical tools to support them in doing the work.

How-to steps for analyzing problems or goals: Community Toolbox 4.0

Analyze the "root" causes of the problem to identify environmental conditions, related behaviors, and promising interventions that might contribute to improvement. Analysis of root causes allows a deeper look at factors that may influence the priority issue. a.) Identify key social determinants that may be affecting health and health disparities (i.e., income/inequality, education, housing) b.) Identify available/potential data sources for examining social determinants » Census data on income, education, housing, etc. » Morbidity and mortality data » Data on behavioral factors such as Behavior Risk Factor Surveillance System (BRFSS) c.) Gather data and organize information on social determinants of health/equity. Consider differences in: » Exposure to conditions (e.g., environmental hazards, toxins, stress) » Vulnerabilities (e.g., lack of education, resources, power) » Consequences (e.g., discrimination, access to care) Assure opportunities for community members and those responsible for implementation to participate in reviewing the information (e.g., public forums) e.) Use the "but why" technique to explore the "root" causes of the problem: » State the priority issue or problem » Ask "But, why?" » For each answer given, repeat the question: "But, why?" » Based on responses, identify environmental conditions and related behaviors that may need to change » Based on the analysis, identify promising interventions that might contribute to improvement. 3.) Identify restraining and driving forces that affect the problem or goal by conducting a "Force Field Analysis." A force field analysis allows you to look more broadly (rather than deeply) at the issues and forces surrounding it. For each priority problem or goal area, ask the same questions: What forces are keeping the situation the same? (These are restraining forces) List all the reasons you can think of that maintain the status quo. » What forces are causing it to change? (These are the driving forces) List all the reasons you can think of that are pushing the situation to change. Indicate how this analysis influences how we would address the problem or goal. What strategies are more promising given this mix of restraining and driving forces?

Analyzing the Problem or Goal Community Toolbox 4.0

Analyzing community problems involves asking questions to "break apart" the problem to see factors affecting it. This learning can feed into simple logic for how we see things working, and eventually a plan for addressing it. Careful analysis of the problem can help us see promising intervention strategies. Answering some basic questions can advance our analysis of the factors contributing to the problem or priority issue: » What behaviors of which people contribute to the problem or goal? » Who is affected? » How are they affected? » When did the problem first occur or become significant? » Why (or through what environmental conditions) are they affected?

What does it mean to analyze a problem or goal? Community Toolbox 4.0

Analyzing community problems is a way of thinking deeply and thoroughly about a problem or goal that matters to community members before adopting and implementing a solution. It first involves looking for possible reasons a problem exists, and further investigating whether those reasons truly contribute to the problem. Then (and only then) does it involve identifying possible solutions, and implementing the best of those.

Assure feedback and participation opportunities for community members and stakeholder organizations. Community toolbox 8.0

Arrange for community forums or listening sessions, as well as meetings with staff of key agencies to be sure that you have local buy-in. Establish comment/feedback period for draft plans for implementation, and communicate adjustments in the plan based on feedback.

An effective logic model can have many benefits, and a few potential limitations. Community Toolbox 5.0

Benefits of a logic model include: a.) Integrate planning, implementation, and evaluation b.) Prevent mismatches between activities and intended effects c.) Enhance accountability by keeping stakeholders focused on outcomes d.) Reveal data needs and provide a framework for interpreting results e.) Define a shared vision and language for change and improvement 2. Limitations and challenges with logic models: a.) Creating an effective logic model can be time-consuming and challenging b.) If not done well, your model may not accurately show your group's work and accomplishments c.) Establishing the boundaries of the model can be a challenge; include enough depth to provide a context but not so much that its clarity is lost d.) The logic model must be revisited and updated over time to keep it current

Why should you assure shared investment and commitments? Community Toolbox 8.0

Commitments and firm agreements help assure that there will be adequate resources for implementation of the plan. Involvement from diverse stakeholders, such as those from government agencies and community organizations, makes it more likely that the initiative will benefit from community engagement and buy-in, and ultimately, that the initiative will be successful reaching its goals. This module covers practical steps for assuring shared investment and commitments of diverse stakeholders.

Lastly, identify the modes of delivery for each intervention component community toolbox 7.0

Common modes of delivery include courses, workshops, personal coaching, support groups, media campaigns, and other programs.

The Lincoln community is working to improve the health of all its children. The community is intending to address this community problem through increased physical activity and healthy nutrition for children.

Community Toolbox 6

What is context? Community Toolbox 7.0

Context refers to community members' experiences, beliefs, history, environments and circumstances. It includes the features of the physical environment such as sidewalks, buildings, parks, and other public resources. Community members are part of the social context: who lives there, how they interact with one another, and their perceptions about their community and their quality of life. Context also includes the goals of the community and what community members envision for their future. One important aim of community assessment is to understand community context: to gather critical information about how a community functions, and in turn, how interventions might be adapted to be successful.

A comprehensive intervention to promote early childhood development might include the following Community Toolbox 7.0

Creating public service announcements about the benefits of reading to children, and providing parent training classes (Providing information and enhancing skills) » Providing quality day care where people work (Modifying access, barriers, and opportunities) » Honoring those who are champions for child causes (Changing the consequences) » Expanding home visitor programs to reach all new parents (Enhancing services and supports) » Extending access to health care for all families (Modifying policies and broader systems)

What do we mean by culture? Community toolbox 7.0

Culture refers to the distinctive behaviors, norms, roles, achievements, and products of a particular group. We can also see culture as the ethnicity, traditional practices, or history that a group of people shares. Within any broad cultural grouping, there are often subgroups with significant differences. For instance, a group of women or youth may have markedly different levels of income or education that would affect the conditions for their health and well-being. Aspects of cultures with varied traditions, histories, or differences include the following: Age » Gender » Ethnicity and race » Social Class »Religion » Sexual orientation Employment » Educational background » Geographic or regional background » Family background » Neighborhood

Why should you assess and identify community needs?

Data-based decision making: Gathering current and historical data is essential for showing the magnitude of the problem, and trends over time. Access to accurate and sensitive measures of community wellbeing can help groups answer the question, "What are the biggest and most serious health issues in our community?" This information can help when it comes time to prioritize the most important issues to address in the plan for community health improvement. - Credibility: Knowing the facts about the exact numbers of people affected by the issue(s) you are concerned about is essential for assuring effective communications and maintaining credibility - Planning for taking action in the community: Assessing and identifying community needs helps in systematically planning interventions to improve community-level outcomes 1.4 and 2.0

Establish a working agreement about stakeholders' roles and responsibilities for implementation Community Toolbox 8.0

Depending on the context, there may be a continuum of formality to the agreements. For instance, once trust and relationships have been established, the group may develop a formal agreement (e.g., signed Memorandum of Agreement) to support the community health improvement efforts.

How-to steps in developing a logic model Community Toolbox 5.0

Describe the intended uses of your framework or model of change Understanding how the model will be used, and its intended audience, will allow the group to make better decisions about what is included and which strategy will be most helpful in development. [Hint: Intended audiences may include: leadership of key organizations, community members, planners, evaluators, advocates, funders, and other key stakeholders.] With the audience in mind, you may decide to use the model to: a.) Convey the purpose and direction of the organization or effort b.) Clearly depict how the elements or factors influencing the problem or goal will interact and what actions need to be taken to bring about change c.) Explicitly plan out what actions are the most likely to lead to desired results. Outline the vision and mission, objectives, and potential strategies for the community health improvement effort An upcoming lesson in this Module will help you more fully explore these elements for your initiative's strategic plan. However, in a tentative and preliminary fashion, at this stage you should try to express the following for your group: a.) Vision: a very brief summary statement of the dream for the future b.) Mission: a concise description of what you will do and why c.) Objectives: specific and measurable anticipated results d.) Proposed strategies and actions to address the issue Find the logic that may already exist in written materials and "de-code" it (put it into a logic-model form) a.) Collect grant applications, reports to funders, and other program documents that explain the basic approach used by the effort b.) Read each document with an eye for inputs, activities, outputs, and effects of the effort c.) As you read, ask the "If, then" and "But how" questions. [Note: Watch for verbs (e.g., teach, support) that are often connected to program activities, and adjectives (e.g., improved, reduced) that are often connected to expected effects or outcomes.] d.) "Decode" these documents and sketch out logical links as you find them. For example: the education and advocacy is expected to change community policy which is expected to affect behavior outcomes. Describe the appropriate scope or level of the logic model a.) Choose the right level of detail, keeping in mind that: » The model is not an exact representation of everything that is going on » A good model has utility and simplicity » It is possible to create "families" of logic models by nesting or zooming-in, depending on intended users and uses b.) Begin with a broad overview or global model that describes the overall effort c.) Consider other models for particular programs or activities that are part of the overall effort Identify all components of the model a.) Purpose or mission - what the group is going to do and why b.) Context or conditions under which the problem exists and that affect the intended outcomes c.) Inputs, resources, and barriers d.) Activities or interventions - what the initiative or program does to effect change and improvement e.) Outputs - the direct results or products of activities of the group (e.g., number of people trained) f.) Intended Effects - more broadly measured outcomes or results including: » Short-term effects, such as new or modified program, policy, and practice. » Intermediate effects, for example a behavior change. » Long-term effects, often an improved health outcome. Draw or graphically depict the framework or model of change This may use the linear form displayed in the boxes above or an alternate form, as appropriate to your situation. a.) Show an expected time sequence (what occurs before what) to arrange the components and elements. Show connections between activities and effects over time, making explicit any assumptions about what kinds of change to expect and when. b.) Use arrows or other methods to communicate directions of influence and sequences of events. Some arrows may point in both directions to show mutual influence; others may circle back to previous components to show that the process is interactive or repeating. c.) Revise the model, as appropriate, to more clearly illustrate relationships or add components Check for completeness and clarity of your logic model It is useful to present the logic model to others for feedback, and to test it out before putting it to use on a full scale: a.) Select a case situation for simulation (real or hypothetical) for which you can get feedback about your logic model b.) Check for clarity of the elements of the model (e.g., "Is it understandable?") c.) Check for completeness of the model (e.g., "What is missing?") d.) Revise and add to make it more clear and complete. Put the model to use in various stages of the effort Consider the usefulness of the model you've prepared for the effort's varied phases: a.) Orientation - used to explain how the elements of the initiative or program work together, where contributors fit in, and what they need to be able to do to make it work b.) Planning - used to clarify your initiative or program's strategies, identify targets and outcomes, prepare a grant proposal, identify necessary partnerships, and estimate timelines and needed resources for the effort c.) Implementation - used to determine what elements you have and don't have in your initiative or program, develop a management plan, and make mid-course adjustments d.) Communication and advocacy - used to justify to others why the effort will work and to explain how investments will be used. e.) Evaluation - use as a framework for guiding the evaluation, including identifying evaluation questions, determining which indicators will be used to measure success, and to frame questions about attribution (of cause and effect) and contribution of the program or initiative to the mission. Revise the model as needed Using the model will allow you to: a.) Clearly link the path of activities to intended outcomes b.) Plan expansion of activities to reach your goals c.) Understand the boundaries of your program or initiative d.) Adjust course for unanticipated changes

How-to steps in developing a strategic (and action) plan Community Toolbox 6.0

Describe the vision for the community health improvement initiative: a.) In a workshop, retreat, or dialogue about the group's vision, capture: » Dreams for the community or initiative » What success would look like » How things ought to be » What people and conditions would look like if things were consistent with that picture b.) Review the multiple vision statements for conciseness (usually two words) and positive framing. Support diversity of vision by including multiple vision statements. c.) Identify vision statements with particular power: » Choose vision statements that are embraced by the group and backed by the findings of the community health needs assessment » (As appropriate) Select/edit the vision statements that are particularly effective in conveying the vision » Check to see that everyone's voice is heard in the final selection d.) Select one statement (or several) that most concisely expresses the vision. It should be acceptable to all members and can be used in crafting the "why" portion of the mission statement (see next step). Identify the strategies (how things will be accomplished). d.) Identify how specific change strategies will be used, including: » Providing information and enhancing skills (to address personal factors related to knowledge and skills) » Modifying access, barriers, and opportunities (to address environmental factors related to barriers; e.g., including financial, physical, and communication) » Changing the consequences (to address environmental factors related to incentives/disincentives that affect the problem or goal) » Enhancing services and support (to address environmental factors related to available services, social support and ties, and other resources) » Modifying policies and broader systems (to address environmental factors related to policies, environmental hazards, living conditions, poverty, and other broader conditions that affect the problem/goal)

Developing a Logic Model Community Toolbox 5.0

Development of a logic model is an iterative process; it evolves as things change Stakeholders from diverse backgrounds will be interested in helping to develop the logic model. Those who will use the model can certainly be of help in creating it (key organizations, community members, planners, evaluators, advocates, funders, and other key stakeholders.) However, you may wish to begin with a smaller group, perhaps a representative group that can prepare a draft document that is then shared with others and further refined.

Consider the strength of the evidence that the "best practice" led to improvement Community Toolbox 7.0

Did what was measured reflect the community's indicators of success? » Did the experimental design make it possible to rule out other plausible explanations of the effect? » Are the effects socially significant? Are the effects large enough to make a meaningful difference?

Some considerations in generating potential solutions 4.0 Community Toolbox

Each stakeholder or member of the community group should have a chance to voice potential solutions There are many approaches for identifying solutions to address community problems and goals; listed are a few of the many different ways. » Review the literature or databases of evidence-based approaches: Ask a member of the group (or outside expert) to present on "what works" in addressing the identified community problem/goal, including the size of the effects and strength of the evidence. » Solicit ideas from the group: One technique: Go around the room and ask everyone to suggest ideas, or send a piece of paper around the room. People can write down their ideas, which can later be discussed without anyone knowing who suggested which idea. » Individual brainstorming. Encourage people to voice or write down their ideas. After individual brainstorming, group members can comment on one another's initial ideas. During and after the meeting, all the ideas are recorded and later summarized in a report. » Group brainstorming. The problem is stated, and a recorder stands in front of a room to write down whatever ideas come up. People say their ideas for solutions, and the recorder writes down all of the comments made, without censoring or discounting any ideas. » Relating and charting solutions. Particularly useful after a brainstorming session, the group can look to generated ideas as a way to further complete the problem or goal chart that is evolving. Gaps in the chart may lead to additional solutions. This step is also useful in evaluating the potential contribution of solutions to factors identified in the analysis. » Internet-based forums. This can be used to enter, retrieve, and extend available ideas. This may be helpful when those providing input are distributed geographically or cannot meet at the same time. Ask the following questions: » Is there evidence of effectiveness? » Can similar results be achieved in our context? » Is it practical to implement? » Is there capacity to implement it effectively? » Does the solution fit the values and accepted practices of those involved? » Are the benefits likely to outweigh the costs? Identify needed adaptations to solutions(s) under consideration, if suggestions have surfaced for areas of improvement. Consider adaptations to fit culture, available resources, and context.

Review the action plan and prepare for implementation: Community toolbox 8.0

Ensure the action plan engages all relevant sectors of the community » Review candidate community programs and policies to be implemented. Ensure there is an evidence base for achieving intended results. » Ensure that the action plan includes all partners' agreed-upon activities for implementation. Friendly Reminder: The action plan should list who will do what activities by when, with what resources, and who should know about it. When considering the timing of activities, make sure you consider how they may compete with or complement one another. » Prepare for action by providing training for implementers. » Assure technical support for full implementation of each strategy. » Plan for how you will monitor and obtain feedback on implementation and results.

Establish explicit criteria for selecting approaches to address prioritized issues Specific criteria for identifying priority approaches/interventions for implementation may include:

Evidence-based approaches » Fit with the local context (i.e., available resources, timing, cultural practices) » Feasibility of implementing and sustaining the intervention long enough to make a difference » Fit with other community efforts and related priorities

When identifying intervention components to be incorporated, consider these five strategies Community toolbox 7.0

HELP TOOL 1. Providing information and enhancing skills to address factors related to personal knowledge and skills 2. Modifying access, barriers, and opportunities to address environmental factors related to barriers 3. Changing the consequences to address environmental factors related to incentives/disincentives that affect the problem or goal 4. Enhancing services and support to address environmental factors related to available services, social support and ties, and other resources 5. Modifying policies and broader systems to address environmental factors related to policies, environmental hazards, living conditions, poverty, and other broader conditions that affect the problem or goal

How-to steps in developing a strategic (and action) plan: Part 3. Community Toolbox 6.0

HELP TOOL 6. Develop an action plan for implementing each priority activity/strategy implemented or community/system change to be sought. c.) Identify action steps for each activity/ strategy to be implemented or community/system change to be sought (who is going to do what by when). Describe: » What will be done (key tasks to be completed) » Who will carry it out » By When it will be implemented (for how long it will be maintained) » Resources required: money and staff needed/available » Communication: who should know what about this Develop an action plan for implementing each activity/strategy or community/system change. d.) Evaluate the overall action plan for: 1. Completeness - Are all the key activities/strategies and changes included? Are a wide variety of strategies and sectors utilized? 2. Clarity - Is who will do what by when apparent? 3. Sufficiency - If all that is proposed was accomplished, would it meet the group's mission and objectives? If not, what additional activities/changes/interventions need to be planned and implemented? 4. Current - Does the action plan reflect the current work? Does it anticipate possible opportunities and barriers in the future? 5. Flexibility - As the plan unfolds, is it flexible enough to respond to changes in the community? Can it be modified as objectives are accomplished, or goals adjusted? Develop an action plan for implementing each activity/strategy or community/system change. e.) Follow through with your plans, track what you accomplish, celebrate your small (and large) wins!

Examples of SMART+C statements for objective type community Toolbox 6.0

HELP TOOL » Implementation objective: By 2013, the curriculum will be implemented in all participating schools. » Community/system change objective: By 2014, there will be a least one walking/biking path on the main routes to the elementary school. » Behavioral objective: By 2015, the percentage of children/adults reporting regular physical activity will increase by 30%. » Population-level objective: By 2020, the number of new cases of breast cancer will decrease by 20%.

Next specify the elements to be included Community toolbox 7.0

Identify the specific elements or distinct activities to be implemented in each intervention component. For example, if a comprehensive intervention to improve access to health screenings included a specific component of modifying access or barriers, that component would likely include elements such as: »Arranging for transportation »Providing child care »Locating services nearer to where people live, work, pray and play.

When numbers or percentages are important in describing things: Community Toolbox 3.0

If your desire is to collect data that is more uniform, surveys ask closed-ended, relatively narrow questions that are quantitatively scored. Respondents often give a categorical or numerical rating, rather than a verbal statement. Surveys can answer questions like "How many people report that they smoke cigarettes?" or, "How satisfied are users with our organization's services?" Surveys collect information about the behaviors, needs, and opinions of the respondents. Surveys can be used to find out about behavior that cannot be observed easily or ethically (e.g., what percentage of people practice safe sex). It can also be used to assess attitudes and reactions, to measure client satisfaction, to gauge opinions about various issues, and to add credibility to your research. Surveys are a primary source of information - that is, you directly ask someone for a response to a question, rather than using any secondary sources like written or archival records (e.g., rates of infant mortality, school dropouts).

Sustain stakeholders' involvement from diverse sectors long enough to achieve improvement in community health outcomes. Community Toolbox 8.0

Indicate how the crucial "6R" qualities will be incorporated into the group's meetings and activities to keep people involved and contributing to the initiative. The "6R's" include: Recognition - Recognize people for their contributions. Respect - Respect and consider people's values, culture, ideas, and time. Role - Give each person a clearly meaningful role through which they can contribute. Relationships - Provide opportunities for people to establish relationships and build networks professionally and personally. Reward - Ensure that the rewards of participating in the group outweigh the costs. Results - Work to achieve visible results that are clearly linked to important outcomes.

Why and when to adapt interventions Community toolbox 7.0

It is unlikely that a "best practice" shown to be effective in a different community or situation will require absolutely no adaptation to fit a new context. The intervention may address a similar problem or goal, such as educational success; but the context, such as an affluent or impoverished school, may be different. Resources, competence, and leadership that made a program successful in one situation can seldom be exactly duplicated across places. Adaptation may likely be necessary. The key is to retain essential components of the intervention, such as support or enforcement, while allowing for specific elements to be implemented somewhat differently in a new situation. With adaptation comes the added responsibility of monitoring results to see if similar effects can be attained.

What are objectives? Community Toolbox 6.0

Objectives refer to specific measurable results for the broad goals of the initiative. They generally lay out how much of what will be accomplished by when. Setting objectives can help prioritize goals and activities, keep the focus on the mission, and provide benchmarks for accountability. There are four basic types of objectives: » Process/implementation objectives refer to the implementation of activities necessary to achieve objectives. An example would be the number of training sessions delivered. » Community/system objectives refer to changes in the environment to be sought to address the mission. These typically consist of new or enhanced programs, policies, and practices. Examples include: a new walking/bike path (for physical activity), available interpreters in safety net clinics (access to health services), or expanded after-school programs (prevention of substance abuse and adolescent pregnancy). Behavioral objectives look at changing the behaviors of people and the products (or results) of their behaviors. For example, a group addressing cardiovascular disease might develop an objective around increasing physical activity (behavior) or the product of behavior (individuals achieving healthy weight). Community-level outcomes go beyond individual behavior to outcomes for groups of people. For example, a group working to prevent childhood obesity might look to reduce the percentage of children/youth with an unhealthy body mass index (BMI).

Why should you use explicit criteria and processes to set priorities?

Outlining what criteria and processes will be used for setting priorities helps ensure the biggest and most serious health issues in the community will be addressed (and not just those perceived to be important by a small group of influential people). These processes should assure participation of community members and key stakeholders, including those from diverse sectors and populations most affected by health concerns. Using explicit criteria and processes to set priorities will help provide transparency about the prioritization process, and is more likely to result in a plan that includes health goals seen as important to the community, as well as approaches sufficient to meet the prioritized goals.

Generating & Choosing Solutions to Community Problems 4.0

Several considerations are helpful in affirming that this problem or goal should be addressed by your community health improvement effort. 1. Importance When judging the importance of the issue, keep in mind the following: » The frequency with which the problem (behavior, outcome) occurs » The number of people affected » The severity of the effect » The perceived importance of the problem or goal to your group » The perceived importance of the problem or goal to others. Feasibility Should you decide that the problem or goal is important and worth addressing, ask: » Will you be able to solve it, or at least significantly improve the situation? » Is the good you can do worth the time and effort it will take? Potential Fit Is someone else better suited to the task? Answer honestly. Recognize the gifts and capabilities of others, and hand off this issue to others should they be able to address it more effectively, or in a more timely way than your group can. Unintended Consequences If you do succeed in bringing about the solution you are working on, what are the possible consequences? Even if there are some unwanted results, you may well decide that the benefits outweigh the negatives. But be sure you go into the process with your eyes open to the real costs and potential adverse consequences of addressing the issue.

What is an evidence-based approach? Community Toolbox 7.0

Sometimes best practices are referred to as having an evidence base. An evidence-based approach is a way of addressing a problem or goal that has research information to suggest that it "works" (i.e., the intervention, and not something else, brought about the observed behavior or outcome improvements). A caution: the "evidence" may be quite modest, shown only with particular populations, or the effects may be statistically significant but too small to solve the problem or achieve the goal. Although it may work in one situation, there may be little evidence that it will work in your situation.

What if I can't find relevant best practices? Community Toolbox 7.0

Sometimes, promising practices and interventions are untried, but are based on a sound theory of practice, past experience, or a thorough analysis of the problem. When the problem or goal is important, and no evidence-based practices exist, the group might brainstorm potential interventions of its own, and develop its intervention based on a clear logic model or theory of practice. Often, a comprehensive community intervention includes a mix of so-called "best practices" and other elements needed to achieve the goal. The ideal approach is to gather information from reliable sources such as online databases of best practices maintained by credible sources. Where possible, find reference material and directly contact the developers and implementers of the programs of interest.

Applying the key considerations in affirming community problems/goals Community Toolbox 4.0

The activities of this Module have led us to at least one priority problem or goal that will be the focus of our group's implementation efforts. Our work of analysis helped uncover aspects of the issue that appear to be more readily solvable, and others which may be more challenging to tackle with our group's available resources. Some considerations in affirming that this community problem/goal should be addressed by your group/initiative: The analysis should yield a clearer understanding of the problem and what it would take to address it effectively. For each problem or goal that you are addressing or considering, consider whether it meets the criteria of importance, feasibility, appropriateness of fit, and possible adverse impact. Having all of the information readily available can help the group choose more easily among candidate problems or goals and ways to address them.

Strategies for developing a logic model community toolbox 5.0

There are multiple strategies that will help you to develop your logic model(s). The two primary types, forward logic and reverse logic, can be used singly, or in combination, when constructing a model. » Move forward from the current situation (forward logic): To identify candidate factors to be addressed, ask "But why?" questions and include "If, then" thinking. (e.g., "The problem is that too many youth commit acts of violence. But why? If we did this activity, then what would happen?") » Move backward from desired effects (reverse logic): To construct a pathway that will yield the desired change, ask the question "But how?" (e.g., "Our goal is to assure that all children have caring adults in their lives. But how will this end be accomplished?")

Adapting and leveraging resources for low-resource contexts Community toolbox 7.0

There is a special challenge when there are significant differences in available resources for implementing the intervention. Often, a "best practice" was demonstrated to be effective under conditions of high resources, both financial and skill level of implementers, not typically found in communities. Tactics for leveraging local resources to implement and maintain interventions in low-resource environments include: » Share staff positions, space, equipment, or other resources with organizations with similar goals » Become a line item in an existing budget of another organization » Incorporate activities or services into another organization with a similar mission » Apply for grants » Utilize volunteers » Solicit in-kind support; seek goods and services the organization would otherwise have to purchase, such as donations of office supplies from a local business » Develop a fee-for-service structure, possibly using sliding-fee scales based on clients' ability to pay » Acquire public funding from legislature or city council First, determine whether it is appropriate to adapt the intervention for your situation Six criteria help determine when you should adapt interventions to fit different community contexts: » You have a promising approach » The practice is already tested and found to be successful » You are actively interested in implementing the approach in your (different) context » You have the needed time, money, and people to do so » Members of the community are interested in this intervention » Members of the community are willing to collaborate to make the intervention a success

1.6 The planning group for Maryville's community health initiative agreed to conduct focus groups as a means of collecting data for their community health assessment. Outline how they could use focus groups as part of a community health assessment.

This group could use focus groups to: - Examine a pre-determined, focused discussion topic, such as ways to promote physical activity or barriers to healthy nutrition - Have a trained leader or facilitator whose job is to keep the group on course - Engage people experiencing a particular community concern (e.g., higher risk for diabetes) - Actively encourage members to express their own opinions about the issue

Why engage in strategic planning?

This process grounds the community's aspirations for improvement. It makes good ideas possible by laying out what needs to happen in order to achieve the vision. » By creating this process in a group (taking care to involve both people affected by the problem and those with the abilities to change it), it allows your organization to build consensus around the vision and necessary steps for improvement. » Strategic planning helps focus on short-term goals while keeping sight of your group's long-term vision and mission for community improvement. It is particularly helpful to use this process: » When you have completed the community health assessment and need to take next steps toward implementation » When you are starting a new initiative » When you are moving into a new phase of an ongoing effort » When you are trying to invigorate an older initiative that has lost its focus or momentum

What is an intervention? Community Toolbox 7.0

To "intervene" literally means to "come between," or to prevent or alter a result. An intervention comes between our current situation and where we hope things will be. It is the means by which we promote healthy behavior and change environmental conditions to assure better health outcomes.

Next, assess the readiness for the group to adapt the intervention for your context Community toolbox 7.0

What cultural values and beliefs are important within your organization or community, and how might they differ from those of the (target) community intended to benefit? » Do you have any experience working with the cultural group that could most benefit and contribute, or with similar groups? » What lessons can you draw from past experiences that might be useful in adapting the intervention? » Are individuals in your organization ready to take on the work of doing the adaptation? Check the readiness of the group targeted to benefit from the adapted intervention Have you engaged those most affected by the problem or issue as resources and partners in the adaptation process? » Is the community or cultural group you wish to work with ready to work with you? » Are they able to work with you? Have you developed relationships with them and sought their input on the intervention's importance and appropriateness to their situation? » How is the group likely to react to your cultural tradition and efforts to adapt and implement the program?

The first step is to identify best practices or evidence-based approaches that have worked elsewhere. Community Toolbox 7.0

What is the best practice? A "best practice" can refer to a program, policy, or practice. Promising or best practices are those particular ways of doing things that have the potential to effectively address priority health issues in your community.

HELP TOOL Best practice for what? Community toolbox 7.0

When reviewing "best practices" or "evidence-based approaches," determine whether they are relevant for your goals. Three broad categories define a continuum of intervention: » Treatment: Treatment programs aim to reduce or minimize the adverse effects of an already existing problem or condition. Such practices are vital, but limited because they often do not address the underlying cause of the issue. » Prevention: Preventive interventions aim to reduce the new instances of a problem or undesirable condition. Such efforts may address personal and environmental factors. » Promotion: Promotion aims to attain an improved level of health and development. It may ask people to do something, rather than to stop doing something. A community may find greater success over the long term if it finds ways to integrate intervention strategies that incorporate treatment, prevention and promotion.

Establish a process for engaging stakeholders and the broader community in using the criteria to select priority strategies Community Tool box. 4.0

When selecting priority approaches/interventions to address prioritized goals: » Review agreed-upon criteria for selecting strategies/approaches » Discuss candidate approaches, including the evidence base and fit with the community context » Rate each candidate approach by importance in achieving the goal and feasibility of implementation » Facilitate a group review and discussion of ratings and potential synergy among approaches » Rank order and select priority approaches/interventions necessary to achieve the goals » Hold a vote

2. Establish a process for engaging other stakeholders and the broader community in setting priorities for community health issues

When setting priority health goals: » Review agreed-upon criteria for setting priority health goals » Discuss candidate community health issues » Facilitate a dialogue about why an issue is strategic and the consequences for addressing (or not addressing) an issue » Rate each candidate health concern by importance and feasibility of producing improvement » Facilitate a group review and discussion of ratings and possible consolidation of issues » Rank order and select 3-5 priority issues » Hold a formal vote on final health issues by members of governance body

Identifying Targets and Agents of Change: Who Can Benefit and Who Can Help

Who are targets of change? Targets of change are the people that the organization or initiative is trying to reach or benefit through the community health improvement effort. They generally fall into two categories: » Those people who are directly affected by the problem or are at risk for it, and/or » Those people who contribute to the problem or goal through their actions or inaction. It is important to note that targets of change often include those who influence conditions such as elected or appointed officials. Do not focus solely on the "usual suspects" by targeting only those who are experiencing the problem.

Lesson 1.4 5. Determine who will find the information

Will it be you? A staff member? A volunteer? Do you want one person to focus on gathering existing information (or collecting new data), or do you want to have several people working on it? Brainstorm who in your organization or partner organizations has experience in collecting data and also who might be interested or willing to do so. How will you assure that they have the time required to do the job?

What is a mission statement? Community toolbox 6.0

mission statement describes what the group is going to do, and why it is going to do it. Although similar to vision statements, mission statements are more concrete and action-oriented. The why portion of a mission statement might refer to a problem or to a goal. The what portion of the statement communicates the broad approach to be used. Mission statements communicate your group's overarching goals. Mission statements should be concise, outcome oriented, and inclusive. Here's an example: "To reduce diabetes and cardiovascular disease [the why] through a collaborative partnership to promote healthy nutrition, physical activity, and access to health services [the what]").

1. Engage the leadership group in establishing explicit criteria for setting priorities for community health issues to be addressed.

» Consistency with the community's vision and goals » Higher incidence/ prevalence/ magnitude » Severity (risk of morbidity/mortality) » Alignment with stakeholders' strengths/priorities » Importance to the community, including those experiencing health disparities » Fits existing assets and resources for addressing the problem/goal » Relationship or synergy with other community issues » Degree to which the issue is addressed by current efforts » Feasibility of change

Use the agreed-upon criteria and process to identify and coordinate priority strategies for implementation. Community toolbox 4.0

» Review agreed-upon criteria (e.g., including evidence/practice base for candidate strategies, fit with resources and barriers to implementation, etc.) » Identify several priority strategies for implementation for each issue (e.g., modifying opportunities for physical activity; enacting policies to increase costs of tobacco use) » Plan to coordinate efforts to implement related approaches/interventions across different health issues

Use the agreed-upon criteria and process to identify and consolidate a list of priority health issues Community toolbox 4.0

» Review agreed-upon criteria (e.g., including fit with community's vision and goals, incidence/prevalence, severity, etc.) » Identify several priority health issues to be addressed (e.g., prevent cardiovascular diseases/chronic diseases; increase access to health services/screenings; reduce disparities in infant mortality; promote early childhood education) » Consolidate list of issues using common factors for multiple issues (e.g., increase healthy nutrition, physical activity, access to health screenings/services; etc.)

Community toolbox 4.0 Why should you analyze a problem?

» To understand potential causes: A problem is usually caused and maintained by personal behaviors and the conditions in the environment that affect these behaviors. What aspects of the situation and broader environment contribute to the problem; or, could help achieve the goal? » To identify potential barriers and resources associated with addressing the problem or goal. It is good practice to anticipate barriers or obstacles before they arise, so you can get around or over them. Likewise, it is good planning to identify and find resources you need, so you can increase probabilities of success. » To identify promising solutions for addressing the problem or goal. Having a plan of action is always better than taking a few random shots at solving the problem. » To maintain member involvement in the effort. It can be debilitating to begin work on a problem or goal only to find you're working on the wrong thing, or to run up against obstacles, especially when avoidable.

Review credible sources of information on best practices Community Toolbox 7.0

» U.S. Centers for Disease Control and Prevention's Community Guide website » Links to Databases of Best Practices featured on the Community Tool Box » Literature reviews » Networking with other professionals » State and national advocacy and professional organizations, such as the American Public Health Organization » International, federal, and state agencies » Researchers at colleges and universities Be sure to cast a wide net. You should consider almost everything that could work. Also be sure to find out what didn't work.

6. Assure open communication of draft plans/findings and opportunities for review and feedback

- Arrange for community forums/listening sessions in the community and meetings with staff of key agencies - Establish comment/feedback period for draft plans for assessment - Communicate adjustments in plan based on feedback

1.5 and 2.0 Why should you identify community assets?

- Assets are the building blocks for community health improvement - External resources, such as public funding or grants may not be available; resources for change may need to come from within the community - Identifying and mobilizing assets enables community residents to gain control over the situation and become active, engaged agents of change

Why should you write a community description? Advantages include to:

- Capture unspoken but important community concerns, rules, norms, and practices - Develop a richer understanding of the local context - Gain perspective about the concerns and conditions of the community - Take stock of the strengths that exist, as well as areas for improvement 1.3,3.0

Identify potential uses of the data and consider implications for geographic areas Community module 3.0

- Clarify potential uses of the data (e.g., to identify priority health objectives, to identify determinants to be addressed, to meet reporting requirements) and let that inform what geographic areas your assessment should include

What is a community health assessment? Community toolbox 2.0

- Collection and interpretation of information to assess the community - Enables communities to prioritize, plan, and act upon unmet health needs to improve quality of life - Uses a collaborative approach and seeks community ownership of the process - Engages community members and stakeholders from different sectors - Helps identify community assets for health improvement efforts - Assesses community readiness and promising approaches to addressing community health problems and goals

community health assessment

- Collection and interpretation of information to assess the community - Enables communities to prioritize, plan, and act upon unmet health needs to improve quality of life - Uses a collaborative approach and seeks community ownership of the process - Engages community members and stakeholders from different sectors - Helps identify community assets for health improvement efforts - Assesses community readiness and promising approaches to addressing community health problems and goals

1.5 and 2.0 How-to steps for identifying assets of individuals

- Decide on the geographic area (or type of community) you want to cover - Decide whose perspectives you will seek - Decide on how many people you are going to ask - Draft the questions you want to ask to obtain the needed information. Are you interested in skills, (e.g., "I am a photographer"), or interests ("I'd love to learn about the history of our neighborhood"), or both? - Keep in mind why you are collecting the information, and how you plan to use it - Design a method by which these questions can be asked. Options include: - Going door to door and asking people - Mailing or emailing a survey - Having a survey available to pick up - Calling people on the phone - Scheduling interviews - Meeting people in groups - Try out your questions on a sample group. Based on their answers and their suggestions, make revisions.

Learning Objectives for Module 1:

- Define community health assessment - Engage community members and assure ownership among stakeholders - Define the geographic boundaries of the assessment - Identify communities with unmet/disproportionate health needs - Describe what matters to people in the community - Describe the resources available for addressing identified issues - Compile and describe evidence about local needs - Use criteria and processes for prioritizing issues to be addressed

3. Identify key outputs from the assessment/planning process and activities needed to produce them

- Develop a logic model or framework that includes a picture of what the group is doing and what should result from it. For example:

5. Establish a written agreement among key stakeholders specifying roles and responsibilities in the assessment, planning, and implementation efforts

- Develop a written agreement, such as a signed Memorandum of Agreement - Outline the key roles and responsibilities of organizations/individuals in implementing the agreed-upon activities (i.e., who will do what activities, with whom, by when, with what outputs or deliverables)

Lesson 1.2 How-to steps for assuring shared ownership among stakeholders: 1. Identify key stakeholders in the assessment and planning process

- Engage stakeholders from the hospital, local health department, United Way/human service agencies, government, schools, businesses, faith community, local community health coalition, law enforcement, concerned citizens, etc. - Engage interested members/advocates from populations experiencing health disparities - Clarify the coordinating entity for the community health improvement process

8. Indicate how stakeholders' involvement will be sustained from initial assessment through implementation of the plan for community health improvement

- Establish a written agreement among key stakeholders specifying roles and responsibilities in the assessment, planning, and implementation efforts - Plan for how the group will assure meaningful roles, appropriate responsibilities, adequate resources, minimal risks, and rewards for those doing this work

2. Determine stakeholders' interests (wants and offers) for this process

- Facilitate a dialogue about this with key stakeholders (individually, as a group), including what they see they may gain or lose from being involved

1.5 and 2.0 7. Create an assets map to communicate where community resources are located

- Find a large street map of your community that has few other markings and identify with a dot, tag, or push-pin (maybe color-coded by type) the geographic location of the groups and organizations you have found - Make use of technology (such as a customized Google Map) to generate a computerized map, which can be embedded into a website for easy sharing/ dissemination - It's also possible to diagram your resources on a non literal map that can still clearly show the linkages among different categories of assets When you have completed these steps, you will have a fairly thorough inventory of group assets in your community: the organizations, associations, individuals, and institutions that are a fundamental part of community life and that can be called upon to help bring about improvements in the community.

3. Determine when you want to use these data Community Toolbox 2.0

- For what time period do you want to find information? Look for current and historical information that can help give you a sense of the scope of the problem, and how trends have been changing over time. Examining information in the period before the intervention can help you track how things have changed, and help determine how effective you have been [For instance, What was the level of educational achievement (childhood immunizations, etc.) before the program was initiated 5 years ago, and what are the current levels of these indicators?] - When do you want to make this information public? You may want to make the information known right away. Or you might want to wait, perhaps to take advantage of a related public occurrence such as a local, national, or international event in order to draw additional attention to the release of the information.

7. Establish the governance and organizational structure for making decisions, managing, and supporting the work of community health improvement

- Form a community advisory board with specified membership (e.g., including leadership from the hospital, local health department, United Way, local community health coalition, community members, etc.) - Establish rules for decision-making - Assure clear functional roles for community members, including oversight

Identify specific geographic areas of responsibility for key stakeholders

- Geographic regions to consider: Specific region, county, tribal area, city/town, school district, zip code, census block, MSA, Congressional district, multi-county rural area, particular neighborhoods in urban area, hospital service area, hospital referral region

Awareness: Data can be used to raise community awareness about:

- How serious the problem is (e.g., the number of people affected) - How well (or how poorly) your community is doing in relation to other communities, or to the state or nation as a whole (e.g., what is the prevalence of childhood obesity for your county as compared to that of the state or nation? Or, how does the local level of educational achievement compare to others?) - How much progress your organization or effort is making in addressing the problem or goal (e.g., a decrease in prevalence of tobacco use associated with implementation of the effort) community toolbox 2.0

1. Describe the make-up and history of the community

- Include information that best describes the community (e.g., characteristics of its people, institutions, places) - Describe the sources of information used - Describe the methods used to collect the descriptive information - Describe strengths (assets) of the community, as well as issues of concern to the community 1.3

1.6 and 3.0 A survey may be your best choice when:

- It is impractical or unethical to observe directly - You need to learn more about the needs of your group or community. A good survey can supplement your own sharp-eyed observations and experiences - You want more detailed information from a larger and more representative group of people than you could get from observation alone - You think you may get a more honest and objective response - You need a quick and efficient way of getting information - You need to reach a large number of people - You need statistically valid information about a large number of people - The information you need isn't readily available through other means

Assess the fit of the proposed geographic area with available/potential data sources for the community health assessment

- Note the overlap/gap between the proposed geographic area (e.g., city) and existing/potential data sources (e.g., data only available for county level or hospital catchment area) - In low-resource contexts, consider selecting a geographic area that fits most key stakeholders and for which there are existing/potential data sources - When resources permit, plan for supplemental data you will collect 1.3 , 3.0

1.4 Identify gaps in your knowledge + community Toolbox 2.0

- Once you have thoroughly reviewed the information you have collected, consider its completeness. Were you able to determine everything you were looking for, or did you not find some important data? Has the information you have found helped you realize there is other helpful information that you should gather? - Brainstorm with others to see if you can obtain any data sources you may have missed. If the information you want just isn't out there, you may need to collect your own (primary) data. However, this process can be time intensive and you may wish to carefully consider whether the information is critical for understanding.

6. Assess the readiness of key organizations/individuals to fulfill their responsibilities and build capacity as needed

- Provide needed training, coaching, and practical tools to support those doing the work

1.6 and 3.0 This lesson provides an orientation to different types of (largely) qualitative techniques used to conduct community health assessments including:

- Public forums - Listening sessions - Focus groups - Interviews - Surveys (Census, Sample, Case study, Concerns, Needs assessment)

Some sources of secondary data (those already available that you obtain) include:

- Public records (e.g., public health database, hospital records). Depending on where you live, some data may not be part of the public record, but it may be possible to purchase some of it, or arrange to use it in some form - Census data: Demographic information (e.g., number of people, education level, income level) may be available for your community. Many states maintain similar information on websites of state agencies (e.g., state department of health, social/human services, or commerce) - Police records: For data such as number of homicides, injuries reported, number of DUIs issued, etc. - Business or Chamber of Commerce data: e.g., for data on new jobs created in the community - School districts for your area. For statewide data, use the State Department of Education - U.S. Centers for Disease Control and Prevention (or the World Health Organization) - Nonprofit community service agencies, such as the United Way, or non-governmental organizations, generally have records on a variety of different issues (e.g., number of children living in poverty, unemployment). These organizations may have already conducted surveys and found the information you need - Statistical abstracts can be a good general source (available from reference librarian in local or university library) - Specialized local, statewide, or national organizations and associations (e.g., state hospital associations, associations of local/county health departments) - Other existing and emerging data sources and resources on the internet: National Center for Health Statistics' Health Indicators Warehouse, Community Need Index, and MONAHRQ

Lesson 1.2 4. Identify human and financial resources needed for the work of community health improvements and secure commitments

- Secure financial commitments from partners for coordination, data collection, etc. (e.g., for part-time paid coordinator to facilitate engagement and follow up on agreed-upon actions) - Apply for additional funding, if appropriate (for example, to local health foundation) - Engage those who have trusting relationships with communities with health disparities (e.g., community leaders, elders, clergy)

Some primary sources of data (those you collect) include:

- Systematic listening including: facilitating listening sessions, public forums, focus groups, and interviews with key informants - Direct observation or systematic recording of what you see (e.g., counts of number of homeless sleeping in public areas, counts of percentage of youth attempts to buy alcohol for which sales were made) - Surveys (e.g., using selected modules of CDC's Behavior Risk Factor Surveillance System, Youth Risk Behavior Survey)

1.5 3. Decide whether you wish to identify the assets of groups and/or institutions, the assets of individuals, or both

- Think about your needs and what is both important and feasible in terms of collecting the desired information

Decide whether you wish to identify the assets of groups and/or institutions, the assets of individuals, or both. Community Toolbox 2.0

- Think about your needs and what is both important and feasible in terms of collecting the desired information

1.4 and 2.0 Compare data for your community with that of other communities or of the state or nation; look for trends in your own community's data over time.

- Use comparisons over time or between groups (communities) to put the information you have found in context, either positive or negative. This can help demonstrate the magnitude of the problem you are facing or put progress in proper perspective for the rest of the community.

1.5 dentify the context for assessing community assets and resources

- What is the size of the community for which you will identify assets? You may need to use multiple assessment methods (e.g., interviews, surveys, focus groups) - What people and community organizations might be available to do the work? - How much time do you have for the task—or how much time can you allow? - What resources are needed for this work (e.g., staff time, copying, mailing)? - What resources are available?

Identify the context for assessing community assets and resources Community toolbox 2.0

- What is the size of the community for which you will identify assets? You may need to use multiple assessment methods (e.g., interviews, surveys, focus groups) - What people and community organizations might be available to do the work? - How much time do you have for the task—or how much time can you allow? - What resources are needed for this work (e.g., staff time, copying, mailing)? - What resources are available?

Lesson 1.4 and 2.0 When not to do an assessment:

- When it is urgent to act right now, without delay, such as in a public health emergency - When an assessment has been done recently, and needs have not changed - When you feel the community would see an assessment as threatening or wasteful, or when it would be harmful to communities - When there is not readiness to create and implement a community health improvement plan based on the results of the community health assessment

When should you assess or identify community needs?

- When there has not been a recent assessment conducted - When necessary for compliance or accreditation purposes (e.g., engaging with the community to identify and address health problems) - When more information is needed to guide community improvement planning efforts - When needs are varied, not quite clear, or when people have differing viewpoints and there are disagreements about priorities - When you need confirmation that others care about the issue, too - such as when you want to convince funders that you are addressing the most important community problems (such assessments may be required for grant funding) - When you want to be sure that you will have community buy-in and support for the initiative (e.g., initiating a Healthy Heart Program in your community)

1.6 Lesson 1.6 Three common survey types include

1. Census surveys are given to every member of the population you want to learn about. These give the most accurate information about a group, but may not be very practical to administer to large groups. 2. Sample surveys ask a smaller portion or percentage of a group to reply to your questions. For the sample results to accurately reflect the results you would have gotten by surveying the entire group, the survey sample must be carefully chosen. Given good sampling choices, this will usually prove to be a more practical and cost-effective option than a census survey. 3. Case study surveys collect information from a part of a group or community without trying to select for overall representation of the larger population. You may need to conduct several of these before you get a sense of how the larger community would respond to your survey. Case study surveys only provide specific information about the individuals studied, and as such are less generalizable to larger populations.

1.6 There are also surveys specifically designed to obtain particular types of information:

1. Concerns surveys ask people to help identify what they see as the most important issues (problems and strengths) in their community and are a great tool for building consensus in the community. Concerns survey results can also help set the agenda for community work that genuinely reflects local perspectives. Specifically, a concerns survey has certain advantages: In community work, we should almost always start off with people's concerns - problems to be addressed and strengths to be preserved or enhanced. It can be a reliable, systematic, and easy-to-use way to tap into information. It helps community members see exactly how they view the top strengths and problems in their community - the good, the bad, and the ugly. It helps community members set the agenda for community work. It builds consensus about what issues to address. . Concerns surveys ask people to help identify what they see as the most important issues (problems and strengths) in their community and are a great tool for building consensus in the community. Concerns survey results can also help set the agenda for community work that genuinely reflects local perspectives. Specifically, a concerns survey has certain advantages: In community work, we should almost always start off with people's concerns - problems to be addressed and strengths to be preserved or enhanced. It can be a reliable, systematic, and easy-to-use way to tap into information. It helps community members see exactly how they view the top strengths and problems in their community - the good, the bad, and the ugly. It helps community members set the agenda for community work. It builds consensus about what issues to address. Needs assessment surveys are a way of asking group or community members what they see as the most important needs of that group or community. The results of the survey then help prioritize future action. A needs assessment can be as informal as "asking around" with people you know in your community or as formal as a professionally written survey that is mailed to a large sample. A needs assessment survey has other advantages: - It helps us become aware of possible needs that we may not have seen as particularly important - or that we never even knew existed - It provides documentation of needs, as is required in many applications for funding, and can be helpful in advocating for the initiative's cause - It helps ensure that any actions the initiative gets involved with are in line with needs that are expressed by the community - It improves community support for the initiative's actions because local people will have stated the need for that action

3. Make community participation and involvement easier

Enhance access by arranging meetings at times and places convenient for community members, with language and physical access, transportation, child care, and other necessary accommodations

How-to steps to proceed for assessing community needs: 2.0

1. Indicate how you will listen to the community to better understand the needs/problems that matter to its members. - Some methods of listening to the community include: facilitating listening sessions, public forums, focus groups, and interviews with key informants - Listen and record how community members name and frame community needs/problems, including as: - Lack of/too few of a POSITIVE condition (e.g., more youth should graduate from high school; lack of physical activity or lack of health care access) - Presence of/too much of a NEGATIVE condition (e.g., too many children drop out of school; high rates of obesity) - Both (if different stakeholders seem to name and respond to different framing)

How-to steps in identifying community assets and resources:

1.5 and 2.0 1. Determine the intended uses of identified assets/resources in your situation Possibilities include: - Finding new ways to bring groups together to work collaboratively on projects that address mutual goals - Publishing a list or map of the assets identified and making them available to all community members - Targeting development efforts on the basis of the asset patterns you have found - Publicizing these assets as a way to attract new businesses, new members, and other assets to your community - Raising awareness about existing assets and thus building community pride - Setting up structured programs for asset exchange, ranging from individual skill swaps to sharing resources and responsibilities among organizations

Why should you use a logic model? Community Toolbox 5.0

A new program or effort will benefit from the clear thinking required to create a logic model. A model of change makes explicit the notions and assumptions people have about how things do (or will) work. Having a logic model will help to communicate purpose, both within the group and to others. Likewise, an existing program or initiative will benefit from creating a logic model to help describe, modify, or evaluate the effort. A new program or effort will benefit from the clear thinking required to create a logic model. A model of change makes explicit the notions and assumptions people have about how things do (or will) work. Having a logic model will help to communicate purpose, both within the group and to others. Likewise, an existing program or initiative will benefit from creating a logic model to help describe, modify, or evaluate the effort. Dialogue and consensus building about key elements can be helpful at any point in the community health improvement effort. By using a common language to describe the effort, we enhance communication among varied stakeholders. One logic model may serve more than one purpose, or variations on a model may be created for different situations or audiences. A logic model can be used for different stages of the effort: » Orientation (for those doing or supporting the work) » Planning » Implementation » Communication and advocacy » Evaluation and dissemination

1.6 5. Using surveys as part of a community health assessment

A survey is a way of collecting information that you hope represents the views of the whole community or the group in which you are interested. It attempts to collect information in as uniform a manner as possible. It may include questions that call for a specified response: a "yes/ no/ don't know" choice, or categorical choices like family size of 1, 2, 3, 4, 5, 6 or more. In a behavioral survey, people are asked to report on their behavior during a specified time period (e.g., "During the past week, how many times did you walk, run, or engage in any other moderate physical activity for 20 minutes or more?"). Sometimes surveys also provide a space for open-ended responses in which more qualitative, descriptive information can be provided. However, surveys generally collect quantitative data. (The U.S. Centers for Disease Control and Prevention (CDC) offers a variety of behavioral survey modules through its Behavior Risk Factor Surveillance System [BRFSS] and Youth Risk Behavior Survey [YRBS].) Surveys can be administered by phone or in person, by mail, email, through websites, or at a particular location, such as a community center, that people frequently visit.

Some tips guiding decision making Community Toolbox 4.0

As a general principle, we advocate consensus as the basis for decision making. The following tips or guidelines may be helpful to keep the group focused on building consensus: » Avoid arguing blindly for your opinions. It's easy to get so caught up in what you believe that you don't hear what others are saying. Be sure to listen carefully. » Don't change your mind just to reach an agreement. If you aren't happy with a solution now, it's not likely it will please you much when you are doing the work later. » It's easy to think of this as an "all or none" situation; someone must win, and someone has to lose. That's not necessarily the case. If the group is locked between two different possibilities, see if a third option will work for everyone involved. » If people are becoming frustrated, or you are making no progress, take a break. Sometimes just a short breather can give people a new perspective. If the group can't reach a consensus agreement, you still have several ways of deciding upon a solution. Try this alternate decision-making strategy: 1. Have an individual or small group decide, and then recommend the decision to the group » Gather input from outside experts or a broader group » Then have one person, or a small group, decide or recommend » Vote, and the majority rules If the group can't reach a consensus agreement, you still have several ways of deciding upon a solution. Try this alternate decision-making strategy: 2. Use the "nominal group technique." [Source: David Quinlivan-Hall and Peter Renner] » Ask each participant to assign a number to every solution, with one being their favorite solution, two being their second favorite, and so on » Add up all the numbers from each participant for each solution, and solutions with the lowest values are then selected for possible implementation Choose not to decide or to defer the decision until later. Some ideas and opinions may change if people are allowed more time to think it over. Solicit feedback from the group Whatever the group decides to do, feedback from group members and others should still be solicited after the decision has been made. Questions might include: Can you live with the adopted solution/approach/strategy?" » "Do you have any concerns about the solutions that we are considering?" » "Do you have any suggestions that might make them better?" » "Are you satisfied with the solution(s) we have chosen?"

1.5 and 2.0 Identifying the assets of individuals (if appropriate)

Compiling assets of individuals can be a bit more logistically challenging, since there are many more people than groups, and because we often don't know people's assets unless we ask them. For these reasons, when it is done, identifying individual assets often takes place across a smaller community area, such as a neighborhood or faith community.

1.5 & 2.0 . Refine and revise your list

Consider organizing your information so that you can later access it in various ways (e.g., alphabetically, geographically, by function, by sector, or by size). You also might want to monitor progress in developing the list of community assets and use the information for improvement (e.g., keep records of new and modified assets; establish a review process for assets).

How-to steps in identifying potential targets of change: Community Toolbox 4.0

Determine who is at risk or directly experiences the problem. Include people directly affected by the problem, those previously affected by the problem, and family members or peers of those affected. Identify who contributes to the problem or goal. Sometimes the people directly at risk aren't the ones whose behavior you will try to alter or maintain. Think about whose action (or inaction) is at the root of the problem or goal. Examples include: » Peers (who may encourage others to use drugs, eat unhealthy foods, etc.) » Parents and caregivers (who may not talk or read to their young children, etc.) » Service providers (who may not use best practices, etc.) » Teachers (who may not provide or assure opportunities for learning) » Business people (who may sell tobacco, alcohol, or other drugs to minors) » Elected and appointed officials (who may not enact or implement policies that promote or protect health) It often makes sense to aim the community program or policy at those at higher risk for a certain problem (the targeted approach). They generally have the greatest number of risk factors and/or the fewest protective factors. But, it may be difficult to affect change in this group, and the costs of doing so may be high. » Sometimes the effort intends to reach all people in the population (the universal approach). This approach may be optimal when there is the need or opportunity to have an impact on a greater number of people. » Sometimes it is best to begin by targeting those most likely to be influenced. This readiness approach may be helpful in increasing the likelihood of success and building the organization's credibility in the community. » In the early stages, it will be helpful to brainstorm all categories of potential targets as broadly as possible, focusing on those whose actions or inaction contributes to the problem.

Lesson 1.4 and 2.0 2. Agree on the value and purpose of the information that you will collect

Discuss and agree on what the information on community problems/needs will be used for. Some possible uses of the resulting information include: - To give focus to and direct your group's efforts for change and improvement - To target a particular area, priority group or issue for your efforts - As part of a publicity campaign that will raise awareness and/ or encourage action - To provide information to potential collaborators and partners who may wish to address the need with your organization - As part of a grant application or project summary for potential funders and evaluators, which gives credibility to your request - To set a baseline measure (level before intervention) against which you can compare later results in order to assess your initiative's effectiveness

Characterize aspects of the defined community and broader context that affect community health status and efforts to improve it

For example, you may want to provide information on: - Demographics of the community (census data), including population size, age (by age groups), income/poverty/S.E.S. (Socio-Economic Position), racial/ethnic composition, nativity/immigrant status, education/literacy, employment/workforce, transportation (e.g., walkability), housing (e.g., owners, renters), and crime/safety - Moderating factors and social determinants related in health/disparities - income inequality; racism/discrimination; access to health care/insurance; social norms for health behaviors; social capital (i.e., trust, social connectedness); food insecurity (e.g., food stamp utilization) - Community Context - organized group with history of working together on shared mission to promote health; new or expanded/reduced resources to address community health issues; community leadership and champions, new or expanded leadership, loss of/change in leadership; political commitment ( i.e., will to act and keep acting) to change conditions; those engaged have power, authority, and jurisdiction to make the changes that are needed

What is the definition of a geographic area for community health assessment?

For the purpose of community health assessments, community most often refers to a geographic area, such as a city, county or region. This geographic area typically covers the city/town or county in which the public health department or hospital resides, but it may also cover the entire service area (if this has broader reach than county borders) or a broader area of collaboration. Arranging assessments that span jurisdictions involves adjusting the geographic parameters or area covered in the community assessment to fit the needs and interests of key stakeholders (e.g., hospitals, local public health agencies, United Way/human service agencies, community health centers, and other stakeholders).

What is the definition of a geographic area for community health assessment? Community Tool Box 3.

For the purpose of community health assessments, community most often refers to a geographic area, such as a city, county or region. This geographic area typically covers the city/town or county in which the public health department or hospital resides, but it may also cover the entire service area (if this has broader reach than county borders) or a broader area of collaboration. Arranging assessments that span jurisdictions involves adjusting the geographic parameters or area covered in the community assessment to fit the needs and interests of key stakeholders (e.g., hospitals, local public health agencies, United Way/human service agencies, community health centers, and other stakeholders).

How-to steps in identifying potential agents of change Community toolbox 4.0

HELP TOOL 1. Identify potential agents of change: Since a change agent's role is to affect the conditions experienced by targets, it helps to identify people who have the access, opportunity, and influence to do so. They may be members of the same group as the identified targets of change. Begin by listing these agents, including those who come into contact with - and could potentially influence - the targets of change. Use the following questions to make your list of change agents more complete: » Who has the power to change the conditions that affect the targets' behaviors and outcomes? » Who has the time, resources, and desire to bring about change? » Who has relationships with those who are targets of change? Who has trust and influence with this group? » Consider people who were formerly or are currently targets of change. Who among them might be effective "agents of change" now? Determine what agents of change can do: An agent of change can influence others in a variety of ways. Understanding the role of the agent will assist in identifying those who can best help address the problem or goal. An agent of change will probably do one or more of the following: » Help analyze the problem or goal. » Establish strong relationships with the groups to benefit. » Convince people of the need for and possibility of change. » Help change communities and systems. » Help maintain the change over time.

Lesson 3: Defining the Community and Geographic Area for the Assessment Recommend the scope or geographic area that will define "community" health assessment. Record your plan in the space provided. Community toolbox 3.0

HELP TOOL The scope or the geographic area for the community health assessment initiative by the Springfield community will defined as: - The geographic area served by the local health department i.e. Jackson County (including the city of Springfield); - For the hospitals, the jurisdictions including Jackson County and nearby Lincoln County as well as two inner-city neighborhoods (East and North) of Springfield.

When numbers or percentages are important in describing things: 1.6

If your desire is to collect data that is more uniform, surveys ask closed-ended, relatively narrow questions that are quantitatively scored. Respondents often give a categorical or numerical rating, rather than a verbal statement. Surveys can answer questions like "How many people report that they smoke cigarettes?" or, "How satisfied are users with our organization's services?" Surveys collect information about the behaviors, needs, and opinions of the respondents. Surveys can be used to find out about behavior that cannot be observed easily or ethically (e.g., what percentage of people practice safe sex). It can also be used to assess attitudes and reactions, to measure client satisfaction, to gauge opinions about various issues, and to add credibility to your research. Surveys are a primary source of information - that is, you directly ask someone for a response to a question, rather than using any secondary sources like written or archival records (e.g., rates of infant mortality, school dropouts).

1.6 Using interviews as part of a community health assessment

Interviews are often defined as conversations with a purpose. - They provide depth of perspective and help you tap into experiential knowledge, or information about how people experience a situation - They give texture and meaning to issues - Interviews can also provide in-depth information on a particular topic from someone who has technical expertise with an issue - Excellent results are achieved when trained interviewers listen well to what is said and can also discern and ask questions about what is often left unsaid Using an interview is the best way to have an accurate and thorough communication of ideas between you and the person from whom you're gathering information. Interviews can be used to gather information from different individuals, but are more expensive and time-consuming than surveys.

Lesson 1.3 2. Share the drafted description with some key community members and stakeholders and invite them to make adjustments 3. Carefully consider the results of your work so far, keeping in mind demographics, strengths, problems, community attitudes and behavior, and current "hot" issues. Compare the current issues in your community to those in past years. What has changed? What has stayed the same?

Lesson 1.3 After reflecting on these, ask yourself: - What issue(s) might be given priority for attention? - What improvements could be made? - What approaches might be continued, changed, or perhaps abandoned? These will be areas for further exploration in your community assessment and planning efforts.

8. Collect the data

List the sources of data you plan to collect; considering the accuracy, sensitivity, and feasibility to collect. At which level(s) are the data available? For rural or sparsely populated areas, data may be available only at the county or even regional level. For urban or densely populated areas, it may be possible (and desirable) to obtain data at the zip code level or even by smaller area such as neighborhood or census tract. Of course, if secondary data are not available, it is always possible (although potentially expensive) to collect the data yourself through listening, observation, or local surveys. If the data do not already exist, this may be a reasonable thing to do if the time and financial resources are available.

4. Make community participation and involvement more rewarding

Make sure that the "6Rs" are incorporated into the group's meetings and activities, including: - Recognition - Recognize people for their contributions - Respect - Respect and consider people's values, culture, ideas, and time - Role - Give each person a clear and meaningful role through which they can contribute - Relationships - Provide people opportunities to establish relationships and build networks - Reward - Ensure the rewards of participating in the group outweigh the costs - Results - Work to achieve visible results that are clearly linked to outcomes of importance

Lesson 1.1 Why involve community members in community health improvement efforts?

People who directly experience a problem have a much different perspective on their needs than does a public official or a helping professional. They know the history of past efforts to address the problem or issue, and what has or hasn't worked. They are local experts. Being able to name people from the community who attended a meeting of your organization, or engaging them periodically to comply with a requirement, does not meet the standard for good practice. There must be a reason for including others, an idea of who those others might be, how many others are needed, and a sense of what those others can do. Attention to these considerations will help recruit members who will enhance the effort and remain engaged over time. Arranging conditions for ongoing community member engagement involves ensuring them opportunities for decision-making and other meaningful roles and responsibilities.

As part of its community health assessment, the Smithville community is examining the issue of high rates of unintentional injuries. Identify available/potential data sources for this potential issue and the geographic areas they represent.

Possible Answer: For the issue of high rates of unintentional injuries, potential data sources may include: - Census data, including population size, age, income/poverty/S.E.S. (Socio-Economic Position), transportation (e.g., walkability), housing - BRFSS (CDC Behavior Risk Factor Surveillance System)—State-level data, with periodic oversampling to represent unintentional injuries in the community - Hospital records, for catchment area of a specific hospital in the community and the geographic area that is being covered in through this effort. - Law enforcement records (e.g., roadway injuries)

Stafford County is conducting a community health assessment and is examining the issues of increased violence and promoting safety in their community. Stafford County includes Wilson City and the nearby city of Parkville. Identify hypothetical geographic areas of responsibility, both distinct and overlapping, for key stakeholders. community ToolBox module 3

Possible Answer: The geographic areas of responsibility for key stakeholders might include: Stafford County, Wilson City, the city of Parkville, the Wilson City Unified School District, the Parkville Unified School District, zip codes included within Stafford County, U.S. census blocks, the Congressional district, particular neighborhoods within Parkville and Wilson City, and Wilson City Providence Hospital and Parkville Memorial Hospital service areas and referral regions.

Activity 1.4.2: As part of its community health assessment, the Southwest community is examining information about obesity. State the value and purpose of information that will be collected about this potential issue.

Possible Answer: The value/ purpose of the information collected by the Southwest community include: - To give focus to and direct the group's efforts for change and improvement - To target a particular area, priority group or the issue of high rates of obesity for their efforts - As part of a publicity campaign that will raise awareness and/ or encourage action - To provide information to potential collaborators and partners who may wish to address the problem of high rates of obesity in the Southwest community with the group. - As part of a grant application or project summary for potential funders and evaluators, which gives credibility to the Southwest community group's request - To set a baseline measure (level before intervention) against which the Southwest initiative can compare later results in order to assess their initiative's effectiveness

Identify available/potential data sources for the community health assessment and the geographic areas that they represent.

Potential data sources include: - Census data (see below) - BRFSS (CDC Behavior Risk Factor Surveillance System)—State-level data, with periodic oversampling to represent adults in the County - Hospital records, for catchment area of a specific hospital - YRBS (CDC Youth Risk Behavior Survey) data representing school-aged youth in the school district - Crime/safety data from law enforcement officials by zip code/precinct within city/county - Department of Education - CMS (Centers for Medicare and Medicaid Services) databases - PRAMS (CDC Pregnancy Risk Assessment Monitoring System) - Data from city/town/county planning office

Identify available/potential data sources for the community health assessment and the geographic areas that they represent. toolbox 3

Potential data sources include: - Census data (see below) - BRFSS (CDC Behavior Risk Factor Surveillance System)—State-level data, with periodic oversampling to represent adults in the County - Hospital records, for catchment area of a specific hospital - YRBS (CDC Youth Risk Behavior Survey) data representing school-aged youth in the school district - Crime/safety data from law enforcement officials by zip code/precinct within city/county - Department of Education - CMS (Centers for Medicare and Medicaid Services) databases - PRAMS (CDC Pregnancy Risk Assessment Monitoring System) - Data from city/town/county planning office

1.6 and 3.0 Using public forums as part of a community health assessment

Public forums, also referred to as town meetings, are open to everyone in the community. They offer people from diverse backgrounds a chance to express their views about key issues of concern and what can be done about them. Typically, participants are asked to limit their time for sharing so that all can be heard. As a result, a variety of opinions are shared, but may not be explored in great depth. Public forums have the advantage of linking your group with people who are able and willing to help and of linking community members to one another. In a public forum, -Community members discuss important issues and identify and solve problems -The facilitators lead a discussion of various aspects of an issue (e.g., strengths, areas for improvement) -A transcript of ideas about the dimensions of the issue—and what can be done to solve problems and preserve strengths—provides a basis for subsequent planning -People of diverse backgrounds get a chance to express their views about key issues of concern

1.6 What are quantitative data? Community Toolbox 3.0

Quantitative methods yield numbers or statistics to help answer the question, "How many?" They give us perspective as to the breadth of the issue: how many people are affected? When we hear that a certain number of adolescents dropped out of our schools, or that a certain percentage of African-Americans can expect to develop diabetes, we are using quantitative data.

Why should you assure shared ownership among stakeholders?

Shared ownership of the process ensures collaboration among key stakeholders, and makes it more likely that assessment, planning, and implementation for community health improvement will be successful. Community health improvement work is multi-sectoral and requires the commitment of diverse stakeholders. Relationship and trust-building are essential to this process. When trust has been established, establishing governance structures and formal agreements can help ensure diverse stakeholders work together effectively over time.

Decide upon the scope or geographic area that will define "community" for this community health assessment

Specify the place to be covered by the community health assessment. For example: - Specified county or city, hospital service area, etc. - For rural context, this might include multiple counties, with targeted assessments for towns with health disparities - For urban context, this might include one city, with targeted assessments for neighborhoods/census tracts with health disparities

1.5 List categories of community assets of groups/institutions relevant to your community health initiative

Start a list. Begin with what you know. Record anything that comes to mind. You can always add to or edit your list later. Ask others about what they know. As a member of an organization, group, or even of a community, your first use of assets is to turn to the others who care about this work and involve them. Record everything they can think of and look for commonalities. Depending on the context, these listed assets may include: - Hospitals and clinics - Public Health Departments - Health advocacy organizations - Schools - Government agencies (e.g., parks and recreation) - Community-based or non-governmental organizations - Grassroots or citizen's associations - Faith-based organizations - Businesses - Populations experiencing community problems (e.g., the poor, youth, individuals with disabilities)

List categories of community assets of groups/institutions relevant to your community health initiative Community Toolbox 2.0

Start a list. Begin with what you know. Record anything that comes to mind. You can always add to or edit your list later. Ask others about what they know. As a member of an organization, group, or even of a community, your first use of assets is to turn to the others who care about this work and involve them. Record everything they can think of and look for commonalities. Depending on the context, these listed assets may include: - Hospitals and clinics - Public Health Departments - Health advocacy organizations - Schools - Government agencies (e.g., parks and recreation) - Community-based or non-governmental organizations - Grassroots or citizen's associations - Faith-based organizations - Businesses - Populations experiencing community problems (e.g., the poor, youth, individuals with disabilities)

What is strategic planning? Community Toolbox 6.0

The planning process gets everyone together, laying out a vision and objectives to direct the group's activities. It gives group members an opportunity for shared decision-making and buy-in to the group's purpose. It helps establish a common language that describes the work and outlines what lies ahead. The strategic plan provides a roadmap for moving from a community's vision to improvements in community-level outcomes. The plan provides overall direction on the path going from where things are now (as seen in the assessment) to where we hope they will be (as seen in the vision and objectives). The action plan identifies specific changes in the environment - community programs, policies, and practices - the group seeks to bring about to achieve its goals. Community work can be greatly enhanced by VMOSA: a clear Vision and Mission statement, explicit Objectives, appropriate Strategies, and a comprehensive and detailed Action plan (who will do what by when).

6. Identify the secondary and primary sources of information to be gathered about community needs

There are a lot of different places where you can find relevant information to assess community needs. Some of the data you need is likely available already, through existing, or "secondary" sources. You also may need to collect some "primary data", information you will collect yourself to supplement what is available through other sources.

How can you use a community description? Community toolbox 3.0

There are many reasons to create a concrete community description and put the information you've gathered together into written form. You can use a written document: - As a reference - To guide your community health improvement efforts - To share with others working in the community - As background information for the media - As part of the justification for a grant proposal or request for funding

Lesson 1.5 and 2.0 5. Identify and use sources to gather information about community assets

These can include: - The Internet: search for agencies, government sites, businesses, community-based and non governmental organizations in your community; United Way's 211 site, http://www.211.org/, may be particularly helpful - Telephone directory: free and fairly comprehensive - Town or city directories published for your community - Lists of businesses available from business groups such as the Chamber of Commerce - Lists of organizations likely available from your public library - Influential community groups identified by locals - The local newspaper - Additional print sources: local newsletters, underground or alternative press - Bulletin boards in local buildings, community calendars, or community websites - Key informants: Well-connected community members, friends, and colleagues can help identify community assets

How-to steps in writing a community description:

Upcoming lessons will give you additional information about how to collect rich data that will ensure a thorough assessment of your community's needs and resources, in addition to the more general methods listed above. When you feel ready to prepare your community description, it can be completed by following these few steps. 2. Share the drafted description with some key community members and stakeholders and invite them to make adjustments 3. Carefully consider the results of your work so far, keeping in mind demographics, strengths, problems, community attitudes and behavior, and current "hot" issues. Compare the current issues in your community to those in past years. What has changed? What has stayed the same? Write a community description Common headings/content in descriptions of communities include: - Geographic boundaries of the community - Length of time the community has been in existence - General history of the community - Key people and leaders in the community - Demographics (e.g., racial/ethnic makeup, male/female ratio, age, education level, income level) - Expenditures, resources, and in-kind support for the community's activities - Issues of most concern to the community - Levels of civic involvement and social connectedness You will find that the completion of this task yields both useful information and a sense of identity and pride among the community members who assist in the process. Despite the uncovering of the community's problems, the process will often yield the beginnings of a wonderful list of the community's assets, which can be very affirming. Community toolbox 3.0

4. Indicate the kinds of data that will be collected in your community health assessment Community Toolbox 2.0

What information is essential to your community health assessment and planning efforts? Consider the statistics, as well as the qualitative information that you need to know. Will determining both the incidence of the problem (e.g., new cases of HIV/AIDS) and the prevalence rate (i.e., existing cases) be important? What about data on community-level indicators of related issues (e.g., levels of injection drug use, sexually transmitted diseases)? Some potentially valuable types of data to be collected include: - Issues and concerns of importance to community members (e.g., violence/safety, jobs, etc.) - Leading causes of death (e.g., heart diseases, cancer or unintentional injuries) - Behavioral risk factors associated with these health outcomes (e.g., physical activity, diet, tobacco use, use of seat belts, etc.) - Environmental factors associated with these health outcomes (e.g., walkability, transportation, availability of healthy foods, density of liquor stores, etc.) - Environmental quality (e.g., water quality, toxins, hazards, etc.) - Social determinants of health (e.g., education, income inequality, housing, social exclusion, etc.)

1.6 and 3.0. Using listening sessions as part of a community health assessment

When a group is gathered to share ideas and experiences about a particular topic or range of topics, we call that a listening session. This experience will be more informational and intimate than a public forum, but will still have enough structure that people can frame their conversation toward a productive end. This is often the format used to first identify community problems and goals that matter to local people. In listening sessions, the participating group tends to be smaller and more targeted, but ideally will still include the diversity of a public forum. Opinions may be expressed in more depth, and the facilitator may have an opportunity to invite participants to fully explore common ideas or themes.

1.6 Lesson 1.6, 3.0 What is qualitative information?

When we think about information that we get from stories or interviews, we glean understanding and can better answer the question "What does it mean?" Qualitative methods help probe different aspects of an issue to give us understanding as to depth - to give texture to the situation and help make sense of the numbers (e.g., "Why would there be such an increase in cases here?"). Within each of these two broad categories of methods, there are different assessment techniques. And as you might suspect, a comprehensive assessment approach often makes use of elements of both. A rich understanding of the breadth and depth of a problem or issue can come from combining numbers (hard or quantitative data) with personal perspectives (qualitative data).

If important data you need for your assessment are unavailable. Community toolbox 2.0

you may consider administering surveys in order to obtain the needed information. Additionally, supplementing the data you find with local peoples' experience and perspectives can be invaluable. Some primary sources of data (those you collect) include: - Systematic listening including: facilitating listening sessions, public forums, focus groups, and interviews with key informants - Direct observation or systematic recording of what you see (e.g., counts of number of homeless sleeping in public areas, counts of percentage of youth attempts to buy alcohol for which sales were made) - Surveys (e.g., using selected modules of CDC's Behavior Risk Factor Surveillance System, Youth Risk Behavior Survey)

Check the list of individuals and groups to be targets and/or agents of change for completeness Community toolbox 4.0

» Have you identified those experiencing the problem, including those with health disparities? » With whom do you think your group can be particularly effective? » Are there specific groups or organizations that would benefit your initiative as a partner? » Are there different community sectors (e.g., faith communities, schools, businesses) that might become involved? » What relationships or contacts do you (and others) have that might help engage them?

Identify the primary targets of change for this community health improvement effort. Community Toolbox 4.0

» Those who directly experience the problem: formula-fed babies and toddlers, children, and youth with high BMI (body-mass index); » Those who are at higher risk: siblings of children/youth with high BMI (body-mass index), children of low SES homes; » All those who are at risk: All babies, toddlers, children, and youth; » Those who contribute to the problem or goal: Parents, children/youth, older siblings, caregivers, teachers, school administrators, businesses that sell high-calorie, low-nutrition foods, the media.