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Programs & Organizations > Chronic Disease Prevention > A Guide For Local Health Departments > Developing A Comprehensive Community-Based Approach

Preventing Chronic Disease

Developing A Comprehensive Community-Based Approach

Historically, federal and state categorical funding streams have set the local public health agenda. Chronic disease prevention program resources have typically been designated based on a pre-determined population, disease or risk factor. Categorical approaches often led to fragmented services.

Efforts to address specific diseases or risk factors such as diabetes or tobacco have had some success. However, messages about increasing physical activity or eating healthy foods, for example, have not been embraced by those communities most at risk for serious consequences from chronic disease.

Collaboration among categorically funded programs requires that health departments first assess existing resources and identify successful projects.

This chapter describes an approach for local health departments that emphasizes:

  • collaboration with communities to set a broader shared agenda and
  • coordination of internal resources to develop more comprehensive and integrated chronic disease prevention programs

Collaboration among categorically funded programs requires that health departments first assess existing resources and identify successful projects and relationships that can be tapped and expanded. Including as many sectors of the department as possible will help build a broad base of commitment and momentum for the effort. The potential benefits are many:

  • Clients get improved access to a continuum of clinical and preventive services.
  • Programs can respond to changing needs of diverse communities.
  • Staff and other resources are used more efficiently and effectively.
  • The health department can seize opportunities for program expansion and funding.
  • Communities are motivated to participate.
  • The health department provides a model of collaboration for other institutions.

It is relatively easy to imagine a collaborative approach to chronic disease prevention, but hard to carry it out. It is challenging to translate a broad vision into concrete steps and frustrating to dedicate a considerable amount of time to thoughtful and inclusive planning. Large bureaucracies make communication and coordination difficult. Categorical funding provides little incentive for integrated programs. Staff may resist new activities on top of an already full workload.

Commitment needs to come from the highest leadership of the health department, and resources designated up front. You may need to start on a small scale, for example, by producing an educational handout describing all of the department's prevention programs within the context of the host of critical risk factors for chronic disease. Subsequent efforts could then build on your success.

Step One: Assess Agency Readiness and Designate Staff

Assign Leadership
Start by assessing the climate for collaboration in the department and identifying potential allies. Choose a project leader, hopefully someone experienced in collaboration and skilled in group process and program planning. Where possible, scale back the person's current assignments by reassigning or postponing other activities. Inform all staff about the person's new assignment and his or her role and responsibilities. It helps lend credibility to the effort if the announcement comes from the top leadership in the health department.

Assemble a team to help organize the project. The team should represent all levels of management and staff and all related programs in the department. Include members who are informed, who can speak frankly from their own experience about the strengths and gaps of the various programs, who can analyze information, and who can help develop realistic priorities and plans. They should also be good communicators, as they will serve as ambassadors for the project to colleagues throughout the department.

Assess resources
Take an inventory of the skills and resources available to the department, including any staff who may have a particular interest or skill to contribute. Assess the context in which you'll be working-how the department's priorities, politics, and organization will set the stage for your project. Several tools are available to catalogue assets and gauge the climate of an organization, specifically a local health department. Tools such as the Assessment Protocol for Excellence in Public Health (APEX) or Mobilizing for Action through Planning and Partnerships (MAPP) may be helpful. APEX and MAPP are available through the National Association of County and City Health Officials in Washington, DC [http://www.naccho.org/tools.cfm].

The method you choose to gather information will depend on the size of the department, your resources, and the extent of your prevention programs to date. Review the department's organizational chart and assess how programs have worked together in the past. Consider conducting interviews with key decision-makers, particularly if there is a suspicion or history of conflict among programs or uncertainty about the commitment of high-level administrators. Generally, interviews should last no longer than 30 minutes and should include an overview of the proposed project. The interview should include questions to identify:

  • Programs that work effectively with communities
  • Skills and expertise of staff
  • Examples of successful collaborations among programs
  • Potential obstacles

View/Print

Assessing Readiness: Interview Questions for Health Department Staff (7k PDF, 1p.)

The interview responses should be summarized and analyzed for recurrent themes. You might convene some of your planning team members to gather and analyze the needed information.

Meet with the project team. Hold a meeting with the project team to introduce the concept of broad, community-focused, chronic disease prevention, present your findings to date, and solicit discussion. The ideal participants will be those who can bring an openness and creativity to the discussion. Consider writing some brief background material to distribute before the meeting. Clarify the meeting objectives at the beginning, and recap decisions at the end.

Sample Format

Health Department Resources for Chronic Disease Prevention (7k PDF, 1p.)

At the meeting, describe the history of the department's efforts at chronic disease prevention and the level of commitment from top leadership to promote collaboration. If possible, present relevant statistics on health status and risk factors in the communities you serve. Give participants a chance to ask questions, respond to the concept, and add information.

This first meeting can be invaluable if it allows people to share their experiences and perceptions and raise issues that might otherwise linger below the surface. A widely representative team can help provide a comprehensive picture of current projects as well as current and emerging community health concerns. It also ensures that decisions reflect a variety of perspectives.

Decide whether to move forward. Write up the findings from the initial meeting and analyze them for common themes. In deciding whether to proceed, staff will need to consider whether there is:

  • A commitment of interest and resources from the top level of administration
  • A natural opportunity to collaborate
  • Staff who are interested and have the time and skill to lead the process
  • Community support

Sample Chart to Summarize Findings

Criteria for Collaborative Projects (8k PDF, 1p.)

Additional criteria may help you decide if the time is right to pursue this approach. It is most likely to succeed if the effort:

  • Is consistent with the department's philosophy and priorities.
  • Enhances current services, or may be incorporated into new initiatives that are being developed.
  • Builds community capacity.
  • Fosters a partnership between the community and the health department.
  • Is likely to be sustainable.

Communicate the decision
If you decide to pursue the project, you'll need to present the initiative to all health department staff working on chronic disease prevention issues. Be prepared to use a variety of channels, such as written materials, presentations at staff meetings, and special orientation meetings. Provide a clear description of the proposal: how it fits with the department's priorities, what you expect to achieve, and a summary of activities to date. Offer ideas of how staff can become involved in the effort, and identify the potential benefit to them of participating.

If you choose not to pursue the project, this also should be communicated. You may want to write a memo to staff summarizing the findings and explaining the reasons for not moving forward at this time.

A few tips as you undertake this effort:

  • Set the stage for clear communication. A shared language among staff is essential from the beginning. Don't assume everyone means the same thing when they talk about 'prevention' or 'collaboration.' See Levels of Working Together (10k PDF, 1p.)
  • Be inclusive. People process information in different ways and at different paces. Create a variety of mechanisms for feedback and input.
  • Accentuate the positive: Set a tone that emphasizes solutions to problems.

In Contra Costa County...

When CDPOP was initiated, CCHS already had a number of chronic disease prevention projects in its Community Wellness & Prevention Program (CW&PP). the Breast Cancer Partnership, Tobacco Prevention Project, On The Move! With Foodwise, Lead Poisoning Prevention Project and CW&PP's Healthy Neighborhoods Project (HNP) met monthly and gave input to the original proposal for CDPOP.

Initially, the group mapped out current activities and identified potential areas for common efforts. Managers quickly decided that they could not add to their workload without adding staff. Once the proposal was completed, a smaller group of managers and field staff designed a retreat to introduce the initiative to all staff. The group included staff working in areas outside chronic disease, such as violence and injury prevention, as well as HNP neighborhood organizers.

While retreat participants were generally enthusiastic about a collaboration, they raised a number of concerns that indicated a need for more groundwork. A work group formed with members from each chronic disease program. They developed a list of shared terms, expanded the criteria for analyzing potential collaborative projects, identified common strategies, and recommended next steps to ensure broad buy-in to the project.

Step Two: Build Vision and Commitment

Once you decide to move forward, you need to widen the circle of people involved in planning. To establish some fundamental agreements, the project leader will need to help:

  • Clarify roles and responsibilities of department staff and of the community.
  • Facilitate a process to set priorities for activities.
  • Identify staff and other resources to carry the project forward.

Who to involve

The local health department can enlist programs with strong community participation, to bring community representatives into the planning process at this point. Any chronic disease-related coalition or citizen advisory group should be represented. At the very least, include coalition staff as well as health workers who work directly with community residents.

Orient new participants on your efforts to date. As you work to accomplish tasks, remember that you are also building relationships that will serve as a foundation for collaboration. Attending to relationships is especially important when team members vary in their positions of power, access to information, and their level of comfort or experience with this kind of planning.

Create a common vision

Consider an all-day retreat or a series of shorter staff meetings to develop a vision. Include as many staff as possible in the process. The earlier assessment may have helped identify a process for creating a vision and a few people willing to lead it. You might use information gathered from the assessment as a springboard for this step. Present a summary of the information at your first meeting, or in advance. You may want to pose questions about the future. How will the local health department look in five years if our effort succeeds? How will our community look different?

Whatever the method, try to draft a working vision relatively quickly so as to maintain momentum. Start each meeting with a reminder of your purpose, where you are in the process, and your decisions to date.

These discussions are an opportunity for community health workers, residents, and other staff to share their perceptions, values, experiences, hopes, and fears about working together. If the exchange is well structured, people will have a chance to reveal and perhaps reconsider their assumptions. They will be able to see one another as colleagues and resources. They will begin to develop a shared understanding of the project. At the end of a meeting, record and review highlights of the discussion and unresolved issues, so that you are sure to include and accurately portray all points of view.

Whether you are working with staff or community residents, people will be unable to attend every meeting. Develop mechanisms to keep the process moving forward with changing participants.

One way to keep the flow going with new participants is to consider using a "rolling flip chart." It summarizes the purpose, history, key decisions and outstanding issues and can be reviewed at the beginning of each meeting. Ask others to report the highlights from previous meetings using this visual aid. This not only brings newcomers up to speed, but also prepares more people to describe the project.

Refine the resource assessment

Make a more detailed and formal assessment of resources based on interviews, written surveys and further discussions with staff. Build on the information gathered in Step One. Also review scopes of work and progress reports for current or proposed chronic disease projects in the department. Write a summary of existing programs that briefly states their missions, priority populations and strategies. Distribute the summary to all staff. Based on feedback from this step, you may need to update the chart of health department resources.

In Contra Costa County...

A work group analyzed and solicited additional information from each health department program to develop recommendations for collaboration. They identified eight potential areas for joint efforts and presented them at meetings with each program. These discussions generated additional criteria for collaboration and prompted the work group to cut the eight strategy areas to four:

  • Community outreach and education
  • Policy development and advocacy
  • Training for staff and neighborhood organizers
  • Creation of standardized process to develop and award health department grants

Managers realized that before they launched any campaign, staff needed more training and time to build a common vision. A small team of managers and health education staff developed a day-long retreat that explored the CDPOP approach. Roundtable groups discussed challenges to collaboration and developed recommendations for each strategy area. A collaboration committee was designated to follow up. Among its recommendations:

  • Establish a system to routinely solicit community input about programs and health department priorities.
  • Hold periodic cross-program planning meetings by geographic region.
  • Develop a comprehensive prevention education strategy for the department's clinic system.

Step Three: Plan and Carry Out Collaborative Activities

With a clear vision in hand you are ready to plan how you will create a more integrated and comprehensive chronic disease prevention approach. The health department will need to establish a process for making decisions and setting priorities. It's best if community leaders can have a role in this as well. You may wish to refer to your chart of Criteria for Collaborative Projects (8k PDF, 2pp.). For more on decision-making, see Case Study of Chronic Disease Prevention: The Contra Costa Experience (217k PDF, 6pp.).

An action plan should include:

  • Goals, objectives, strategies and activities.
  • Timeline for completion, with benchmarks for measuring progress along the way.
  • Designation of individuals/programs responsible for each task.
  • Resources needed.
  • Methods to track progress and evaluate results.

If the health department pursues more than one initiative, you'll need a separate action plan for each. Build in periodic reviews and update your plans on a regular basis, taking on new efforts as you complete others. Initial efforts are likely to focus on establishing systems in the department that support collaboration. You may develop policies and procedures to:

  • Share routine information among projects and jointly solve problems.
  • Involve the community in planning.
  • Cooperate with community agencies that have common missions and activities.
  • Share staff resources and promote staff development.
  • Improve data and information systems.

View/Print

Other Resources (8k PDF, 2pp.)
E (7k PDF, 1p.) & F (7k PDF, 1p.): Action Plan Forms

Step Four: Evaluate the Impact

You will need procedures to document the success of your efforts and identify any unanticipated outcomes. Look at whether and how well you have accomplished specific activities you set out to do. (See Introduction section on evaluation.) You may want to write monthly activity reports or have staff keep simple logs summarizing activities, obstacles encountered, solutions tried and how successful they were. It will also be important for staff to document any potential new partnerships that are identified.

Also you will want to assess whether you have made progress toward the objectives stated in your action plan, and whether the activities chosen helped you accomplish the objectives. Since resources for evaluation can be limited, consider how to use them most wisely. You might choose to evaluate only your most critical objectives, or you might look at all your objectives in less depth.

Leave time for evaluation at all of your meetings, allowing people to reflect on the tasks they're working on and the process they've engaged in. Ask whether meeting objectives were met and what moved the process forward or seemed to stall it. Staff should record the comments for future reports.

[next section: Mobilizing Neighborhoods]

Content provided by the The Community Wellness & Prevention Program of Contra Costa Health Services.

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