Community-based health evolved as national agencies and organizations worked to develop tools and resources for state and local health departments. A 1997 booklet provided much needed guidance and defined community engagement as “the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people.”1 The National Association of County & City Health Officials improved assessment processes by incorporating strategic planning and focusing on assets and needs into the development of Mobilizing for Action through Planning and Partnerships (MAPP). The National Association of County & City Health Officials piloted MAPP through the Turning Point Initiative,2 which had the mission to “transform and strengthen the public health system in the US to be more effective, more community based, and more collaborative.” South Carolina received statewide Turning Point funds.3 This article describes the challenges of implementing community assessment-related initiatives by SC partners. These experiences combined with influences from changing web-based resources, the Accountable Care Act, and the collective impact approach contributed to the conceptualization of the community engagement framework. The components and distinctions of the framework are discussed as well as implications to the field.
Community Health Assessment Initiatives and Challenges
South Carolina partners
The South Carolina Department of Health and Environmental Control (SCDHEC) and the University of South Carolina's Arnold School of Public Health partnered to receive the South Carolina Turning Point Grant. Activities included developing curriculum to increase capacity in using data, providing funds to local communities to implement the MAPP process, producing a DVD tutorial on MAPP, and sponsoring training in collaborative leadership. SCDHEC also issued a policy stating that local health departments should use a MAPP-like process whenever doing community assessments. While Turning Point activities officially ended in 2006, the capacity and commitment to collaboration remained in South Carolina.
Through participation in the Centers for Disease Control and Prevention's Academic Health Department initiative, the South Carolina partners formalized their collaboration by creating the South Carolina Public Health Consortium (Consortium).4 The state also participated in other Centers for Disease Control and Prevention programs that involved community health assessments, including disease-specific programs; Healthy Communities Program (2008-2012); Communities Putting Prevention to Work (2010-2012); and the Community Transformation Grant (2011-2013).5 While these programs provided essential resources to work within communities, the lack of long-term commitment by the CDC to any one program or initiative caused confusion, frustration, and distrust in practitioners and stakeholder groups, in addition to a sense of abandonment by communities and negative perception of assessment.6
In developing and implementing these programs, South Carolina used MAPP as the foundation of community health assessment and planning activities and developed South Carolina toolkits based on National Association of County & City Health Officials' (NACCHO) manual.7 In addition, the Consortium developed complementary courses on community health assessment. The policy of having a MAPP-like process gave local health departments flexibility to select which assessments or stages of the MAPP process to perform, with many opting to omit the Health Systems Assessment due to time and resource constraints. While community health assessments or improvement plans were not required and public health department accreditation was not being pursued, SCDHEC was active in performance improvement initiatives and becoming accreditation-ready through initiatives to develop consensus on state health priorities.
As a whole, MAPP is fundamentally sound. The communities in South Carolina that received South Carolina Turning Point funds and assistance to implement MAPP found the process beneficial in building community and transformative collaborations. When the project ended, time and resources were not formally allocated for the provision of technical assistance and support. Dedicated SCDHEC staff continued to help their fellow practitioners and the Consortium developed additional training on community assessment and later community engagement, based on the statewide workforce assessment.8 The partners documented barriers and challenges to implementation identified in South Carolina through facilitated conversations, grant reports, and anecdotes. These included issues around different processes and foci by varying agencies and other academic units; assessments taking up to 2 years to complete; communities feeling trapped in a cycle of assessment without getting to plans or implementation; and participating in a linear process that did not take into consideration readiness or prior progress.9
Availability of Web-based resources
Another issue impacting assessment was the availability and analysis of data. The community health status indicators were included in MAPP as the community health status assessment with the 2000 data available through the Web for the MAPP pilot. After the 2000 data were released, the community health status indicators project lapsed and the data were not compiled again until 2008. Subsequently, the 2008 data were updated in 2009 and then released again in 2015.10 Having only sporadic access to the community health status indicators data hindered the ability to use common measures and assess progress. Communities without epidemiologists and data analysts were challenged to compile and make sense of health data. The 2010 release of the County Health Rankings offered an option that met both the challenge of compiling data and presenting it in ways that were easy to understand. The subsequent development of the community road map brought data and relevant tools from existing models and programs together in a user-friendly, internet-accessible environment.
The Affordable Care Act (ACA) of 2010 requirement for tax-exempt (nonprofit) hospitals to conduct a community health needs assessment (CHNA) and develop and evaluate an implementation plan every 3 years reinforced the importance and infrastructure for community assessment and planning. The components of the CHNA are similar to the MAPP model and include defining the hospital's service area and compiling demographics and analysis of health indicators; taking into account input from the community and public health; identifying resources; and prioritizing needs. After completing the CHNA, hospitals develop an implementation plan on those needs they will address; justify those they do not address; and describe strategies, collaborators, resources, and evaluation plans. The final guidance for this legislation requires nonprofit hospitals to perform community health assessments every 3 years with implementation plans evaluated annually.11 While the regulations are relatively new, nonprofit hospitals have existing outreach programs that will be considered when implementing the ACA guidance.
These similarities and requirements align with public health models and expertise, providing an opportunity for public health to offer leadership in the process. The challenges with using a model like MAPP is that the NACCHO guidance recommends staying within its stages and phases process and spending 12 to 16 months in organizing, visioning, and assessing. That timeline and linear process are incongruent with the 3-year cycle for hospital CHNAs. In addition, many nonprofit hospitals are not ready for such an in-depth process, and we need tools that assist hospitals in performing CHNAs that range from doing as little as possible for compliance12 to developing partnerships to reach the full potential of community benefit.13
The complementary concept of collective impact also gained momentum and form. Studies on large, successful collaborations that achieved goals on complex issues identified 5 conditions necessary for successful collective impact:
1. A common agenda in which the many stakeholders agree to the priority and scope of their collaboration.
2. Shared measurement allows partners to agree to which of the many contributors to the prioritized complex social issue they will tackle and provides a mechanism to assess ongoing, crosscutting progress.
3. Mutually reinforcing activities minimizes duplication of services and aligns efforts to achieve goals.
4. Continuous communication keeps all stakeholders engaged and on task.
5. Backbone support provides administrative, logistical support that often includes technical assistance for data analysis and meeting facilitation.
In unsuccessful collaborations, communities were frustrated by lack of coordination between community-wide initiatives and well-intentioned projects not producing meaningful change.14,15 The initiatives that were studied to derive the 5 conditions included many public health programs. Collaboration and its study are not new to public health. The concepts of aligning resources and mutually reinforcing activities as well as creating an open space for inclusion of new stakeholders as programs progress and change are more challenging in older public health models.
A New Framework
The community engagement framework (CEF) was conceptualized to address the identified challenges from experiences with the MAPP process and issues and opportunities with new initiatives. The challenges identified by communities in South Carolina had left a strong, negative perception of “community assessment” within many key partners, citizens, and stakeholder groups across South Carolina. The dilemma became how to authentically engage communities in community health assessment and improvement planning, while not focusing on assessment? The solution was to focus on the main objective: engaging the community. The assessments became just 1 component of a multicomponent framework. The graphical depiction of the process illustrates the challenge of using MAPP: the main focus is the assessment phase. The 4 assessments encircle the entire process and then are listed again in the center of the linear presentation of the phases. The graphic implies that the main point of MAPP is continuous assessment (see Figure 1).
The CEF is based on a modified MAPP process that incorporates new developments and opportunities from the ACA, public health accreditation, and collective impact (see Table 1). Engagement binds the five components of the CEF: Organize, Assess, Prioritize and Align, Act, and Evaluate. The CEF involves organizing community members and organizations, assessing the needs and assets of the community, prioritizing issues and aligning resources to address them, acting in a coordinated manner to reach collective impact, and continuously evaluating and monitoring progress and process. The framework includes continuous engagement and communication through all components and with all stakeholders. The process is intended to be nonlinear and organic, allowing communities to start where they are and move in and out of components as needed.
Engagement and Components
Successfully engaging multiple stakeholders across sectors requires skills in convening and data analytics. These skills are technical assistance roles, or backbone support, provided by external entities (see the Collective Impact column in Table 1). The components and roles operationalize the CEF (see Table 2). Backbone support organizations often provide assistance in coordination, data analysis, facilitation, and communication. Having someone dedicated to the coordination of multiple committees across multisector organizations is important to keep community members active and on task. Also, data analysis or epidemiology skills are hard to find in the general population. Providing assistance in analysis and helping others make sense of health assessment data increases capacity to prioritize issues.
By using facilitation methods such as Technology of Participation's Focused Conversations and Action Planning,16 meetings are designed to allow everyone to have a voice while moving groups to consensus. Appropriate facilitation and designed meetings are important tools to successful, engaged collaborative efforts. Community members (and practitioners) tire of attending unproductive meetings. By using Action Planning, communities organize activities around what they are willing and able to do. People are more likely to be invested and implement plans that they create. As long as external partners respect the difference between doing for and doing with, these types of technical assistance activities empower communities to address their own issues.
Organizing often begins with a few, the catalyzers, and then grows purposefully. The catalyzers may already be engaged in collaborative activities for their communities and build their relationship in existing programs. In this scenario, partners actually start the process in the Act component. The point is that once a small group decides to move forward with an assessment or planning process, it can move in and out of the components of the framework according to its readiness and resources. Organizing activities make sure that people are included in the process based on the vision, values, and priorities of the community. With this understanding, it becomes inherent that organizing activities continue throughout the process through the development of future action plans, reorganization of workgroups to meet current needs, and new members joining the group. Introducing easy-to-digest data early and often helps build capacity to use more complex data from the assessments and evaluation and causes community members to reflect on committee composition.
Assessment activities provide information to empower communities and inform decisions. Counties and cities as well as several nonprofit organizations have performed assessments throughout the United States. Gathering and understanding what has already been assessed in any locale honors existing organizations and is an important part of engagement. The assessment component should be considered an ongoing activity, not something to be completed perfectly. In MAPP, the assessments hold the process together. In the CEF, assessment is one of several components held together by community engagement. Initial assessment informs organizing activities and continues as priorities are identified and additional information is needed.
Prioritize and align
Bringing together a multisector group of stakeholders means that team members have many different personal and professional priorities. Prioritizing activities helps communities settle on what are the most important issues to address at any given time. Prioritization and alignment do not keep the stakeholders from continuing to work on their own initiatives; rather, they allow them to identify existing programs addressing the issue and/or focus a portion of time and energy on the agreed-upon priorities. Aligning activities ensures that communities are using scarce resources wisely.
The community health improvement plan provides the blueprint for community activities. In high-resource areas, the team members will likely already be involved in programs or activities that address the prioritized issues. They continue providing existing programs, adapting as needed or able. New programs are implemented to fill gaps or combine resources. As gaps in resources and activities are identified, team members can recruit and include others as well as take advantage of emerging strategies.
A continuous feedback loop occurs throughout the process based on developmental evaluation, which is appropriate when working on complex social issues with new solutions or existing solutions in new areas. As programs mature, other evaluation approaches are more suitable. Agreeing on measures across programs also allows shared goals that can be measured.
The CEF remains consistent with the MAPP model while focusing more on engagement rather than the assessments. This shift allows communities to view assessment as a natural part of collaborating rather than a separate process. In addition, by moving away from the “Phases” and “Steps” language in MAPP, communities more intuitively start where they are. While strategic alignment was always a goal of MAPP, actual alignment was difficult to achieve through the existing tools. Experiences in past programs coupled with the scholarship of collective impact and the requirements of the ACA provide much needed guidance for actualizing the promise of community engagement. The process engages multisector stakeholders in addressing complex social issues. Keeping with an original intent of the Turning Point initiative, the process is itself an intervention to break down silos and empower communities.
Implications for Policy & Practice
* Basic demographic and health status data should be introduced early in organizing activities to build capacity to make sense of data and understanding for broad committee participation.
* The community engagement framework (CEF) meets all Public Health Accreditation Board (PHAB) Standards and Measures associated with Community Health Assessment and Improvement Planning.
* The CEF meets all assessment, implementation planning, and evaluation ACA requirements for nonprofit hospitals, providing an opportunity for public health to offer guidance and leadership in helping hospitals meet their community benefit missions.
* The CEF provides a mechanism to combine best practices from various models, according to the needs of a community.
1. Clinical and Translational Science Awards Consortium, United States, National Institutes of Health (U.S.), Centers for Disease Control and Prevention (U.S.), United States, eds. Principles of Community Engagement. 2nd ed. Washington, DC: Department of Health & Human Services, National Institutes of Health, Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry, Clinical and Translational Science Awards; 2011.
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3. Turning Point: Collaborating for a New Century in Public Health. Princeton, NJ: Robert Wood Johnson Foundation; 2008.
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5. Past Programs, Division of Community Health (DCH), CDC. https://http://www.cdc.gov
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10. About CHSI. https://wwwn.cdc.gov/CommunityHealth/info/AboutProject. Accessed January 21, 2017.
11. Assessing and addressing community health needs: a summary of new requirements and recommended practices. https://http://www.chausa.org
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12. Community Health Needs Assessment Toolkit: KershawHealth. South Carolina Hospital Association. July 2012.
13. Assessing and Addressing Community Health Needs. June 2013. https://http://www.chausa.org
/docs/default-source/general-files/cb_assessingaddressing-pdf.pdf?sfvrsn=4. Accessed May 5, 2017.
14. Kania J, Kramer M. Collective impact. Stanf Soc Innov Rev. Winter 2011. https://ssir.org/articles/entry/collective_impact#. Accessed January 21, 2017.
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community engagement; community health assessment