Noel Chrisman, PhD, MPH University of Washington School of Nursing HSERV 576/NURS 557 Health, Culture, and Community Coalitions and Evaluation Honor and pleasure to be here. Respect for faculty and institution. Sorry I have to leave at 3:30. I must teach tomorrow. I’m here as a non-nurse, a person who is not a nurse, but knows it and knows how important nurses are. Gail Worden at Henry Ford Health System. Noel Chrisman, PhD, MPH University of Washington School of Nursing HSERV 576/NURS 557, Chrisman, week 5

PRIMARY CARE LONG TERM CARE COMMUNITY NGOCBOSHG Temple, Church NGOCBOSHG COALITION Pharmacy Clinics Schools Business Local Gov’t Media HOSPITAL PRIMARY CARE LONG TERM CARE PUBLIC HEALTH CONTINUUM OF CARE Academia Chrisman 2006

Community Partnership: Interlocking Dynamics Community Competence Felt Needs Community Assessment and Evaluation mobilization capacity building Participation Empowerment success Noel Chrisman., 1997

Community Partnership Research Community Assessment Evaluation, Feedback Loop Involve Community, Set Priorities Sustain Implement Program Culture, Involvement, Capacity Building, Shared Power Noel Chrisman, University of Washington, 1996

Assess Health Needs: Distribution of Health Problems, Understanding of “Risks,” Demographic Data. Perceived and Felt Needs: Perceived, what is noted; Felt, what people feel strongly about. Stakeholders, Assets, Resources. HSERV 576/NURS 557, Chrisman, week 5

Involve/Prioritize/Plan Assessment done with and returned to community. Community sets priorities: winnable, simple, specific. Joint planning. Mobilize assets and resources. Assess barriers. HSERV 576/NURS 557, Chrisman, week 5

Implement the Plan Use community personnel. Use community assets and resources. Essential to have an evaluation and feedback system. Sustainability plan must be in place. HSERV 576/NURS 557, Chrisman, week 5

Sustain Local economic development. Community board. Community personnel. Celebrations. Outreach for new participants. HSERV 576/NURS 557, Chrisman, week 5

Evaluation, Feedback to the Community Qualitative and quantitative research. Understandable analysis. Continuous communication with community board. Integrate with assessment data. HSERV 576/NURS 557, Chrisman, week 5

Collaborative Coalition Network Types of PARTNERSHIPS Structure A well organized, differentiated structure with great longevity. A more enduring and highly structured organization of diverse groups working together to achieve multiple goals over time. Collaborative Additional structural strength and longevity with some effects on each organization’s actions. Perhaps a limited time period. "An organization of individuals representing diverse organizations, factions, or constituencies who agree to work together in order to achieve a common goal” (Wandersman et al., 1996) Coalition Organizationally loose, and very flexible. Perhaps an initial step toward other structures The set of linkages among people or organizations. Network structure may have effects on the behavior of network members. Network Can include any of the structures below An organizational form in which member agencies or individuals possess equal power over decision making Types of PARTNERSHIPS Structure Definition Organization Honor and pleasure to be here. Respect for faculty and institution. Sorry I have to leave at 3:30. I must teach tomorrow. I’m here as a non-nurse, a person who is not a nurse, but knows it and knows how important nurses are. Gail Worden at Henry Ford Health System. Chrisman et al., 2002

Plotting Coalition Growth Stages/Elements of success* Organizational structure Heterogeneity of participants Resources Activities Accomplish-ments Formation Implementation Maintenance Outcome *Formation: Initiation of funding, recruit members, est. structure and training, task identification Implementation: Needs assessment and progress. Development and implementation Maintenance Monitoring and upkeep of membership and planned activities Outcome: Impact that results from deployment of community-wide strategies. (Butterfoss et al. 1996) HSERV 576/NURS 557, Chrisman, week 5

Table 8: Coalition Phase I Products Strategy Measure Asset map and needs assessment existing public health data key informant interviews focus groups community forums use of defined planning process (Green 1991) asset mapping (McKnight 1992) written needs assessment which includes assets and goals of included communities Defined priorities formal priority setting process written priorities Intervention plan build from existing community assets blend community knowledge and expert approaches written intervention HSERV 576/NURS 557, Chrisman, week 5

Table 9: Current and Future Actions to Promote Sustainability: Element Action Money ADA has just received a grant for API community outreach State DOH has been ongoing contributor to Community Diabetes Initiative Health Action Plan has pledged $30,000 towards diabetes activities Seeking additional funding from local and national foundations Seeking additional funding from local and state government Shared Goals See Table 8 above Mature subsystem Multiple partners have extensive coalition experience No Brokering Funds will go directly to community or clinical interface organizations Trust Past history of partnership Public support Effective use of media Effective advocacy with local government officials Community outreach HSERV 576/NURS 557, Chrisman, week 5

Phase I Timeline HSERV 576/NURS 557, Chrisman, Feb 7, 09

Participation Involvement of people to define their own needs, set their own priorities, control their own solutions, and evaluate their own progress. Green 1996, p. 212 HSERV 576/NURS 557, Chrisman, week 5

Participation To be part of the project. Have some part of the benefits. Work in the project. Decision-making role in the project. Work on monitoring and evaluation. Develop and implement the project. Stone 1992 HSERV 576/NURS 557, Chrisman, week 5

Aspects of Participation: From the Literature Relationships between researchers and CBOs & communities: >consultation >planning >implementation Within an organization: >degree to which the community has an influence; >degree to which staff members affect direction. HSERV 576/NURS 557, Chrisman, week 5

Aspects of Participation: SPHC Community Collaboration Principles Early involvement Real influence Involved with projects Respect of values, confidentiality Benefit the community HSERV 576/NURS 557, Chrisman, week 5

Common Organizational Schemes for Community Feedback Advisory Board/Steering Committee -offers advice -range of power and control Broker, like Seattle Partners Grass roots committee Focus groups/surveys/other assessment Town Meetings HSERV 576/NURS 557, Chrisman, week 5

Mission and Goals are Crucial Elements SPHC Mission: work to improve the health and quality of life of urban, disadvantaged Seattle communities by promoting activities which are effective in preventing disease, promoting healthy behaviors and environments, and influencing the underlying social factors which affect health such as education, income, housing and economic development. HSERV 576/NURS 557, Chrisman, week 5

Evaluation Is a research process to assess and monitor the degree to which stated goals are reached HSERV 576/NURS 557, Chrisman, week 5

Three Types of Evaluation Outcome. Did the project have the effects that it projected? Intermediate (“impact”). Were the correct steps taken to fulfill the theory/method of the project? Process. How was the project carried out? HSERV 576/NURS 557, Chrisman, week 5

Levels of Outcome Individual level. E.g., personal knowledge and skill. Risk factors. E.g., diet, smoking, seat belts. Community level. E.g., organizational change, sustainable coalitions. Social determinants of health. E.g., poverty, education, environmental toxicity. HSERV 576/NURS 557, Chrisman, week 5

Conceptual Model, Process Evaluation of Seattle Partners Participation: joint action, members and researchers. Relationships: growth of personal networks. Capacity Building: skill acquisition. Empowerment: belief in future success. Products: publications, projects, evaluations. Policy change: influence policy makers. Community work: involvement in projects. Chrisman et al., 2002

SPHC Process Evaluation Model Variable Definition Indicator Participation Joint action for community needs Involvement Relationships Social bonds Network description Capacity Building Enhance abilities and skills Training sessions, TA Empowerment Community belief in future control Interview, observation Products Concrete achievements Publications, evaluations, grants Policy change Influence other to make policy change Community organizing Define, mobilize, and sustain community Designate communities, activities

Glue Relationships Stringer Networks Individual level Master Variables Variables Data Source Analysis Tool Added Benefit Reference Relationships Networks Individual level Organization level Technical Assistance Form (TAF) Meeting notes Network analysis Include informal social relationships Granovetter Mitchell 1969 Collaboration (working united) Coalition Partnerships (equal power) Grant proposals New interviews? Project evaluation (individual projects) PAR checklist Discussion of PAR Pew-Morse Aagard-Hansen Himmelman (collaboration) Francisco, Payne & Fawcett Glue Interviews i.e. SIP 1. Did you make contacts? Will you work with them again? 2. What are the concrete actions taken to precipitate cohesion/organizing? Pub vs. midwife (catalyst/community organizer) vs. middleman (e.g. asthma) Stringer

Mission and Goals are Crucial Elements SPHC Goals: find existing programs and draw lessons from them, create and/or evaluate new programs, foster mutually beneficial relationships, work to change institutions to make them more responsive to communities, provide technical assistance and create new models for community participation in health. HSERV 576/NURS 557, Chrisman, week 5

Process evaluation provides data to describe whether and how: We found existing programs from which to derive lessons. We have created and/or evaluated new programs. We have fostered mutually beneficial relationships. We have worked to change institutions and increase community responsiveness. We have provided technical assistance. We have created new models for community participation in health. HSERV 576/NURS 557, Chrisman, week 5

Other goals from successful community organizations Successful coalition development (collaboration). Power sharing. Set and act on priorities. Identify and work with community assets. Community involvement. Cultural competence. HSERV 576/NURS 557, Chrisman, week 5

REACH 2010 Coalition Agencies Public Health Quality Assurance University/HMC Clinics Diverse Partnership at the Table: Average attendance in 2000 was 25; 17 in 2005. HSERV 576/NURS 557, Chrisman, week 5

Evaluation Criteria for Community Boards Competent leadership Perceived Benefits of participation Perceived Costs Active participation and accountability Retain staff/ define member-staff relations Trust Communication Decision Making Diverse and Appropriate Membership Cultural Competence Shared purpose/mission Formalization of rules/procedures HSERV 576/NURS 557, Chrisman, week 5

REACH 2010 Coalition HSERV 576/NURS 557, Chrisman, week 5

REACH 2010 Coalition HSERV 576/NURS 557, Chrisman, week 5

Asian/Pacific Islander REACH 2010 Coalition Community Clinics African American Asian/Pacific Islander Latino Clinic/Health Provider Change DEMS Registry Case Management Provider Training Patient Education Individual Behavior Change Peer Educators Support Groups Education Classes Self Management Training Classes Community Systems Change Make community environment more favorable to diabetics Community Capacity Building REACH Coalition Organizational Networking Provider/Patient Training Environment & Systems Change Interventions

Skills involved in REACH 2010 Process Evaluation Participant observation (and training) Depth interviewing (and training) Moderate focus groups (and training) Document analysis Network analysis Research design IRB competence HSERV 576/NURS 557, Chrisman, week 5

Focus Group Questions: REACH 2010 Process Evaluation Do you talk about diabetes differently as the result of the project? How do you feel about the amount of information you have received about diabetes? What have been the most significant events to you during your involvement in this group or class? Tell us about the involvement of your family and friends in helping you manage you diabetes. Is there anything you would like to change? HSERV 576/NURS 557, Chrisman, week 5

Findings REACH 2010 Process Evaluation “This class is very helpful, helps us gain a better understanding of the disease.” Vietnamese woman Causes, how to control diabetes and how to handle high blood sugar A great deal about diet. The importance of exercise and how to exercise. And what to do when meeting with physicians. HSERV 576/NURS 557, Chrisman, week 5

Findings REACH 2010 Process Evaluation “It was a lot of information. I learned about so many different kinds of food and where to get them.” African American woman Managing diabetes through diet What to eat How much food to eat How to prepare food How to read labels Where to shop for food (learn from each other) HSERV 576/NURS 557, Chrisman, week 5

Findings REACH 2010 Process Evaluation “When I eat fish, I don’t even use the kind of sugar they teach us here. I use onion, pepper and a tiny bit of fish sauce. I cannot eat salty food and I steam it . . . My children say ‘How can you eat stuff like that’? and I say I have to. . . I eat much simpler than before because I am sick. I eat to live, not to enjoy myself.” Vietnamese woman “Before I didn’t know what to eat or what time. Now I know to control the portion size.” Latino man HSERV 576/NURS 557, Chrisman, week 5

Findings REACH 2010 Process Evaluation “How do I exercise? I walk; I walk. In the past, I walk for an hour each day. Now, I still walk for an hour, but I also do Tai Chi. Before, I didn’t know Tai Chi. Because I have this illness, I forced myself to learn Tai Chi. I don’t learn anything else, I just learned Tai Chi.” Cantonese man How to exercise The importance of exercise for controlling Diabetes HSERV 576/NURS 557, Chrisman, week 5

Findings REACH 2010 Process Evaluation “It is surprising the information you don’t get from the doctor. Most of what I learned was from this class.” African American woman “I’ve learned to be ready for the doctor . . . When I go to the doctor’s office and I go into the examining room, I take off my shoes and socks. I don’t wait to for him to tell me . . . On the counter I lay my monitor book with all my blood pressures and all my sugar. So it’s all there so he don’t have to walk out and come back. I’m getting every bit of the minutes he’s supposed to be giving me.” African American man HSERV 576/NURS 557, Chrisman, week 5

Coalition Evaluation Approach The use of multiple methods to discover and monitor: Involvement in and reactions to the project Aspects to celebrate and those to remedy Desires and directions for change HSERV 576/NURS 557, Chrisman, week 5

Coalition Evaluation Approach Open-ended questions to discover: Relationships with other members; Description of recent activities; future suggestions Feelings about participation HSERV 576/NURS 557, Chrisman, week 5

Coalition Evaluation Approach I use these data, theory and best practices from the literature, and my experience to offer suggestions for change. This happens in reports, in email to members, and in coalition and committee meetings. HSERV 576/NURS 557, Chrisman, week 5

Theoretical Perspective for the REACH Evaluation Power-sharing: all voices heard, participation in decisions. Partnership: coalition structure, wide reach to community sectors (strength of weak ties), participation, benefits, capacity building. Cultural competence: culturally appropriate projects, solid connections with ethnic communities, interpersonal relationships. HSERV 576/NURS 557, Chrisman, week 5

Theoretical Perspective for the REACH Evaluation Communication: vertical with the intervention and with policy makers; horizontal with partners. Relationships: among coalition members, interinstitutional. Dynamics of change: personnel, function, structure (Firth); innovation. HSERV 576/NURS 557, Chrisman, week 5

Where we’ve been; how we did; what to do next. Evaluation Where we’ve been; how we did; what to do next. HSERV 576/NURS 557, Chrisman, week 5