systems change


Several members of the Jicarilla Apache Tribe, along with other community members who worked on the reservation but were not tribal members, developed the Decade of Hope Coalition. Many of the residents struggled with alcohol abuse some time in their lives. Many of the tribal elders died from neglect and alcoholism, often dying of exposure during the long mountain winters. The coalition began in 1989, following a string of suicides among young tribal members. Mothers of these teens and young adults decided that something needed to be done about the problem beyond the limited efforts of the Tribal Council. The authors and collaborators began our involvement with this coalition near the end of 1991, when we were asked to help with evaluation of a successful grant proposal to the Community Partnership Program of the U. S. Center for Substance Abuse Prevention (CSAP).

A community action planning guide for substance abuse prevention provided a framework with which to create and adapt a vision for a healthy community and statement of what the community will do and why (vision and mission statement). The process also facilitates making that vision concrete through the development of a culturally-appropriate blueprint for action (objectives, strategies, and action plans). Unlike many other strategic planning processes, the Action Planning Guide provides a group with specific prompts for potential community changes (i.e., new or modified programs, policies and practices) that could be sought to reduce risk and enhance protection for substance abuse. Tribal members developed their own unique action plan to reflect local strengths, culture, needs and resources.

One result of the strategic planning process was the identification of sectors of the community targeted for change by the Decade of Hope Coalition. These sectors included tribal and non-tribal businesses, religious organizations, public schools and tribal education, tribal government, cultural organizations, tribal police and courts, youth organizations, media, as well as health and service organizations and native healing. During action planning, tribal members identified specific community changes to be sought (i.e., new or modified programs, policies and practices related to substance abuse) for each sector. For example, there were a number of changes identified for tribal and non-tribal businesses, such as a ban on people fighting in the local bars. A total of 85 objectives for community change were identified. It remained the task of coalition members to further specify who would do what by when to bring about the changes in the action plan. Coalition members and staff reviewed the objectives and related accomplishments during monthly coalition meetings and informally in the coalition office.

This coalition was instrumental in bringing about changes in the community relative to substance abuse prevention. The total of 69 documented changes included new programs, such as the establishment of a micro-grants program to create alternative activities for youth and address health-related problems in the community, the coordination of services among human service agencies, and policy changes such as requiring the local public radio station to air substance abuse prevention Public Service Announcements in Jicarilla as well as English.

The local evaluation coordinator (a tribal member) reviewed the records of the local Indian Health Service clinic to collect these data. Data were available from January 1985 through June 1993. There was a steady increase in the number of alcohol-related transports through January of 1992. The patterns were somewhat cyclical, with a series of peaks occurring in the summer months when tribal festivals are held. Although data for 1993 are not complete (because we only had data for 6 months), alcohol related transports decreased sharply when those months are compared to the same time period from the previous years. When viewed alongside data from the documentation system, the results show an association between decreased alcohol-related transports and changes facilitated by the coalition in 1992 and 1993. Although limited by data availability, this association is suggestive of coalition impact.

In the late 1990’s, I worked closely with staff of the Partnership for Children (PfC) in the Kansas City Metro area. In particular, I worked with Dr Jim Caccamo, the Executive Director, to help him use data to improve the efforts of the PfC to increase immunization rates, develop a large scale youth mentoring initiative, and to develop and implement a social marketing campaign on behalf of children (the #1 Question Campaign). This slide show summarizes the findings of the #1 Question Campaign in terms of leadership, community systems changes facilitated by community leaders, reach of the campaign in terms of health outcomes (immunization rates), and the behaviors of community members in caring for youth. In the presentation of these data, you can see how the community became progressively engaged in facilitating systems improvements (e.g., new and/or modified programs, policies and practices) relating to the campaign, and that it appears to positively affected more engagement in the lives of children as measured by the random digit dial phone survey. It appears that with significant strategic leadership, a community can influence positive youth development through systems change, social marketing of a consistent sticky message, and leveraging relationships for important shared outcomes.

In July 1997, the Hawai’i District Health Office (HDHO) in partnership with the University of Hawai’i at Hilo Department of Baccalaureate Nursing, the Hawai’i County Office of Aging, the Hilo Community School for Adults and the Hawai’i Alliance for Community Health sponsored a workshop “Action Planning for Community-Based Initiatives.” A basic concept emerging from the meeting was the belief that it is important to change the environment in which individuals engage in “unhealthy” behaviors in order to maximize efforts to reduce the prevalence of those behaviors within the population. It encourages citizen participation and the development of a community’s capacity to address local health problems. In the workshop, participants identified barriers to creating and maintaining community partnerships/coalitions. Existing concerns of child abuse and neglect, promoting health for older adults, adolescent pregnancy, substance abuse, risk for chronic disease, and youth violence were topics used as examples for training purposes. These topics were consistent with priority health concerns for the 6 island communities as well as being reflected in Healthy Hawai’i 2000 objectives.
A community initiative focusing on building the capacity of community members on the Big Island of Hawai’i was created following the workshop. Four principal program objectives were identified in this project. They include:

  • Community partnership development in each of the 6 districts on the Big Island;
  • Providing initial staffing to coordinate and facilitate coalition development;
  • Providing training for the initial staff and for key community leaders in core competencies for doing the work (e.g., planning, facilitation, grant writing);
  • And documenting community change and the successes of the local community partnerships.

This Prezi presents the development of a grassroots movement to address the above issues, the capacity built as part of the initiative, findings from a participatory evaluation, and future directions.

Where I live now, the past is still present for so many people. I know people here that can point to the house of the family that owned their family members as slaves. I have a close friend who is very light skinned African American, and people seem oblivious to her rich family experience (which is their loss). Her African American heritage is part of why she is so awesome, but others are quick to deny that part of her background because she is so successful. I’ve had to learn that it is much more important to walk with humility, and let others teach me about their cultural heritage. Once we assume their experience, we are no longer friends or have a harder time becoming friends. When we listen to them, we find that we have many more experiences in common than not, and we have a much richer friendship too. We all inherited this world, but we don’t have to perpetuate the problems. We can work to stop it, even if it is a little at a time.

We are working with folks in Greensboro to improve access to health care among the low (and no) income, and the chronically under served. The divide is huge and problematic. We will change the system, but it will take a while. I seem to have to learn every day that it is as much about becoming friends as it is about changing systemic and institutionalized bias. People are so used to being excluded that it will take a while for them to learn to use the services that are becoming available. The Affordable Care Act was a nice first step, but we have a LOT of work to do to change a few centuries of exclusion and all the behavior associated with it. The trust that comes with friendship is the only way it will move forward.

One potential way forward is to create a new partnership with the Faith Community (often not present at the table for community change initiatives), health service providers and Universities to facilitate new systems changes (new and/or modified programs, policies and practices) that will have a positive impact on a larger segment of the community. These may be as small as changing the location of bus stops to allow for easier access in under served communities, or as large as creating free health clinics at Churches. This builds on the extraordinary trust present within the Faith Communities, and allows for greater access to health services. Universities can play a role through their academic training mission (creating new programs and jobs), as well as with new measurement systems that would allow for ongoing improvement in health outcomes based on the hundreds of innovations that are anticipated.

For more information about how to facilitate lasting improvement in the community, see the Community Tool Box, especially Chapter 1, which contains much more about community collaboration, systems improvement, community action planning, and evaluation of these kind of open systems initiatives.