Photo by Adam Derewecki | Pixabay
Community-level change is likely to be our best bet for chipping away at pervasive health inequities, yet communities are each nestled inside local, regional, and national policies, attitudes, and expectations. Can such diverse ecosystems be changed? Yes, but it requires more than change. It requires a transformation.
To meet this challenge, the Spreading Community Accelerators through Learning and Evaluation (SCALE) initiative from the Institute for Health Improvement — in partnership with Communities Joined in Action, Community Solutions, and Network for Regional Healthcare Improvement — developed a community transformation roadmap for achieving a culture of health. The development, use, and evaluation of this roadmap is described in the American Journal of Orthopsychiatry and summarized below.
SCALE helped communities around the United States shift from focusing on problems to embracing adaptation, abundance, and connection: becoming a Community of Solutions. Based on the literature of sustainable development, being a Community of Solutions requires three catalysts of change:
- Relationships are defined as how people relate to themselves, each other, and to those affected by inequity.
- Improvement refers to how the community approaches the change process.
- Equity describes how the community creates abundance through leadership, adaptability, empowerment, and connection.
Becoming a Community of Solutions transforms communities into places where health is a shared value, there are thriving cross-sector partnerships, and there is improvement in population health, well-being, and equity.
A Tool for Transformation
The complexities of community relationships, improvement, and equity are distilled into a 40-item tool for assessing and planning community transformation called the Community Transformation Map (CTM). It took nearly a year for the CTM to be developed and refined by a SCALE workgroup of implementation scientists, evaluation experts, and community leaders. The workgroup scanned the community change literature for similar tools, cross-referenced items against these resources, and conducted multiple feedback rounds with participating community coalitions.
Each item is graded on a five-level maturity map ranging from “not yet started” to “spreading and scaling.” (See Figure 1 below.)
Figure 1 — Sample Community Transformation Map items
Using the Community Transformation Map
The CTM brings community members together to reflect, reconcile perspectives, and chart an action plan.
As the authors of the American Journal of Orthopsychiatry article state:
“The CTM is intended to foster a holistic view of community coalition functioning from the perspective of system leaders, community facilitators, and community residents with lived experiences of inequities. Therefore, respondents should include community members across hierarchical structures and leaders with lived experience of inequities. During assessment, each member of the coalition first considers each CTM item from a personal perspective and assigns a score (from 1 to 12) for both the current capability level (‘Now’) and for where the member would like to see the community be in six months (‘Goal’). Individual ratings are then compared by participants in a collaborative discussion session and discrepancies of score differences (of five or more points) are reconciled. In translating the CTM from assessment to action, individual items are reflected upon by visually inspecting high/low scores and gaps a between ‘Now’ and ‘Goal’ scores. Priorities are determined by the coalition members.”
Each coalition self-administers the CTM semi-annually and uses the information to revise their improvement plans.
Community Response to the CTM
The first cohort of community coalitions that used the CTM completed it twice a year for two years. Interviews showed a favorable perception of the CTM, stating for example: “[It] actually gave a structure to the discipline we needed to keep going and saying: ‘Are we where we want to be? Are we doing what we want to be doing? Are we making a difference?’” The greatest value is in breaking down the complexities of transformative change into digestible, actionable pieces.
One coalition used the CTM for assessment, goal setting, and gauging progress:
“After the first administration [Coalition 3] selected ‘shared stewardship’ (a Relationship construct) as a priority area. This included three items: ‘There is a shared commitment to health, well-being, and equity across the community’ (baseline ‘Now’ rating = 7); ‘People see themselves as stewards of the community’s well-being’ (baseline ‘Now’ rating = 4); ‘Stewards in our community are committed to change for the long term’ (baseline ‘Now’ rating = 3). They set their goals to increase each item by two points, to the next maturity level. In their action plan, strategies to address this included inviting new community-based organizations across the region to learning academies held by the coalition. These academies brought together community leaders to discuss salient regional health concerns, learn improvement methods, and create new collaborations. This coalition asked all health educators to co-lead sessions at this event and encouraged rural health networks from surrounding counties to attend the event. One method for doing so was developing memorandums of understanding with expectations for rural representatives to be active in the event, incentivized by tying involvement to their community health improvement plans. To assess their success, they sent post-event surveys to attendees and received favorable feedback on the respondents’ comfort and confidence in working with their local health education network. As these activities took time to bear results, the coalition did not score themselves significantly higher during the second administration of the CTM. However, by the third and fourth administration, they reported adding the largest county in their area to their collaboration, and perceived health educators as more involved and committed to local change. As a result, Coalition 3 rated the three CTM ‘shared stewardship’ items roughly the same at the first two administrations, but felt confident enough to rate themselves higher by the third (8, 5, 5, respectively) and fourth (8, 6, 6, respectively) administration. At the same time, they also noted ongoing challenges of defining health educators’ roles in each county, engaging people with lived experience of inequities, and described that some counties were more advanced than others in collaboration and measurement, indicating further areas where work was needed. Used as intended, the CTM helped Coalition 3 to identify areas where they felt improvement was needed, to set goals toward these improvements, and to assess progress over time.”
CTM offers an adaptable, coalition-led process for understanding complex change. As such, it continues to be adapted and refined. For example, the Georgia Health Policy Center and County Health Rankings & Roadmaps adapted CTM items into the Assessment for Advancing Community Transformation, a self-assessment for communities to understand improvements in health and equity. With future applications, we can continue to learn how to make transformation achievable.
Ariel Domlyn is a doctoral candidate in Clinical-Community Psychology at the University of South Carolina and a co-author (with Jonathan Scaccia, Niñon Lewis, Shemekka Ebony Coleman, Gareth Parry, Somava Saha, Abraham Wandersman, and Rohit Ramaswamy) of “The community transformation map: A maturity tool for planning change in community health improvement for equity and well-being” recently published in The American Journal of Orthopsychiatry.
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