Felesia Bowen, Center for Urban Youth & Families at Rutgers University School of Nursing, moderated a workshop session on community engagement. Kelli A. Komro, Rollins School of Public Health at Emory University, and Michelle Rodgers, College of Agriculture and Natural Resources at the University of Delaware, explored the potential impact on achieving health equity by creating partnerships across organizations and engaging individuals within their communities.
ADDRESSING YOUTH ALCOHOL USE WITHIN THE CHEROKEE NATION
Kelli Komro presented on work she conducted in partnership with the Cherokee Nation in Oklahoma, a 5-year prevention plan to reduce underage drinking in high school students through community organizing. She facilitated partnerships between the leaders of Cherokee Nation Behavioral Health Services and prevention scientists, such as herself, which resulted in the development of grant proposals and funding from the National Institutes of Health to implement a trial using two evidence-based strategies.
The first intervention was Communities Mobilizing for Change on Alcohol (CMCA), a community-organizing intervention designed to reduce alcohol access, use, and consequences among underage youth. The second strategy, CONNECT, was an individually delivered screening and brief intervention (SBI) in schools. The SBI was implemented universally among all students along with motivational interviewing, which is responsive to
individual student needs and readiness to change; a combined intervention was also used (see Figure 7-1).
The study followed freshmen and sophomores for 3 years (Komro et al., 2017). The cohort of 1,623 high school students had nearly equal representation of males and females as well as Native American and white youth. Economic diversity was also noted in that just over one-half of the participants received free or reduced-price lunch. Quarterly surveys measured current alcohol use and heavy episodic drinking over the previous 30 days and also measured alcohol-related consequences across academic, social, and physical health. Over the period of 3 years, 12 waves of surveys were conducted, with a response rate of 83 to 90 percent. On the basis of data from the surveys, Komro noted that the use of the CMCA intervention saw a 24 percent reduction in heavy episodic alcohol use; CONNECT saw a 19 percent reduction; and the combined CMCA-CONNECT intervention saw a 13 percent reduction (see Figure 7-2).
Community-Mobilizing Efforts Through CMCA
Initially implemented and tested in the 1990s in communities throughout Wisconsin and Minnesota, CMCA was found to be successful in reducing alcohol-related consequences. Komro later partnered with the Cherokee Nation to implement this intervention in Cherokee communities.
Komro highlighted the theory of change: community organizing to change community policies, practices, and norms. She pointed to the value of partnerships between community members and the scientists: community members identify the issues that need to be addressed, and scientists develop a menu of evidence-based programs from which the community chooses to implement. Three core elements of CMCA and community organizing are (1) community driven with grassroots leadership, (2) focus on structural change, and (3) engagement of citizens in action design and implementation.
As part of the implementation process, Komro described how community members were recruited and trained to lead community action teams. The first team provided an analysis of community issues and needs, resulting in the selection of one of the evidence-based strategies the scientists had supplied. Through this process, the team continued to identify and meet with supporters (i.e., faith community, youth-serving organizations, health care and public health officials, and school personnel and teachers) and what were called opposition parties (i.e., elected officials, law enforcement, school administration), strategically working toward the goal of restructuring policies.
Working together, community action team members synthesized multifaceted strategies to combat underage drinking. This involved media strategies (e.g., letters to the editor, op-eds, social media); law enforcement strategies (e.g., reporting parties, increased hot-spot policing, compliance checks); ordinances and policies (e.g., social host enforcement and countywide response plan); and vendor training (e.g., how to spot a fake ID).
Komro highlighted the essence of organization to include being driven by citizens while involving leadership development and relationship building. She stated the importance of involving everyday citizens in community action teams who can work together to get support from the larger community and having the freedom to push upward to create change (see Box 7-1).
BUILDING A CULTURE OF HEALTH
Michelle Rodgers presented on the National Framework for Health and Wellness project, which was launched at the University of Delaware just 2 months prior to the workshop—a partnership involving Cooperative Extension, the National 4-H Council, and the Robert Wood Johnson Foundation. Cooperative Extension is taking on improvements in health through community engagement, which, according to Rodgers, has meant changing the culture of Cooperative Extension to work as a system with the local community. Then, she said, the community engagement process can link the organization’s national network with other organizations to change health outcomes.
National Framework for Health and Wellness
The Cooperative Extension’s focus for the past 100 years was providing education to individuals. When addressing health and wellness, however, the organization acknowledged that programs must incorporate a socioecological model to address community- and societal-level issues, highlighting the importance of addressing the environment and not only the individual (see Figure 7-3). This approach, Rodgers noted, involves a shift to develop partnerships with new stakeholders and organizations in the area of health and wellness, specifically the medical community and public health colleges. The program gives health facilities the opportunity to gain input from community members and ultimately obtain better outcomes. To increase the impact, she said, Cooperative Extension will need to change contexts in which people live and address socioeconomic factors.
Rodgers acknowledged several key elements integral to the shift in her work. These elements include establishing shared values with partners; fostering cross-sector collaboration to improve well-being; creating healthier, more equitable communities; strengthening integration of health services and systems; and focusing on improved outcomes for population health, well-being, and equity. A unique component of this partnership, Rodgers highlighted, is the emphasis on youth leadership. With 4-H serving approximately 6 million youth between the ages of 8 and 18 across the country, the program seeks to make youth active members in community-based interventions. In a group setting, youth-adult partnerships are forged to solve challenges pertaining to social justice and community issues and to strengthen organizations.
Participants underwent technical training in community needs assessment, planning, and evaluation. Educational training addressed health-related topics, such as nutrition, physical activity, health behavior change strategies, and mental and emotional health. Rodgers anticipates diverse
outcomes, including improving personal health, increasing community leadership, improving equitable access to health resources, contributing to community development, and reaching new audiences.
Pilot Program Selection
The first stage of the program funded 5 states. According to Rodgers, 26 states applied to take part in the pilot program through Cooperative Extension. States not selected were allowed to self-fund if they were interested in participating. At the time of Rodgers’ presentation, 10 states decided to self-fund programs. All 15 states were required to work with three communities with the condition that one community must be rural. They also must work with three types of program-wide coalitions categorized as (1) Innovators, (2) Implementers, and (3) Planners. Programs with established coalitions and ready to launch are the Innovators. The Implementers are emerging groups with some infrastructure, but some
components are still in the development process. Planners are communities still developing plans for councils or coalitions.
The project timeline at the time of Rodgers’ presentation (November 2017) was to have the programs established and ready for action at the end of 2 years. The program orginally planned for 15 pilot communities, but this number is steadily increasing with a 10-year long-term goal of more than 1,000 communities by creating new partnerships with an additional 66–76 land-grant universities. Through the widespread implementation of this program, communities are expected to benefit with an increased number of Americans who are healthy at all stages of life, growth in youth leadership who support healthy lifestyles, and deeper extension connections and relationships to support community development.
A primary focus of the discussion was on sustainability, including building the community’s capacity to self-govern on constrained budgets. Other topics participants considered were on working with youth and community dynamics.
Several participants enquired about how to ensure programs are sustainable in terms of finance and compliance once researchers depart. A participant from West Baltimore commented that his organization integrates a plan to build up communities’ capacities to self-sustain. “What we were challenged to do is to move from engagement to community driven to community led to ultimately community owned,” he said. “The goal from day one is always ‘you don’t need us anymore’ 2 years before our grant funding drops off.”
According to Komro, CMCA was designed to be financially sustainable. Grant money was set aside to pay a community organizer and action teams. The community also raised concerns about the ability to fund the interventions going forward. In response to the concern, Komro’s team tailored interventions with the existing social infrastructure. For example, community members drafted plans to help police officers in their enforcement. If police officers were not willing to comply, community members would pressure the mayor’s office to ensure law enforcement officers were fulfilling their duties.
One participant asked how Rodgers’ team is ensuring young people’s voices are being heard, recognized, and respected. According to Rodgers, the program has an educational component to teach adults the dynamics of being mentors to youth. Rodgers also noted most of the adults in the program have previous professional experience working with youth.
Another participant questioned Komro about making the initial connection with Cherokee Behavioral Health and earning the trust of the
community. Komro acknowledged her colleague, an established clinical psychologist in Oklahoma, as her introduction to the Cherokee community. “They [Cherokee Behavioral Health] were wanting to expand their prevention science-based approaches,” Komro said. She also attributed the success to her time spent in Oklahoma and having the team involved early in the process, including co-writing the grant.
Another participant raised a concern about community members’ attitudes toward introducing change. Rodgers commented many initially did not see the program’s relevance to the 4-H’s traditional role as an agriculture organization, even though other components are part of its mission. She said community members began to accept the program after she emphasized the organization’s expertise in youth development. Given the community’s strong ties to agriculture, Rodgers also marketed the One Health approach of making plant and animal health relevant to human health. “People will come to bring their pets in first for health care before they bring themselves [for their own health care] in this community,” she said. While people wait for their pets, nursing students are available in the waiting room taking pet owners’ blood pressure and distributing educational materials.