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BY: JULIA WEAVER

Ms. Weaver is senior community adviser, Healthy Communities Programs, National Civic League, Denver.

Groups Tackle Health Problems That Have Social, Economic, and Cultural Aspects

Improving community health, what many healthcare leaders call "building healthy communities," is a tough business. When we look at our communities' health status, we see that many of the most troubling health issues—such as smoking, sedentary lifestyle, nutrition, substance abuse, and teen pregnancy—are often not amenable to traditional medical interventions. What makes such issues so incredibly complex is the fact that they are connected to social, economic, and cultural problems.

To achieve real gains in our society's most pressing health issues, healthcare providers must collaborate with other groups and institutions—including faith groups, schools, local government, public health organizations, neighborhood groups, businesses, and those portions of the public that are directly affected.

In the past, it has been common for healthcare leaders to tackle the medical aspects of complicated health issues while other sectors focused on their own "pieces." In dealing with teen pregnancy, for example, health professionals have traditionally focused on prenatal care and safe deliveries, leaving the educational aspects of the problem to schools and the social service aspects to social service professionals. However, such groups have found that, in working separately, they might ameliorate the negative effects of teen childbearing but they could not so much as dent the teen pregnancy rate.

In the case of teen pregnancy, healthcare leaders are increasingly collaborating with others to address some of the "upstream" issues and thus create a community context that will help young people delay childbearing. This new approach—sometimes called "Youth Futures"—deals with the social, economic, and cultural aspects of teen pregnancy. Youth Futures involves partnerships among school systems, social service providers, healthcare providers, businesses, local government, and community-based organizations, all of which work together to provide mentoring, education, supervised recreation, and good job opportunities for populations of at-risk youth. (Providence Health System, Inc., and Baystate Health Systems, both based in Springfield, MA, are two providers that support such an initiative.)

Healthcare leaders are working with community collaboratives all over the nation to discourage smoking, reduce juvenile crime, and strengthen community infrastructure, as well as to cut the teen pregnancy rate. The most successful efforts, like the Youth Futures initiatives, are marked by strong collaborative relationships among the public, private, and not-for-profit sectors.

Collaboration Calls for Special Skills
But building collaborative relationships among the three sectors is easier said than done. The National Civic League (NCL), which has worked with scores of communities across the nation has found, first, that special skills are required in the creation of such relationships; and, second, that many otherwise talented people have not yet had an opportunity to develop these special skills.

Using Process Design
"Process design" is one of the skills required for people building collaborative relationships. It means arranging an environment in which individuals and groups from different parts of the community feel welcome and included, allowing them to participate effectively in setting priorities and getting work done.

Process design involves a number of issues, each of which raises questions that must be answered.

• Participation. Who will be involved? Will the group attempt to include representatives from the entire metropolitan area, or will it focus on a particular neighborhood? How can the group include both traditional power brokers and those who have not previously been at the table?
• Focus. What is the scope of the effort, and who should decide what the scope will be? Will the group consider "community health" broadly, or will it focus on a single community health issue?
• Process. What sort of process will the group use to gather information, make decisions, and do the work? Will the group host large, facilitated meetings? How will committees function? Will the group use consensus to make decisions?
• Logistics. Which meeting location will feel most welcoming? Is there ample parking? Will child care be provided?

Using Data to Inform Decisions
The correct use of data is another important skill. Data are more effective in collaborative efforts when they are used to inform decisions, rather than to drive them. Data should be timely and accurate, and should measure what is important to the community.

Data should also be a tool the group uses to set priorities for its work. This does not mean that the group should expect its data—taken from a community health assessment, for example—to tell it what to do. Rather, good information can help people from diverse perspectives develop a common picture of their community. The group can then talk about its perceptions and concerns and determine where the intersections are.

For example, statistics indicate that in many communities children are more likely to die from drowning than as a result of violence. But if the community feels more threatened by violence than by swimming pools, it should work on violence prevention first.

Data can also be used to get the immediate community directly involved and to interest the larger public in the effort. Groups should not gather information simply because it is of a type that social scientists traditionally measure. They should collect data on what community residents care about.

For example, residents of Colorado's Roaring Fork Valley region are concerned about the lack of jobs in the community and the detrimental effect long commutes can have on family life. Therefore, the community now gathers data on drive time to work.

The residents of Hampton, VA, have developed a community-specific measure of community safety, called the "Chilleno's Index," which tabulates the number of neighborhoods the local pizza delivery place (Chilleno's) will deliver to after dark. This provides the community with meaningful information about the safety of their neighborhoods.

But groups should remember that whether a collaborative effort succeeds or fails will depend on the quality of the relationships between the partners. Data can be sensitive. School dropout rates, crime statistics, hospital discharges—all are tools that can be used to inform decisions. But they can also be used as weapons. A group employing potentially embarrassing information should be careful not to use it in ways that might harm other groups.

Dealing with Trust, Turf, and Time
Everyone involved in a collaborative effort can expect to be frustrated at some point by issues involving trust, turf, and time. A group may find, for instance, that it lacks the level of trust necessary for sharing resources and decision making. Or certain organizations may discover they are cooperating ineffectively because each is trying to protect its turf. Or groups may find they get little real work done because they spend huge amounts of time trying to fit the project to various participants' schedules.

One of the most important skills collaborative leaders can develop is keeping group members focused and energized even as they work through these tough issues.

Trust One useful strategy is structuring time to work on trust, relationships, and accountability. Leaders should make sure that participants have the opportunity to articulate why they are involved and what they need to stay involved.

Turf An effective way to deal with potential turf problems is to design the process so that those concerned about losing control over their work, or organization, or issue, are brought in early. Leaders should let such people know that their contribution is honored and work hard to keep turf battles from splitting the effort.

It may be that a community already has a collaborative going. In that case, the leaders of a new initiative should think about how their project relates to, for example, the local Healthy People 2000 group, the local health and human services network, or the mayor's blue ribbon panel. Leaders should ask, Is a new effort really needed, or can the necessary work be done within the existing structure?

Time A collaborative effort will almost always take longer to carry out than one conducted by a single organization. That is because of the difficulty of managing multiple schedules—for example, the local chamber of commerce meets on the second Tuesday of each month, and the high school basketball team plays on Thursdays.

Also, some groups come to the table ready to make decisions and allocate resources, while others are at a more exploratory stage. And new people join the group and need to be oriented. When the effort gets bogged down, its leaders should:

• Set meeting dates as far in advance as possible, urging participants to schedule their meetings around the effort's meetings.
• Work on small issues if the collaborative group cannot agree on larger ones. If, for example, the public health department must get the legislature's permission before participating in a health plan for underserved children, the group can start work on a smaller initiative in the meantime.
• Keep meetings public and open to newcomers, but also organize an effective orientation process, so that newcomers can be brought up to speed outside regular meeting times.

For more information, call Julia Weaver, National Civic League, 1-800-223-6004.

Data from an older, depressed, African-American neighborhood showed problems with teen pregnancy, crime, and unemployment. Social service groups launched programs to deal with these problems, but failed to get neighborhood residents interested in them.

Finally, someone did a survey of the residents' perceptions. Their top concern turned out to be that rats were coming into their houses and biting children and the homebound elderly.

A community group helped the neighborhood get rid of the rats—and in doing so found a way to engage the residents.