Promoting Health at the Community Level


Edited by: Douglas V. Easterling, Kaia M. Gallagher & Dora G. Lodwick

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    Grantmaking foundations in the United States have traditionally played a leadership role in developing and testing innovative ways to improve the human condition. Similarly, since its inception in 1985, The Colorado Trust has employed a variety of grant-making approaches and philosophies designed to advance the health and well-being of the people of Colorado. For example, some Trust initiatives have tested new program models designed to improve health outcomes such as birth weight and child abuse. Other initiatives have supported community-based organizations in designing and implementing programs to address health issues as diverse as suicide, obesity, violence, and the needs of immigrants and refugees in the state. Still others have been directed at improving policy, both within health care organizations and units of government.

    To ensure that Trust resources make a real contribution to the health and well-being of Coloradans, we devote considerable time to planning and designing initiatives. This process often requires that we balance competing interests. For example, in selecting topics for Trust initiatives, we strive to incorporate not only objective health assessment data, but also community concerns. Likewise, in making grants to community organizations, we look for health promotion programs that are justified based on research and those that are a good “fit” for each community.

    This book describes both the successes and the challenges that arose in implementing seven of The Colorado Trust's community-based health promotion initiatives. These initiatives supported various community groups (e.g., nonprofit organizations, local health departments, school districts, community coalitions) in their efforts to prevent teen pregnancy, improve home visitation programs and school-based health education, address the Healthy People 2000 objectives, maintain seniors in independent-living situations, and promote community health, broadly defined.

    Although this book describes initiatives that were designed and funded by The Colorado Trust, it was not written by Trust staff or under the direction of the foundation. Each of the seven case studies was written by a team of independent evaluators. The Colorado Trust highly values evaluation of its initiatives in order to assess the effectiveness of its grant making. We hope that other funders, as well as individuals and organizations operating at the community level, will gain insights that improve their own practice.

    In reflecting on our experiences with the community-based approach to health promotion, we believe that there are significant opportunities and critical challenges. On the one hand, we have seen a number of our grantees make significant progress in addressing health issues in their communities. Indeed, many of these organizations and individuals have established themselves as leaders at the local, state, and even national levels. On the other hand, the community-based approach calls for considerable flexibility and patience on the part of a funder, particularly with regard to achieving measurable improvements in health status.

    Clearly, supporting communities in their own problem solving has strengths and limitations. We have come to believe that the best approach to promoting health is to combine community-based initiatives with a variety of other strategies that lead to outcomes such as more effective program models, more efficient and equitable systems of health care delivery, more appropriate health policy, and improved living conditions. Only by assembling a diverse portfolio of mutually reinforcing approaches can a funder—and a community—hope to make significant, lasting progress in improving people's health.

    Findings from the evaluations of all past Trust initiatives—including the seven profiled in this book—help shape future initiatives of the foundation. We encourage readers of this book to browse through our Web site ( for a current perspective on The Trust's grantmaking efforts.

    John R.Moran, Jr.


    This book brings together the evaluation findings from seven community-based health promotion initiatives developed and funded by The Colorado Trust in the 1990s. It goes without saying that the evaluators would have had nothing to write about were it not for all the hard work carried out by the organizations and individuals involved in these initiatives.

    More than 150 groups throughout Colorado (nonprofit organizations, coalitions, government agencies) received funding from the foundation across the seven initiatives. These grant-funded organizations have included many, many individuals who taught us what community-based health promotion looks like (and should look like) in practice. To each of you, we commend you for the leadership and commitment that you brought to your projects, and we thank you for your openness and candor in sharing your experiences with your individual evaluators. We hope that you will recognize your accomplishments, struggles, and lessons in the chapters that follow.

    Supporting the work of the grantees were a variety of managing agencies, including the the Center for Public-Private Sector Cooperation at the University of Colorado at Denver, Colorado Action for Healthy People, the Colorado Rural Health Center, the Kempe Prevention Center for Family and Child Health, the National Civic League, OMNI Institute, and the Rocky Mountain Center for Health Promotion and Education. We would like to acknowledge the staff of these organizations for contributing to the outcomes reported here. In addition, we are grateful for their willingness to enter into the evaluation process as colleagues in discovery.

    Obviously, none of these initiatives would have seen the light of day were it not for The Colorado Trust. The foundation invested significant financial resources in the strategy of community-based health promotion, even though this sometimes represented uncharted territory. In addition, the staff and board of the foundation displayed their leadership by setting the vision for these initiatives, encouraging community groups to tap into their underlying potential and persevering with this support as the inevitable real-world complications arose. The following staff members played a distinctive role in the design, management, and evaluation of the seven initiatives included here: John Moran, Jean Merrick, Sally Beatty, Carol Breslau, Nancy Baughman Csuti, Susan Downs-Karkos, Walter LaMendola, Sharon Mentzer, Dana Nickless, and Holly Woods. We would like to express special appreciation to John Moran for his support of the book-writing project (even when it was unclear what the book would say) and to the staff members who provided many useful comments during the review of the manuscript. We are particularly indebted to Jean Merrick for being so conscientious in overseeing this review process.

    The folks at Sage have all been amazingly supportive and understanding throughout the entire process of transforming the initial prospectus into a polished book. Marquita Flemming immediately recognized the importance of this topic, affirmed our ideas, and encouraged us through the fits and starts that characterized the early stages. Al Bruckner, who replaced Marquita as senior editor in 2002, provided clear and sound counsel at a critical juncture in the process. MaryAnn Vail, Sanford Robinson, and D. J. Peck each brought a high degree of professionalism, efficiency, and wit to the editing of the manuscript and the production of the book.

    As with all research, our work builds on the hard work and creative thinking of those who walked the path ahead of us, or in some cases carved out the path. We are grateful to have had the opportunity to talk with and learn from so many of the people who have developed the theory and practice of community-based health promotion. In addition to the individuals who contributed chapters to the book, our thinking has been informed by conversations with Quinton Baker, Marshall Kreuter, Dorothy Meehan, Steve Fawcett, Bob Goodman, Abe Wandersman, Bill Beery, Kristin Bradley-Bull, Pauline Brooks, Christine Lowery, Joann Tsark, Colin Laird, Nancy Wilson, Michelle Sturm, Sam Burns, Marsha Porter-Norton, Susan Eliot, Alan AtKisson, David Swain, Terri Shelton, and Paul Wellstone.

    Finally, we would like to acknowledge the many colleagues, friends, and family members who have encouraged us along the way, particularly our respective spouses, Lucinda Brogden, Paul Nutting, and Weldon Lodwick. It is possible to bring complex projects like this to fruition only because we are connected to a much larger web of supportive people, organizations, and communities.

  • About the Editors

    Douglas V. Easterling, Ph.D., is Director of the Division for Community-Based Evaluation within the Center for the Study of Social Issues at the University of North Carolina at Greensboro. Through the division, he has served as the principal investigator on evaluations of the Winston-Salem Foundation's initiative to build social capital and the Z. Smith Reynolds Foundation's initiative to improve race relations. He has also assisted the Community Foundation of Greater Greensboro, the Warner Foundation, the Mary Reynolds Babcock Foundation, and The Conservation Fund in designing evaluation systems and clarifying program intent. From 1992 to 1999, he served as the director of research and evaluation at The Colorado Trust. In that capacity, he commissioned evaluations of the foundation's initiatives (including the seven initiatives described in this book) and facilitated the foundation's process of learning from the results. He has published articles and books on the topics of program evaluation, community-based health promotion, and nuclear waste policy. He also teaches the evaluation module for the Health Forum's fellowship programs, and he served on the CENTERED Blue Ribbon Panel that was convened by the Centers for Disease Control and Prevention to improve the evaluation of projects that aim to reduce racial/ethnic disparities in health. In February 2002, he delivered the Fischer Francis Trees & Watts Keynote Address at the Community Trust Conference in New Zealand. He holds a Ph.D. in public policy and management from the University of Pennsylvania, an M.A. in quantitative psychology from the University of North Carolina at Chapel Hill, and a B.A. from Carleton College.

    Kaia M. Gallagher, Ph.D., is Director of Evaluation and Manager for the Center for Research Strategies, a research and evaluation consulting firm in Denver, Colorado. With more than 25 years of experience, she currently serves as the evaluator for a number of federal, state, and local programs, focusing in particular on the effectiveness of prevention programs designed to change the risk behaviors of youth. Her career focus has been on promoting the use of strategically collected information to enhance the development and performance of programs in the health, education, and social service sectors. In this capacity, she provides consulting services in the areas of strategic planning, needs assessment, outcome evaluations, and development of outcome assessment tools. She also develops business plans that disseminate research models into marketable products and services. Previously, she worked in a number of evaluation offices within the U.S. Department of Health and Human Services (DHHS), including the Office of the Assistant Secretary for Planning and Evaluation. She currently provides evaluation services to DHHS programs funded by the Centers for Disease Control and Prevention, the Office of Adolescent Pregnancy and Parenting, the Family Youth and Services Bureau, and the Health Resources and Services Administration. She is Assistant Clinical Professor in the Department of Preventive Medicine and Biometrics within the University of Colorado Health Sciences Center. She is a member of the board of directors for the National Organization of Adolescent Pregnancy, Parenting, and Prevention. She earned her Ph.D. in sociology from Brown University.

    Dora G. Lodwick, Ph.D., founded the REFT Institute, which focuses on research, evaluation, facilitation, and training, in Centennial, Colorado. She has evaluated programs and other initiatives in the areas of participatory community- development, leadership development, health, immigrants and refugees, aging, and environmental impacts. She has published in several of those areas for more than 20 years. She has worked extensively in Latin America, and she speaks Portuguese and Spanish. She has been a university professor for 15 years at Miami University of Ohio, Oregon State University, and the University of Denver, where she established the master's degree program in applied social research and evaluation. She has served the Society for Applied Sociology (SAS) as president, as a board member, and in other capacities and has represented SAS on the Commission on Applied and Clinical Sociology. She has also held leadership positions in the American Sociological Association.

    About the Contributors

    James V. Adams-Berger, M.A., is President of OMNI Research and Training and OMNI Institute and has worked for these companies since 1992. His primary technical areas of expertise include survey development, program evaluation, and both qualitative and quantitative data analysis. He has served as the principal investigator for a number of research and evaluation projects with a wide range of focus areas, including suicide prevention, childhood immunization, community development, school dropout prevention, and substance abuse.

    Ross F. Conner, Ph.D., is Director of the Center for Community Health Research at the University of California, Irvine. He received his Ph.D. and M.A. from Northwestern University (social psychology/evaluation) and his B.A. from Johns Hopkins University. His research focuses on community health promotion/disease prevention programs. Currently, he is the principal investigator for the ACCT Project: Achieving Cancer Control Together With Koreans and Chinese in Orange County (California), a multiyear collaborative effort involving the university and three community-based groups. He is also collaborating with other community colleagues on an HIV prevention program for Spanish-speaking Latino men. His recent work on the Colorado Healthy Communities Initiative (described in this book) received the American Evaluation Association's 2002 Outstanding Evaluation Award. He is the author or coauthor of nine books and numerous articles. He is the past president of the American Evaluation Association. He also works with various foundations, government agencies, and organizations on evaluation and community health issues.

    Marc B. Davidson completed his undergraduate work at the University of California, San Diego, and the University of California, Berkeley, in the areas of anthropology and psychology. His graduate work in health psychology and community health at the School of Social Ecology at the University of California, Irvine, involved research in the areas of program evaluation and health promotion. He also has been extensively involved in community health initiatives outside of the university environment. Combining a formal education in health psychology with patient care experience as an emergency medic, he has presented chronic illness management talks to counseling psychologists, nurses, and patients, with an emphasis on effective day-to-day coping skills. In addition, he has planned and promoted events for the American Diabetes Association and has conducted publicity campaigns for medical symposia.

    Catherine L. Dempsey, Ph.D., is Senior Instructor in the Division of Substance Abuse within the Department of Psychiatry at the University of Colorado School of Medicine. She received her B.S. in psychology and M.P.H. in health administration from Emory University and recently received her Ph.D. in health and behavioral sciences from the University of Colorado. Currently, she is a co-investigator and node coordinator for the National Institute on Drug Abuse Clinical Trials Network, Rocky Mountain Node, a research grant investigating the differential efficacy of various treatments for substance abuse in diverse populations. She has several years of experience in implementing community-based research in diverse populations. Her areas of expertise include psychiatric epidemiology, psychiatric assessments, cross-cultural community-based research, posttraumatic stress disorder, and substance abuse in diverse populations.

    Jodi G. Drisko is Director of Survey Research and Evaluation in Health Statistics for the Colorado Department of Public Health and Environment. She received her M.S.P.H. in 1994 from the University of Colorado Health Sciences Center. She worked from 1993 to 1999 evaluating The Colorado Trust's Teen Pregnancy Prevention 2000 Initiative, conducting needs assessments for the Ryan White Title I and II programs, and researching barriers to prenatal care for teens. From 1999 to June 2002, she managed the quality improvement and program evaluation department for Denver Health's Community Health Services. She has years of experience in data analysis, assessment, performance improvement, and program evaluation.

    Donna K. Duffy, M.A., was project director of the Colorado School Health Education Initiative (described in this book) for 6 years and has worked extensively with school districts throughout the United States in the area of health education. She provides technical assistance and professional staff development to school personnel in the areas of school/community partnerships, health education curriculum selection and implementation, and health education staff/committee development. She also works with school boards to support health education.

    Jill A. Elnicki, M.P.H., is Evaluation Consultant with the Rocky Mountain Center for Health Promotion and Education (RMC), a national training and technical assistance center focused on school health programming. She joined the RMC team in 1995, serving as an evaluation liaison to the Colorado School Health Education Initiative (described in this book). Currently, she oversees evaluation of RMC projects and provides technical assistance to school districts and other youth-serving agencies in the areas of program evaluation, tobacco use prevention and reduction, and standards-based health education. Prior to her years at RMC, she worked at the Colorado Department of Public Health and Environment in community health education and in the Division of Epidemiology at the University of Minnesota.

    Douglas H. Fernald, M.A., is Professional Research Assistant in the Department of Family Medicine at the University of Colorado Health Sciences Center. He received an M.A. in medical anthropology from the University of Colorado, Denver, and a B.A. in history and political science from Colorado College. He has expertise in research and evaluation using qualitative research methods, including research design, instrument design, interviewing, data analysis, and qualitative data analysis software. His research interests include improving care for medically underserved populations, improving patient safety, examining the role of the family in medical decision making, and using innovative qualitative research and evaluation methods.

    Peggy L. Hill, M.S., works for Rocky Mountain Institute, an entrepreneurial nonprofit creating a more secure, prosperous, and life-sustaining planet. She is a curious observer of living systems and the ways in which individuals learn and behave. She sees humans as semiconscious but powerful actors within those systems, and she believes that nature will become an increasingly severe teacher on many levels unless we soon learn a bit of humility. She earned graduate degrees in agronomy and education from Purdue University, where she studied the ecology of agriculture, human development, and community organization. Over the past 20 years, she has developed and managed a variety of programs in vulnerable and marginalized populations. While at the University of Colorado Health Sciences Center, and with the support of The Colorado Trust, she applied the concept of a learning group to assist family service workers and their supervisors to engage in reflective practice and program improvement.

    Michelle Miller Kobayashi, M.S.P.H., is Vice President of National Research Center. She has a master's degree in public health with an emphasis on epidemiology and biostatistics. She has designed and overseen a wide variety of research and evaluation projects on topics such as after-school programming and positive youth development, palliative care, obesity prevention, domestic violence, rural mental health service provision, health care access, and community performance measurement. She has worked extensively on outcome assesssment in cancer, speech and audiology, biofeedback, and asthma. She coauthored (with Thomas I. Miller) Citizen Surveys: How to Do Them, How to Use Them, What They Mean.

    Deborah S. Main, Ph.D., a social psychologist, is Director of the Behavioral Sciences Core in the Colorado Health Outcomes Program and Associate Professor in the Department of Family Medicine at the University of Colorado Health Sciences Center. She has more than 15 years of experience in behavioral and practice-based research with a particular interest in understanding the individual and organizational features that affect the uptake and outcomes of health and health care interventions. She is also the research director of the Agency for Healthcare Research and Quality-funded Colorado Research Network (CaReNet), a practice-based research organization consisting of 18 primary care practices and more than 250 clinicians dedicated to understanding the health and health care issues of disadvantaged populations. She has considerable experience in both qualitative and quantitative methods of data collection and analysis. She has been the principal investigator on two large funded studies that used mixed methods of data collection to understand the adoption, implementation, and realistic impact of health education interventions in school and community settings.

    Thomas I. Miller has worked in state and local government since 1977, founding National Research Center in 1994. He received a Ph.D. in research and evaluation methods from the University of Colorado. He has designed, overseen, and written results of hundreds of research projects and has presented his findings to a wide variety of audiences (both academic and lay). He has written about survey research in journals devoted to public management, including Public Administration Review, Journal of the American Planning Association, Journal of Policy Analysis and Management, Management Science, and Policy Analysis and Governing. He also was cofounder of Evaluation Systems International, a health care outcome research and software company. He also has published in a variety of health care journals and is coauthor of Benefits of Psychotherapy, a book reporting the results of the first meta-analysis.

    John R. Moran, Jr. serves as president and chief executive officer of The Colorado Trust, a grantmaking foundation dedicated to advancing the health and well-being of the people of Colorado. In this capacity, Moran represents the interests of The Trust in the community as well as regionally and nationally, leads (in his words) “a most competent staff” of program officers, evaluators and financial administrators, and serves as an ex-officio member of the Board of Trustees. Before being named president of The Colorado Trust in 1991, Moran served as legal counsel to The Trust from the time of its founding in 1985. From 1958 to 1991, he was a practicing attorney in Denver representing, among others, health-care-related clients and foundations. Moran also served as a member of the Colorado House of Representatives, and as a commissioned officer on active duty with the U.S. Navy. He received a bachelor of laws degree in 1955 and a doctor of laws degree in 1970, both from the University of Denver. In 1952, he earned his undergraduate degree from the University of Notre Dame. Moran is an active member of many civic and professional organizations, and a frequent speaker on issues affecting foundations.

    Kathryn A. Judge Nearing, M.A., is Senior Research Associate at OMNI Research and Training and OMNI Institute. Her responsibilities include instrument development, qualitative consultation, project management, and grant writing. Her projects include the evaluation of the Assets for Colorado Youth Initiative (she leads project components exploring integration of the Asset framework/philosophy at the organizational and personal levels, the spread and reach of the Asset movement in Colorado, and Asset Champions), the evaluation of a Colorado Trust-funded initiative to prevent suicide through school-based intervention, the evaluation of the Daniels Fund's first year of grant making, and a needs assessment for Jewish Family Service of Colorado focused on assessing the needs of individuals living with disabilities and their family members in the Jewish community. She also serves as a qualitative consultant for Prevention Evaluation Partners, an evaluation system supporting substance abuse prevention block grant providers funded by Colorado's Alcohol and Drug Abuse Division.

    Gabriela Robles, M.A., has more than 10 years of experience working on community health efforts in different capacities. Most recently, for the past 3 years, she was the program officer at the St. Joseph Health System Foundation in Orange, California. In this capacity, she led health system efforts to benefit the economically poor and to promote healthy community efforts. In addition, she has worked for several health-related nonprofit organizations in Southern California. She has worked directly with monolingual immigrant communities and has conducted numerous community trainings on health promotion and advocacy. She has a master's degree in urban and regional planning, with an emphasis on community-based planning for health, from the University of California, Irvine.

    Sora Park Tanjasiri, Dr.P.H., M.P.H., is Researcher in the School of Social Ecology at the University of California, Irvine. Her work focuses on the community health needs of diverse populations, including both physical health and community capacity building. For 3 years, she has participated in the evaluation of the Colorado Healthy Communities Initiative (described in this book) and examined the ways in which community coalitions have improved the individual capacities, community collaborations, and health outcomes of their citizens. She is especially interested in the concerns of Asian Americans and Pacific Islanders, and her current projects include the evaluation of cancer prevention and early detection efforts among Cambodians, Chamorros, Chinese, Hmong, Koreans, Laotians, Samoans, Thais, Tongans, and Vietnamese throughout California. In addition to her professional work, she serves as an adviser to numerous nonprofit community organizations and coalitions. She received her degrees in community health sciences from the School of Public Health at the University of California, Los Angeles.

    Carolyn J. Tressler, M.S.P.H., has worked in the area of research and program evaluation for 15 years, including several community-based health promotion initiatives. She received an M.S. in public health in 1988 from the University of Colorado Health Sciences Center. Her areas of interest and expertise include instrument development, interview survey design, focus group development, and qualitative analysis. Populations of particular interest to her include the medically underserved, refugee families, and adolescents.

    Allan Wallis, Ph.D., is Associate Professor of Public Policy in the Graduate School of Public Affairs at the University of Colorado at Denver, where he directs the Ph.D. program in public affairs. His principal areas of research are regional governance and growth management. His current work on regionalism is being funded by the MacArthur Foundation. He is the author of Wheel Estate: The Rise and Decline of Mobile Homes. He holds a Ph.D. in environmental psychology from the City University of New York, a master's in public administration from Harvard University, and a bachelor's of architecture from the Cooper Union. He has taught architecture at the University of Colorado and at Ball State University. He has also taught urban design and town planning at the Pratt Institute and the Cooper Union.

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