Prioritization & Consensus-Building
Through the completion of HumanaNatura’s Community Assessment Form by a small assessment team and then its evaluation by a larger assessment review group, a comprehensive, sufficiently accurate, and often quite revealing community assessment can be completed in a short period of time. This assessment will credibly reflect the health status of your community and contains important ideas for promoting progressive change.
As the community assessment is compiled, vetted or reviewed, and finalized – initially and during periodic re-assessments – focus for many people quickly shifts from the facts and findings of the combined assessment to its ideas for new health promotion in the community. You may find that some of your team members are better-suited to and proficient at either assessment or action, while others can move between the two quite comfortably.
Special care must be taken as Health Action Group’s finalized community assessment takes shape. Its findings and the initial community health promotion ideas it might suggest are likely to inspire calls for immediate action within the group – which can lead to insufficiently-considered and uncoordinated action. It is precisely here, in fact, that otherwise sensible health initiatives are sometimes apt to initially founder or fail to inspire community action, or be met with significant alarm and resistance within the community. There are several reasons for this, including:
- Competing agenda items – perhaps most important is the simple fact that the public policy agenda in any community is usually full, even if some of its agenda items may be less urgent or important than the health and quality of life issues have been raised in your assessment process. Discussion of new community health ideas and proposals often must push away other issues in the community, especially if health topics are to be adequately considered and then result in positive change. For this reason, it is essential to expect that it will take time and effort to build awareness of new health issues and support for their consideration, and that this effort will often require considerable grass roots efforts and the framing and introduction of health issues in ways that resonate with people in the community.
- Under-appreciation of health opportunities – a second reason that new public and community health ideas sometimes fail to find strong initial support is that there is frequently an under-appreciation of the general opportunity for increased health within a community and the combined effect of sustained health-promoting action. This is especially true if the community is in a low state of health or has not implemented health and quality of life initiatives before. Careful selection of health issues for discussion, and credible and compelling data and case studies summarizing the costs and benefits of change, often prove essential in the work of prioritization and consensus-building on health actions, and this takes some amount of time. In practice, you should expect the case for new community health measures inevitably to be made, each step along the way, by winning hearts and minds in roughly equal proportions. In this way, your Health Action Group can both increase the chances for achieving short-term success on specific issues and build a larger and longer-term constituency within the community that favors progressive health promotion and quality of life investments generally.
- Change can be disruptive – a third reason that otherwise sound community health initiatives do not get the initial traction they deserve is that they can be far-reaching, disruptive, and sometimes, expensive. The status quo of any community will have supporters, either for emotional or self-interested reasons, and the case for change almost always involves work against these and other barriers. Communities of course can and do regularly engage in actions and social investments that are disruptive and involve significant resources, but it is worth noting that they often do so incrementally and over time. This approach frequently takes the form of experimenting with small or initial steps in a direction, gaining information and confidence from these steps, envisioning new states of change, and then gradually moving forward, building on successes and existing systems and structures. Although significant community decisions and large-scale projects make news headlines, they are frequently preceded by more gradualist and smaller-scale investments, or by an extended period of analysis and discussion, and so too, it will be in the case of many successful health initiatives and quality of life investments.
All of these considerations underscore the ongoing need for consensus and credibility-building around health and quality of life issues facing the community, but they also suggests another critical aspect of successful community health advocacy: a progressive or compounding strategy, one that begins with issues that are impactful and relatively easy to implement, which lay the essential foundation for larger and more substantial community health initiatives over time.
The work of setting health priorities, for the short and long-term, thus proves an essential part of community health promotion and step in our process. Importantly, as priorities are set, an important and necessary test of them and the team’s work is to see if they form a compelling and shared vision of a future state for the community – which proves quite powerful over time to motivating both your group and community toward sustained health action.
We will cover both prioritization and visioning next.
Setting new community health priorities
Although the prioritization of potential community health actions must be based first on scientific considerations of community health factors and the availability of proven solutions that improve a community’s health landscape, the final prioritization of specific health improvement actions or campaigns is as much a political process as a technical one.
As we have suggested, sustained community health promotion involves increasing community involvement in, ownership and advocacy of its health. It thus suggests a strategy of successful progressive action and learning to build support for more ambitious and compounding health actions. For this reason, ongoing care in the section of health actions, based on both desirability and feasibility, is essential.
Because of the need to show progress and build support, successful community health strategies are likely to share three essential and interrelated objectives:
Three key objectives for successful long-term health promotion
- Accomplish health promotion goals and demonstrate positive impact
- Ensure the community favorably views recent and current initiatives, and the general goal of health and quality of life promotion
- Increase community involvement and willingness to engage in new health promotion efforts
Once your combined community assessment is drafted, vetted, and finalized, all or many of the people involved in the assessment process (members of both the core assessment team and larger assessment review group), and others interested in the overall process, can move forward to the work of issue prioritization by your Health Action Group, and then to active health promotion in your community.
The number of working members in your Health Action Group can vary according to the size and complexity of your community, and whether its focus is on a local community or a region of communities. Often, a core working group of 5-25 people will strike the right balance across three critical considerations: 1) ensuring a diversity of views and representing key constituencies, 2) allowing ease of discussion and decision-making, and 3) providing adequate resources for getting work done. If you have additional people seeking to become involved, they can form an advisory counsel, tasked with reviewing the group’s work prior to public dissemination (and potentially assisting in this dissemination).
At this stage, involvement of your local public health agency in the Health Action Group’s work is highly desirable, if not essential, as is review of your initial assessment findings with interested members of your local government and community. If there is sufficient interest in the work of your group, one or public information sessions might be advisable as well.
Mapping paths to greater health
As the working rhythm of your Health Action Group is established through the assessment process, this will create needed momentum and working relationships for the next steps in the community health process:
- Prioritization – sorting or mapping and ranking the potential actions contained in the finalized community assessment
- Visioning – developing an initial vision and operating agenda for promoting new health-based action in the community.
This important work, as well as subsequent efforts to operationalize your Community Vision and Community Health Agenda, may require your Health Action Group to bring in one or more community or health experts for guidance in specific domains, a step that will likely become a regular part of the group’s operating procedures.
There are a variety of options for sorting out your health issues and prioritizing potential actions from your combined community assessment. A very effective way is to plot the potential actions on a two-dimensional or four-quadrant chart, locating each action on the chart based on: 1) its potential health impact or benefit to the community, and 2) its potential difficulty or cost of implementation.
Plotting possible actions is made fairly easy by giving each potential health action a separate 1=low to 5=high rank for Impact and then for Feasibility. If you take this approach to sorting or mapping your potential actions, a prioritization chart can be organized as follows:
Likely, there will be considerable discussion within your Health Action Group as you sort out your health issues and discuss potential actions, but eventually you will end up with all of your potential actions (potential agenda items) mapped into four categories, each with an implicit general strategy:
Mapped potential health actions | Implied strategy |
| Purse |
With this simple sorting of potential actions, a fairly clear map of potential health actions and a high-level strategy will quickly emerge, one that can shed added light on your community’s health landscape. The work of sorting thereby begins to build consensus and shape a Community Vision for your Health Action Group and its needed initial Community Health Agenda and health campaigns in your community.
As your initial action sorting is completed, it may be worthwhile having a small team spend time to see if some of the sorted or plotted actions are common, synergistic, or complementary, and to then propose to the larger group a clustering of some actions into a common potential initiatives or campaigns.
For example, an action for new walking trails might be combined with an action to change the community’s master plan for development. In this way, a higher number of potential actions can be clustered into a smaller and more manageable number of multi-part general initiatives, each with its own sequence of short and longer-term objectives. In some cases, however, clustering is not possible and potential health actions will remain as stand-alone items.
As your map of potential actions or clusters of actions emerges, discussion can and will turn to consider which actions or groups of actions to pursue first. As suggested before, your group should put general emphasis on potential actions that are more impactful and relatively easy, and downplay or avoid entirely actions that are less impactful and relatively difficult. In this way, a health strategy can be crafted to increase the likelihood of success in the short-term, thereby promoting future community support for other impactful measures that require greater resources or effort.
In general, potential actions outside of the impactful and easy category normally will need to wait at first, however compelling or important they may be. Important but more involved actions can be very difficult to build consensus around and act on in the beginning, and even may be hard to analyze and operationalize into an effective campaign with a new Health Action Group.
For this reason, impactful but difficult items normally should be held until your group has had some successes and built a base of support for more ambitious health efforts in the community. Still, sometimes a difficult health issue may be so important that it will need to take precedence over this general rule and perhaps can be used to provide immediate broad visibility for your group (for example, action on threatening environmental contamination or security issues), but this approach should be viewed as riskier and harder to manage than a strategy of building from simpler initial actions toward more complex ones.
Interestingly, in planning your early agenda, you may find that there are a selected number of less impactful and relatively easy actions that find their way into consideration, especially if there is at least some positive impact and it is believed the actions can help to build visibility and support for the group’s overall efforts. Such actions are unlikely to trump more impactful and relatively easy actions, but may serve the Health Action Group and the community in the short run.
On the other hand, we would again underscore that this will unlikely ever be the case with less impactful and relatively difficult items, which almost never should be taken up.
Envisioning a healthier community
As work proceeds to prioritize and cluster potential health actions and form your Health Action Group’s initial agenda, an excellent way to test and enrich this process, and to better align and integrate your Health Action Group, is to build one or more visioning sessions into your work process. Visioning sessions are particularly helpful once you have a high priority “short list” of perhaps 5-15 potential actions in consideration, but before this list is further refined into your initial Community Health Agenda.
While the idea of conducting a visioning session may seem abstract and tangential to the pragmatic workflow we are introducing, these sessions are often extraordinarily beneficial. They can be an important opportunity to step back from group’s initial or ongoing work, surface previously unseen issues, and make the planning process much more robust and impactful. Visioning sessions encourage the group to consider how potential agenda items fit together into an integrated whole and the tangible outcomes in the community they are likely to combine to create. These considerations are essential to finalizing the group’s initial and subsequent agendas – and to communicating your agenda in the community more generally.
Logistically, conducting a visioning session is similar to holding any other working meeting. There is a need for clear objectives or desired outcomes, people to facilitate or support the working group, a thoughtful process or meeting agenda, and gently managed interpersonal dynamics. Together, these considerations are included in the “GRPI” model (Goals-Roles-Process-Interpersonals) for effective group endeavor, an approach intended to begin from and encourage a shared commitment to openness and learning
Like all other forms of group work, visioning sessions are subject to the same risks of selective attention to facts, and premature convergence and information-limiting “groupthink” that we discussed before. For this reason, as was the case during the assessment process, independent individual pre-work is again highly recommended, so that participants come to the session with specific and well-formed ideas and questions and a more diverse and robust dialogue is naturally engendered.
As with other meetings, the number of people attending the visioning session can vary. Smaller groups are easier to manage, but risk limiting the diversity of ideas and the level of engagement and shared perspective of across your Health Action group. Larger groups require more meeting planning and management, but can bring added ideas and are more apt to be inclusive and motivating to all the members of your group. As a general rule, we will suggest that your full Health Action Group attend the visioning session. As alternative to this, you might again form a smaller working team and larger review group for the visioning exercise, as you did during the assessment process.
Whether the work of visioning occurs in one session or over several sessions, the needed workflow is the same:
- Discuss individual actions – with the goal of anticipating how potential actions in consideration will fit together, the work of visioning should begin with discussion of each potential action and a clear statement of expected inputs and impacts (its scope, including costs and benefits)
- Consider combined effects – the group will then move to a larger discussion of how all the actions will fit together, looking for common issues and potential conflicts, and evaluating the ability of the group and community to implement the potential changes
- Set priorities and envision change – based on the discussion of individual actions, including support and resources needed, and combined effects, both immediate and longer-term priorities need to be set and shared visions formulated of community life after these two sets of changes are completed
Although this overall workflow is linear, just as with the assessment process it naturally will involve recursive or circular movements within it, as various ideas for the inclusion and timing of potential actions and assessment of their combined effects are considered and reconsidered.
This work is sometimes called synthetic reasoning (constructive thinking) and is quite different from the reductive reasoning (deconstructive thinking) that forms the majority of the assessment and prioritization process. You will find that skill and familiarity with synthetic reasoning will prove critical to your Health Action Group, especially as the group moves from analysis of its needed Community Health Agenda to the creative formulation and promotion of its needed health campaigns. In addition to building a more cohesive sense of the group’s needed work and aims, visioning therefore prepares the group for the much longer work community health campaigning.
In practice, the work of crafting a shared vision is much like completing a puzzle: some actions will emerge early on and be seen as clear priorities with predictable impacts, while other actions will require examination until their fit is found (or until they are eliminated from consideration for your initial working agenda). If we can extend this metaphor further, the group may also find that one or more pieces to its puzzle are missing, and must be brought up from the larger action list or elsewhere to complete its needed vision of what it wants to initially accomplish.
As suggested before, one way to productively simplify and focus the visioning process is to consider the timeframe for the shared vision you are crafting. Just as with larger working groups, longer-term visions are more expansive but harder to manage forward to consensus and sustained commitment. On the other hand, shorter-term visions, like small groups, can be too focused on tactics and not produce a sufficiently compelling sense of the full future sum of ongoing efforts in and by the community.
By thinking ahead to the eventual needed content of your group’s Community Health Agenda, we can find a way to resolve this dilemma and greatly reduce the complexity inherent in the task of visioning. If we assume your group ultimately will end up with: 1) 3-5 actions or health advocacy campaigns that it wants to move ahead with right away, 2) another 3-5 actions that you will want to pursue in a second round of campaigns after the first round, and 3) other actions that will need to be reconsidered or taken up after this, a two-part timeframe for your visioning work naturally emerges. This two-part timeframe involves creating one vision for the impact of first round of changes (with a time horizon of perhaps 12-24 months) and a second vision after the added impact of the second round of changes (with a horizon of perhaps 36-60 months).
Given this this two-part visioning recommendation, we would strongly suggest that your group not feel obligated to vision and plan far into the future, particularly at first. Your efforts at health promotion will often produce unexpected results and learning for the Health Action Group and your overall community, initially and on an ongoing basis, and your vision and agenda are sure to change and evolve before you ever reach the distant future.
For this reason, we would encourage your group to have at all times: 1) a shared mid-term vision of how your agenda items fit together that is clear but also always subject to change, and 2) an approach that is pragmatic and progressive, always seeking learning and insight from your work. In this approach, you can and should regularly evolve your vision and agenda forward (our recommendation is one per year). Since both pragmatism and vision have been shown essential to successful leadership, your Health Action Group and its campaigns will become far stronger as it successively masters both of these critical aspects of leading progressive change.
The format for the individual pre-work by the visioning session participants, and for the group’s work together and eventual vision statement, can be the same. Using the vision session goals and structure we have introduced, we would recommend creating a simple Community Vision by pursuing 3-7 key descriptive items in each of the following five sequential categories:
Community Vision Worksheet
Our Mission: New Community Health & Quality of Life |
||||
Community Today |
Initial Actions |
Result |
Future Actions |
Result |
Reconsider later |
||||
As suggested, this format can be used to help others in the community envision and consider needed health-based change as well, and as a tool to communicate and discuss essential ideas.
When working with larger groups and when communicating your Health Action Group’s vision and agenda to the community, it is usually best to convert the items from your vision statement worksheet into a more visually-oriented format, showing as much as telling the changes you want to implement and their intended result and benefit. One way of doing this is with a simple photo montage showing before and after conditions in roughly the following format:
Our Community Vision
Today
(Photos)
|
|
Tomorrow
(Photos) |
||
|
|
|||
By the end of your prioritization and visioning work, a Community Health Agenda targeting 3-5 initial health actions or campaigns should be agreed to, based on your work at mapping and visioning potential health actions.
This agenda should be finalized with the understanding that other items can be added later, once early actions are implemented, as your initial vision is validated or evolves through implementation of earlier actions, and as support is created in the community for more ambitious health promotion actions.
Building the case for change
As your Health Action Group forms its first Community Vision and Community Health Agenda, and as it evolves both of these documents over time, campaign leaders will need to be assigned and working campaign teams formed for each agenda item.
Normally, each campaign leader and working team will be charged with eight key tasks that result in the production and management of a community health advocacy plan:
Health Advocacy Plan - Key Tasks
- More deeply investigate the issue – causes and effects
- Evaluate the soundness & feasibility of ideas for action
- Conduct cost-benefit analysis of feasible actions
- Map the political landscape – including stepped influencing options
- Recommend a course of action – detailing what should done & why
- Build a health campaign – a detailed implementation plan to achieve goals
- Lead the health campaign – subject to the full group’s approval
- Quality assurance – plan to monitor and/or manage execution of change
In addition to the critical tasks of gathering data, considering options and technical issues, preparing the factual case for action, and developing a creative campaign to drive success, it is essential that each campaign leader and team take on the non-technical issues it faces in the community with equal intensity. This begins by completing a detailed assessment of the political landscape it faces and formulating a plan to approach and influence key decision-makers and stakeholders (item four above).
This critical step ensures equal attention to the political and organizational dimensions of health-based change, which as we have discussed are often more challenging and important today than assimilating information and building a technical case for change. Ideally, a political assessment will be completed before the campaign team recommends a course of action and formulates its implementation plan, and will be as robust and insightful as all other items in the campaign scope of work. To help in the critical and sometimes difficult step of political analysis, a fairly simple but often quite effective way to begin this work is via a stakeholder analysis.
A stakeholder analysis begins with a list of individual community leaders and groups of people (constituencies) with significant decision-making or influencing power related to the issue, or who may be positively or negatively affected by the change. The analysis then adds an assessment of how each individual or group “stakeholder” is likely view the issue today and how strongly they must eventually support action to ensure campaign success. The analysis then includes an influencing plan for each person or group. The overall analysis can take the following form:
Stakeholder Analysis Worksheet
Stakeholder |
Position Today* |
Needed Position* |
Key Issues |
Influencing Strategy |
|
|
++ |
++ |
|
|
* Each individual or group stakeholder’s position can be assessed in one of five ways: |
||||
When assessing various stakeholders for a planned health campaign, it is important to keep in mind that strong support may not be essential from every stakeholder. Sometimes, as long as disagreements are friendly or cordial and there is strong support elsewhere, neutrality or even moderate opposition may be a sufficient position for some stakeholders. The test of this is whether the support allows an action to move forward, while not undermining the Health Action Group’s overall agenda or standing goal of building increasing community support for health efforts over time.
As suggested already, when working with stakeholders, in almost all cases the best long-term strategy is consensus-building, openness and transparency regarding intentions and goals, and gentle honesty regarding views and feelings. In this way, trust and respect are reliably built and are generally reciprocated, promoting progress and increasing support across successive campaigns in the community.
As health advocacy plans are drafted, reviewed, and refined – within a working campaign team and with your larger Health Action Group – plans of action will emerge for health campaigns that are compelling and impactful, and ready for final review and approval by your Health Action Group (or its executive committee in the case of larger groups) and implementation in the community.
Let’s next turn to the essential step of implementation.