Strategies to Build Readiness in Community Mobilization Efforts for Implementation in a Multi-Year Teen Pregnancy Prevention Initiative.

PURPOSE: This paper describes an assessment of community readiness to implement a community-wide teen pregnancy prevention initiative, Youth First, and presents strategies used to enhance this readiness as informed by the assessment.
METHODS: Twenty-five community stakeholder interviews were conducted to assess four domains of readiness: (1) attitudes, perception, and knowledge of teen pregnancy; (2) perceived level of readiness; (3) resources, existing and current efforts; and (4) leadership. Interview transcripts were coded and analyzed to identify key themes.
RESULTS: Stakeholders acknowledged teen pregnancy as an issue but lacked contextual information. They also perceived the community as ready to address the issue and recognized some organizations already championing efforts. However, many key players were not involved, and ongoing data collection to assess teen pregnancy and prevention efforts was limited. Though many stakeholders were ready to engage in teen pregnancy prevention efforts, they required additional information and training to appropriately address the issue.
CONCLUSIONS: In response to the assessment findings, several strategies were applied to address readiness and build Youth First partners' capacity to implement the community-wide initiative. Thus, to successfully implement community-wide prevention efforts, it is valuable to assess the level of community readiness to address health issues.

In 2006, the Massachusetts Alliance on Teen Pregnancy (the Alliance), a statewide teen pregnancy prevention (TPP) advocacy organization, collaborated with a Hampden County-based coalition, the Youth Empowerment Adolescent Health! (YEAH!) Network to address TPP. In 2010, the Alliance received a grant from the Centers for Disease Control and Prevention in partnership with the Office of Adolescent Health to develop and implement a 5-year community-wide TPP initiative called Youth First in Holyoke and Springfield, Massachusetts. These two communities came together to jointly address the overarching goal of Youth First to reduce teen birth rates among youth aged 15–19 years by 10% by 2015.

Holyoke and Springfield have had some of the highest teen birth rates among 15- to 19-year-old females in Massachusetts, with Holyoke rates ranking first (83.6 per 1,000 females aged 15–19 years) and Springfield rates ranking third (54.3 per 1,000 females aged 15–19 years) among all municipalities in Massachusetts in 2010. These birth rates were much higher than the state teen birth rate (17.1 per 1,000 females aged 15–19 years). Moreover, racial/ethnic disparities in birth rates have persisted in Holyoke and Springfield. In 2010, the non-Hispanic white teen birth rate was 16 and 36 per 1,000 females aged 15–19 years in Springfield and Holyoke, respectively, while the Hispanic teen birth rate was 84 and 99 per 1,000 females aged 15–19 years in Springfield and Holyoke, respectively [1].

Prevention activities such as task forces focusing on teen pregnancy and implementation of evidence-based sexuality education were underway in Holyoke and Springfield prior to the initiation of Youth First (Figure 1); however, program efforts were limited primarily to some schools and selected organizations. With support from the Centers for Disease Control and Prevention/Office of Adolescent Health grant, Youth First expanded upon existing efforts by implementing a five-component, community-wide approach. This approach included delivery of evidence-based TPP programming, increased access to youth-friendly contraceptive and reproductive health services, engagement of various public and private sectors to sustain the work through mobilizing the community, education of stakeholders about Youth First’s efforts, and incorporation of strategies across all efforts to ensure TPP efforts were effective and culturally appropriate.

Figure 1.

Timeline of activities prior to and during Youth First. CIP = collective impact partners; GTO = Getting To Outcomes; MATP = Massachusetts Alliance on Teen Pregnancy; TA = technical assistance; YF = Youth First.

To inform community mobilization efforts, it was important to understand the community’s level of readiness to address teen pregnancy [2] as an initial step in the adoption and implementation of successful prevention efforts [3,4]. Understanding readiness is critical from several perspectives. Effective community-wide programming can be impacted by the community’s readiness to implement said programming [2]. Community acceptance of or norms related to the issue (i.e., community’s perceptions of the gravity of a health issue) [5,6] or the community political climate or resources may influence program implementation [4]. To increase the potential of successful implementation, intervention efforts should align with community’s awareness of problem and their readiness to change [4].

Community readiness has been conceptualized in the literature as a multidimensional construct [3,4,7] that incorporates (1) community attitudes, perceptions, and knowledge of an issue; (2) perceived level of readiness; (3) resources, including existing efforts around a particular issue; and (4) leadership. One widely used model to assess community readiness is the community readiness model (CRM). CRM is a validated approach to measure how ready a community is to take collective action on a social problem [4]. This model is comprised of nine stages that include the following: (1) no awareness (of the issue); (2) denial; (3) vague awareness; (4) preplanning; (5) preparation; (6) initiation; (7) stabilization; (8) confirmation/expansion; and (9) professionalization where people are knowledgeable about the issue, community is engaged, key stakeholders are supportive, and effective programming efforts are underway [2,4]. CRM has been used to assess community readiness to address community health problems including obesity prevention [8], physical activity promotion [9], substance abuse prevention [10], and TPP [11]. CRM measures community readiness by conducting key informant interviews using open-ended questions assessing domains of readiness [2,4]. Identifying the stage of readiness can inform potential barriers to implementation and strategies that can be used to help communities progress to advanced stages [4] and guide decisions in program development, implementation, and evaluation [12].

This paper describes an assessment of community stakeholders’ readiness to address teen pregnancy in Holyoke and Springfield, Massachusetts. This paper presents assessment findings and describes how they were used to determine which strategies could be implemented to enhance community readiness to prevent teen pregnancy.

Methods

To assess community readiness, Youth First contracted with the Institute for Community Health (ICH), a research and evaluation organization, to conduct semistructured phone interviews with 25 community stakeholders from Holyoke and Springfield in the first year of the community-wide initiative. In our study, “community” includes both Holyoke and Springfield as they collaborated to implement the Youth First initiative jointly. Holyoke is part of the Springfield New England City and Town Area, and a number of social service, family planning, youth development, and clinical providers work across both Holyoke and Springfield. Thus, data were collected from a range of stakeholders across the community and analyzed collectively to assess readiness to address teen pregnancy jointly as one community.

Interviews consisted of 10 open-ended questions conducted via phone by ICH staff. A key informant interview protocol originally developed by the Massachusetts Department of Public Health Bureau of Substance Abuse Servicesd—MassCALL2 Guiding Documents—was adapted for this purpose by revising the questions to make them relevant to teen pregnancy [13]. These questions were organized into the four community readiness domains that were drawn from the CRM: attitudes, perception, and knowledge of teen pregnancy; perceived level of readiness; resources, existing efforts to prevent teen pregnancy; and leadership.

Youth First staff identified stakeholders through existing relationships and by contacting local community-based organizations, then used a snowball sampling strategy to select additional stakeholders. To obtain a range of community perspectives, Youth First included stakeholders who were and were not directly engaged in TPP efforts and had no involvement with the Youth First initiative. Stakeholders included program coordinators, program directors, and executive directors of community-based organizations and health centers; a pharmacist; members of the mayor’s teen pregnancy task force; school nurses; a school principal; a health teacher; a school committee member; a social worker; and a city council member. Stakeholders were drawn from a variety of youth-serving and/or community-based organizations and health centers (n = 12), schools (n = 4), political leadership (n = 3), funders (n = 3), an employment agency, a faith-based organization, and a clinic pharmacy. Also, among the 25 interviewed, there were three stakeholders each representing a different Latino-based organization.

At the start of each phone interview, stakeholders read a formal consent form that was emailed to them and provided oral consent to participate. The interviews took 30–60 minutes to conduct. Evaluation staff audio-recorded the interviews. The ICH evaluation team reviewed a sample of transcripts and used a grounded analysis approach to develop a codebook to guide further analysis. Two individuals from the evaluation team then coded transcripts, added codes as new themes emerged, and identified themes. The interview protocol and instrument were reviewed and approved by the Cambridge Health Alliance IRB.

Results

Attitudes, perception, and knowledge of the issue

All stakeholders acknowledged that teen pregnancy is an issue in their community. Some stakeholders expressed that teen pregnancy is the “status quo” yet believed that the community viewed it as “not my problem.” Some stakeholders stated that teen pregnancy is a critical issue and they had not seen improvements since they began working in Holyoke or Springfield. Stakeholders noted that teen pregnancy is a difficult problem to address. They indicated factors contributing to the persistence of teen pregnancy including entrenched poverty rates; low graduation rates; lack of jobs; lack of activities or programs for adolescents; lack of sexual health education information or programs; lack of parent involvement; racism in the community; ineffectual and stagnated community groups and committees; and lack of funding for TPP efforts.

Perceived level of readiness

A majority of stakeholders perceived their organization/ agency as ready to address teen pregnancy; however, some cited the need for additional staff and funding, as well as opposition to sexual health education in the community. About half of stakeholders felt that the community at large was ready to take on the issue. However, some stated that the “right players” were not engaged, specifying that organizations from within the community should be leading efforts. Some stakeholders mentioned that community interest is diverted to other issues such as drugs and alcohol; thus, teen pregnancy is not seen as a priority. Another few individuals expressed that teen pregnancy was seen as too large an issue to tackle—“there is the sense that ‘we have to do something’ but it is not overly inspired. I think there is a medium level of readiness and interest. But when it comes to looking at what is really going on, the readiness drops. It’s very complex and so people give up.”

Resources and existing efforts

In response to the question about past and current initiatives, all stakeholders noted that their organization had engaged in past TPP efforts. Some stakeholders had provided evidence-based or evidence-informed sexual health education, offered contraceptives to adolescents, or participated in TPP coalitions; a few had provided financial investments in TPP efforts. A small number of stakeholders mentioned they were aware that the mayor’s task forces in Holyoke and Springfield were working on TPP and noted that other organizations were also involved in efforts to prevent teen pregnancy. A few stakeholders discussed the need for collaborative work as “no one can do it alone” and to educate the community about the issue; one stakeholder specifically noted that current “efforts are fragmented.” Some felt that the issue is too large to tackle, while a few other stakeholders believed that they do not have the tools, resources, or skills to address pregnancy prevention. However, one stakeholder stated that there is “new excitement and (their organization) want to work on (teen pregnancy prevention).”

Stakeholders were asked whether they collect data to inform the assessment of teen pregnancies and/or their prevention efforts, and almost half of the interviewees reported that their organization/agency did not. Some of the stakeholders expressed a need to share data on teen pregnancy assessment and impact of prevention work with organizations, and a few stated that specific data on TPP work should be collected, though they did not specify the type of data.

Leadership

More than half of the stakeholders expressed interest in playing a role in the community by representing their organization/agency in TPP work. One interviewee stated that their organization “could provide training and education to the community and teens.” Another interviewee expressed “if there is legislation or proclamations to help raise awareness, myself and other counselors, we would love to be part (of that effort).” Some stated that they were already playing a role in the community in TPP efforts, while a few preferred to not take on an additional role, as they felt there were already individuals and organizations taking the lead in such efforts. Another few are concerned with the time and resources of taking on a leadership role in the community. When asked who were the leaders/ champions on the issue, several stakeholders mentioned Holyoke and Springfield mayor’s task forces and the YEAH! Network, a local TPP coalition.

Discussion

Youth First conducted an assessment to understand the readiness of Holyoke and Springfield to implement a large-scale, community-wide TPP initiative. The community’s level of readiness was examined using the qualitative data collected across all stakeholders to assess four readiness domains. Based on this study, we identified that the overall community was in the preplanning stage to address TPP. We concluded this based on the definitions of the stages of readiness articulated in the CRM across the stakeholders interviewed. Most stakeholders indicated that the community was in the preplanning stage, as they acknowledged teen pregnancy as an issue and recognized leaders in the community who were able to address this issue. A smaller number of stakeholders indicated that the community was in the preparation stage, as they perceived there was some community-level support and availability of general information on teen births. Also consistent with this stage was that champions like the mayor’s task forces and the YEAH! Network were already engaged in prevention efforts. A few stakeholders implied that the community was in the initiation stage, as some existing TPP activities were underway prior to and/or at the start of Youth First. [2].

The study results combined with a review of the literature on creating collaborative partnerships to support prevention efforts were used to determine how best to structure efforts and develop strategies to better prepare the community to address TPP. The community readiness findings that identified the need for the strategies, as well as the strategies themselves, are described in more detail in the following sections. Table 1 illustrates how strategies to build readiness mapped onto the readiness domains.

Table 1

Strategies implemented to build community readiness

Readiness domains	Highlight of findings	Strategies
Attitudes, perceptions, and knowledge of teen pregnancy	Acknowledge teen pregnancy is an issue in Holyoke and Springfield Limited progress made to date to address teen pregnancy A need to educate the community stakeholders so everyone is on the same page	Educate local stakeholders Develop fact sheets with teen birth statistics Create a brief summary highlighting key assessment findings and disseminate
Perceived readiness	Presence of general readiness in the community but lacking key players at the table	Line up appropriate stakeholders Disseminate evaluation results annually Share initiative’s evaluation findings through presentations to community mobilization teams
Resources and existing efforts	Current efforts are insufficient and fragmented Lack of tools, resources, or skills to address teen pregnancy prevention (e.g., staff capacity, training)	Provide funding to partners of the initiative Provide technical assistance and training to build partners’ capacity to engage in teen pregnancy prevention efforts (e.g., contraceptive counseling, training on evidence-based sexual health education curriculum)
Leadership	Efforts around teen pregnancy are fragmented Key to find opportunities to build coalition to increase visibility around the issue as well as to align efforts, share resources, and collaborate Critical to engage all sectors of the community	Secure and cultivate a strong primary leader Identify a local champion to lead initiative’s efforts and to help build local leadership structure Establish community mobilization teams with diverse stakeholders Engage appropriate stakeholders and ensure diverse members are represented on community mobilization teams including youth

Strategies to address domain 1: attitude, perception, and knowledge

With respect to perception, participants acknowledged teen pregnancy as an issue; however, they lacked the contextual information about the issue, which indicated a need for improved stakeholder education. When a community is primarily in a preplanning stage, the goal is to garner support by collecting community-level data to promote knowledge and understanding and to disseminate this information broadly [2,4]. Therefore, Youth First conducted a community needs assessment examining the quality and cultural appropriateness of services, programs, and policies related to TPP. A reader-friendly summary highlighting key findings from the assessment was developed. This summary shared the perceptions of youth, parents, youth/community-based organizations, health centers, and the faith community on the issue as well as existing resources to support prevention work and identified gaps in efforts. This summary was distributed to Youth First’s community mobilization teams and a broader group of stakeholders, such as local leaders and businesses, to educate them about teen pregnancy and community perceptions. Fact sheets were created to draw attention to the importance of TPP and Youth First’s approach. These materials helped deliver a consistent message about TPP in the community. As a result, a local funder, United Way of Pioneer Valley, recognized the problem and the need to support prevention efforts and awarded three new grants to Youth First partners for teen pregnancy and dropout prevention.

Strategies to address domain 2: perceptions of readiness

Through the readiness assessment, stakeholders identified TPP activities but noted that the impact of current efforts was not pronounced enough to see changes in outcomes. This was critical, as promoting positive outcomes can facilitate support, continued interest, and momentum toward addressing an issue [14]. Thus, ICH annually presented initiatives’ evaluation findings to the community mobilization teams to provide them with current data and celebrate progress.

Readiness assessment findings further indicated that the “right players” were not at the table to address teen pregnancy; thus, it was important to engage the most appropriate players to support evidence-based TPP efforts [15]. Efforts were made to ensure that diverse community members who had a stake in TPP were represented on the three community mobilization teams (described below).

Strategies to address domain 3: resources, existing and current efforts

Stakeholders identified barriers to addressing teen pregnancy, including lacking appropriate tools and resources (e.g., staff capacity, training) to support prevention efforts. Moreover, stakeholders shared concerns about the complexity of the issue; thus, it was important to work with Youth First partners to build their capacity and clarify their role in supporting prevention work. The Alliance provided funding, training, and technical assistance (e.g., training on evidence-based TPP programs or contraceptive counseling, guidance on selecting and implementing culturally appropriate curriculum) throughout the Youth First initiative to help community partners advance from the preplanning/preparation stages to initiation/stabilization stages of readiness [4].

An evaluation and data infrastructure were also identified as an important tool to support prevention efforts. The evaluation developed by Youth First provided ongoing monitoring and a process for using the data in meaningful ways to inform future efforts. Sharing results of the evaluation provided an opportunity to strengthen communication around the initiative’s progress and accomplishments, engage key stakeholders on community mobilization teams, and foster collaboration opportunities among team members.

Strategies to domain 4: address leadership

The readiness assessment also highlighted that current and existing TPP efforts were fragmented and could benefit from a unified leadership structure. A clear leadership structure is critical for partnerships to function well [16,17]. To ensure that efforts were aligned and unified, Youth First developed and implemented strategies to promote local leadership and build community infrastructure to support collaboration. Additionally, committed and effective local community leadership is a critical component of collaborative work, to sustain efforts, and can facilitate systems change [14,15]. Consequently, the community selected the YEAH! Network, to lead initiative efforts, a choice that was also informed by the readiness assessment, which indicated that the YEAH! Network was a local champion for TPP work. Prior to Youth First, the YEAH! Network received technical assistance from the Massachusetts Alliance on Teen Pregnancy in developing bylaws and advocacy strategies and was therefore an ideal local partner in the effort to build local leadership and community infrastructure. The YEAH! Network also played a key role in promoting local leadership by participating in the development of a supportive leadership infrastructure comprising the three community mobilization teams that were tasked with involving and educating the community and implementing TPP activities. The formation of these teams, which was required as part of the initiative’s funding, directly addressed the concern identified through the readiness assessment regarding fragmented local efforts. Additionally, as highlighted in the assessment, the community groups provided another opportunity to identify and leverage existing resource for organizations/agencies to support one another.

Through the course of Youth First, three community mobilization teams were formed comprised of stakeholders from Holyoke and Springfield. In year 1, the core planning team (CPT) was convened to advise project staff on the design and implementation of Youth First; later, they focused their work on a few priority areas that were identified through the community needs assessment. The CPT was drawn from the pool of local TPP “champions” already known to the YEAH! Network and the Alliance and included medical professionals, youth workers, mayor’s health task force leaders, teen parent program providers, and family planning providers. This leadership structure was critical for this initiative. The youth leadership team (YLT) was formed in year 2 to ensure that the youth perspective was incorporated into the initiative. YLT members contributed to the development of Youth First’s vision statement, provided input on a social marketing campaign, reviewed and scored proposals for youth-led sexual health projects, and assessed youth friendliness of local clinics. That same year, the collective impact partners design team was formed with traditional stakeholders who influence public policy to help garner community-level support and guide direction of the initiative. To guide and sustain the efforts of the initiative to address teen pregnancy, the YLT and the CPT groups merged with the collective impact partners design team in year 4 of the initiative to form the collective impact partners.

Furthermore, a series of leadership trainings were held with the CPT to help build their capacity, specifically broadening their knowledge of what makes a good leader, increasing their skills and practical tools, and developing their vision of the impact of their leadership. YLT members were also trained and provided with tools for leadership and facilitation skills. These skills helped members support, expand, and continue current TPP efforts.

Limitations

There are a number of limitations to this study. First, the sample size was relatively small with a total of 25 stakeholders. Second, the sampling strategies used may have resulted in the stakeholders not reflecting the full spectrum of views of the community; however, the diverse stakeholders interviewed represented a variety of sectors who work in different capacities. Future studies should consider measuring community readiness both qualitatively and quantitatively and comparing readiness level across stakeholders and the various sectors they represent as well as explore changes in readiness over time. It would also be valuable to link level of readiness to intervention outcomes and sustainability efforts. Third, adolescents’ perception on community readiness was not reflected in our study, and other studies may consider eliciting their perspectives on readiness. Finally, these findings and strategies applied were specific to our community and may not be generalizable to other communities.

In conclusion, to implement successful community-wide prevention efforts, it can be valuable to ensure that communities are ready to implement large-scale initiatives. The readiness assessment can help gauge the stage of readiness and inform appropriate strategies to build readiness capacity. To determine the overall success of the project at reducing teen birth rates in Holyoke and Springfield relative to other similar communities, a quasi-experimental outcome evaluation is underway [18].