Abstract
Our global population is aging at an accelerated pace. While the average life expectancy has seen dramatic increases, chronic disease and disability have also increased, with rural America tending to be older, sicker, and poorer. This article examines the implementation and outcomes associated with the community engagement method of the world café that was instrumental in developing a “culture of health” aimed to reduce diabetes-related inequalities for older adults in rural counties of Kentucky. Older residents and the organizations that serve them participated in world cafés, which resulted in collective action due to the wisdom and capacity that evolve from the core element of the method, conversational sharing via multiple small group interactions. Four world cafés were held to explore the desires of the communities related to healthy eating, exercise, smoking cessation, and diabetes care. The world cafés brought a diverse group of community residents and governmental and business leaders to discuss topics that matter to their community, leading to the development of a strategic plan and a scorecard and, ultimately, community empowerment.
In the United States, 25% of older adults (≥65 years) live with diabetes (Centers for Disease Control and Prevention [CDC], 2017), 66% of older adults are diagnosed with multiple chronic conditions, and 95% of the health care costs for older adults is for chronic diseases (CDC, 2013b). By 2030, it is expected that 1 in 5 Americans will be an older adult (U.S. Census Bureau, Population Division, 2014), and with the expected 30% increase in the number of 55- to 75-year-olds who will migrate to nonmetropolitan areas by 2020 (Cromartie & Nelson, 2009), constructing strategies to prevent health complications for older adults and their rural communities requires community empowerment. To achieve sustainable health outcomes for vulnerable populations like older adults living with diabetes in rural communities, individual interventions are best coupled with policy, system, and environmental changes (Jack, Jack, & Hayes, 2012; Whelan et al., 2014). These multifaceted approaches should be informed by the residents’ daily life experiences and should be developed with a diverse group of organizations who are engaged in collaborative problem solving with each other and the residents (Goode & Jack, 2014; Roussos & Fawcett, 2000).
In late 2010, the Kentuckiana Regional Planning and Development Agency (KIPDA), Area Agency on Aging, received a grant from the CDC for 5 years to reduce the diabetes-related inequalities in vulnerable populations, specifically older adults living in the rural counties. The rural counties of Bullitt, Henry, and Shelby, Kentucky, were selected because of their high prevalence of diabetes, ranging from 10% to 12% of their population (CDC, 2013a), and the high percentage of older adult residents. The success of the grant depended on significant community engagement, beginning with the development of a tricounty community-based coalition of residents, professionals, natural helpers, and grassroots activists, named the KIPDA Rural Diabetes Coalition (KRDC). The coalition’s mission was to improve the health of older adults living with type 2 diabetes by engaging the community through education, by developing social support and formal organization network connections, and by advocating in their communities.
Community engagement has been identified as a two-way process by which the aspirations, concerns, needs and values of citizens and communities are incorporated at all levels and in all sectors in policy development, planning, decision-making, service delivery and assessment; and, by which governments and other business and civil society organizations involve citizens, clients, communities and other stakeholders in these processes. (https://aifs.gov.au/cfca/publications/community-engagement/what-community-engagement)
However, the engagement of the community can vary greatly as noted by the Engagement Spectrum framework, developed by the International Association for Public Participation (n.d.; the Public Participation Spectrum). The Engagement Spectrum delineates five levels of engagement, with the lowest level of engagement characterized by a one-way process of keeping the public informed accomplished by newsletters or websites. At the highest level, communities are empowered because they are making decisions. Significant time commitment and capacity building are required to achieve this level. Empowerment of the community aligns with the International Association for Community Development’s (n.d.) definition of community development, which states that community development is characterized by the promotion of “participative democracy, sustainable development, rights, economic opportunity, equality and social justice, through the organization, education and empowerment of people within their communities.”
KRDC’s ultimate objective was community development as was evidenced by the way the coalition has worked through the various stages of the Engagement Spectrum. One strategy that assisted the coalition to deepen their engagement with the community was the world café method. The purpose of this article is to examine the process, outcomes, and impact associated with the community engagement method of the world café, used with rural older adults living with diabetes and the organizations that support them, to develop a multiyear strategic plan focused on their community’s vision of health.
General Method
In the community engagement method of the world café, individuals and organizations have conversations about topics that are relevant to their local life and work for the goal of strategic intent. A world café is staged for conversational sharing with round tables covered in paper cloths used to capture ideas and patterns in response to a question of significance to those in attendance. World cafés allow for the sharing of world views, as well as the creation of a context for collective action due to the awareness of the collective capacity (Schieffer, Isaacs, & Gyllenpalm, 2004). Participants who engage in world cafés report having increased learning and understanding as compared to those who are exposed to large group facilitation methods (Fullarton & Palermo, 2008).
A world café is an inclusive, community participatory process (Brown, Isaacs, & Wheatley, 2005) in which collective knowledge and thinking grow and evolve because participants rotate through the tables in a random fashion, producing a melting pot of ideas. World cafés were typically used in business and organizational settings to develop strategic plans through conversational leadership (The World Café, n.d.-a). The utility of the world café method with vulnerable and oppressed populations has received limited attention in the literature, with the exception of (1) world cafés with young caregivers of parents with mental health issues (McAndrew, Warne, Fallon, & Moran, 2012), parents of children living with significant disabilities (Carter, Sweden, Cooney, Walter, & Moss, 2012), and youth with borderline disorders (Noack et al., 2016); and (2) world cafés with older adults regarding their preferred desired delivery of fall prevention materials (Khong, Bulsara, Hill, & Hill, 2017) and perceptions of effective relationships in institutional care (Roos & Toit, 2014). Capturing the lived experience and desired services or policies to address needs of the aforementioned populations led to greater awareness of their needs and, to some degree, generated programmatic changes and created new partnerships.
In the first 2 years of the KRDC, a three-county–specific comprehensive needs assessment was completed comprising (1) an individual health status survey with 260 residents, (2) a photovoice project with 24 residents (Yankeelov, Faul, D’Ambrosio, Collins, & Gordon, 2015), (3) a service density analysis that included geo-mapped county-specific services known to promote healthy and unhealthy community living (e.g., pharmacies, hospitals, farmers’ markets, liquor store, and pawnbrokers), (4) a census data analysis, and (5) county at large and organization-specific health policy and program analysis with 81 organizations using CDCs
World Cafés
Four world cafés were held, three of which were county-specific cafés and the fourth was a regional-focused café, aimed to generate the strategic plan. In the county-specific cafes, county-specific fact sheets from the needs assessment were shared, and in the regional-focused café, the draft strategic plan was shared with representatives from each county.
Participants of World Cafés
Community members self-selected to participate in the world cafés. Both personal and formal invitations were extended to the members of county chapters of the coalition. Letters and e-mails were sent to those who had participated in any aspect of the comprehensive needs assessment or the community-wide Diabetes Day events. Flyers were posted in businesses and health care offices, and ads were placed in the local newspaper. County judge executives and other local government officials were personally invited by KRDC members. The county-specific world cafés were held in county cooperative extension offices, which offer numerous enrichment classes to older adults, or the local health department. These locations were useful as they were familiar to community residents. Participation in the world café included attending a 3-hour session during which refreshments were served.
Thirty-six participants attended the three county world cafés. See Table 1 for a description of the county-specific world café participants. The majority of the participants came from the two larger counties, specifically Shelby County and Bullitt County. Majority of the participants were female, over 50 years of age, and living with type 2 diabetes. Two thirds of the participants self-identified as residents, while one third indicated that they represented government (e.g., county judge executives or proxies, county extension offices) or business entities including nonprofit (e.g., community action agencies), and for-profit organizations (e.g., pharmaceutical companies, pharmacies). The majority of the individuals had participated in at least one of the assessment activities and had participated in at least one KRDC meeting.
Characteristics of the County Café Participants (N = 36)
Sixteen participants attended the regional world café; three were KRDC-affiliated community organizers, two KIPDA Area Agency on Aging staff, and two community residents, and the remainder represented regional, health-oriented organizations, specifically a regional representative from a national pharmacy and a representative from a local-owned pharmacy, a diabetes educator from a regional hospital, a director of clinical services from a regional behavioral health organization, a nurse from the Health Department that covered two of the three counties, three nutrition educators from the county extension offices, and one representative from a tricounty community action coalition. Fourteen had participated in two or more KRDC meetings prior to the regional world café. Of the participants at the regional world café, 10 also participated in the county world cafés (3 community organizers, 2 community residents, and 5 organization representatives).
World Café Process
In the county world cafés, community members rotated through four tables in 30-minute cycles. Community members were provided guidelines for engagement which included to have fun, to listen together for patterns and insights, to focus on what matters, to contribute to their thinking, and to speak with their mind and heart (The World Café, n.d.-b). After each 30-minute cycle, a chime would sound and community members would shift to another table. Community members were encouraged to mingle with a different group of people each time the chime alerted it was time to move to another table.
At each table, a moderator offered the results of one of four county-specific, colorful fact sheets, including a healthy eating fact sheet, an exercise fact sheet, a tobacco fact sheet, and a diabetes care fact sheet to the table community members. The moderators were university faculty members affiliated with the CDC grant. The fact sheets highlighted the strengths and needs in each topic area per county based the needs assessment’s findings. Then, community members were invited to dialogue and write down desired programs and services on a large paper table cloth. Community members were able to build on other community members’ ideas by continuing to write on the same table cloth, and the moderator remained at each table offering highlights from the previous dialogue using the written dialogue on the table cloth. Light refreshments were served throughout the 3 hours, with each ending in a debriefing session and two of the three ending in a lunch. During the debriefing sessions, the moderator who remained at the table held up the paper table cloth noting common and unique ideas discussed and requested assistance from the participants to ensure all relevant ideas were communicated.
The regional world café followed the same method as the county world cafés, with the moderators at each table providing a brief overview of the needs assessment results and a recap of the specific ideas generated at the county world cafés and of the corresponding possible evidence-based interventions of the developing strategic plan specific to each table’s topic area. Participants were asked their impressions and ideas related to the results and logic models during the 2-hour session. As with the county world cafés, participants in the regional world café rotated to a new table every 30 minutes.
Data Analysis
Either the participants wrote their own ideas on the paper table cloth or a fellow participant wrote the idea down on the paper table cloth. The moderators remained at each table, and a KRDC leadership team member transcribed the ideas communicated at each table to ensure accurate capture. The ideas written on the paper table cloth were later compared to the transcriptions to further ensure there were no missed ideas that were written but not discussed. The transcripts were coded by two moderators who were university faculty members who worked independently initially, then worked collaboratively to finalize the categorization of the ideas. Coding of the ideas was modeled after focus group analytic techniques (Krueger, 1998; Krueger & Casey, 2015). All ideas generated in a particular topic area were compiled together. Each idea was denoted by county name and whether it corresponded to a county or regional café. The analysts began by reading and rereading the transcribed list of ideas to familiarize themselves with the breadth of the offerings, then used idea by idea coding denoting the categories of the ideas. Questions that guided the analysis included what were the themes per health topic, how do the counties compare, and were there any unique ideas. Participants generated similar ideas across the four cafés; therefore the following presentation of the themes include the topics that were discussed across the three counties and the regional world café.
Results of County and Regional World Cafés
Healthy Eating Highlights
The participants indicated that focus should be on teaching older adults what to eat, portion control, and importance of eating throughout the day; identifying peers who have been successful in their self-management of their diabetes to model best nutrition practices; supporting local groceries and farmers; supporting community support agriculture; and self-gardening and introduction of fresher produce into senior centers. A national pharmacy was identified as a partner due to their emphasis on bringing fresh produce into the local pharmacies. The county extension offices were identified as willing partners to KRDC to offer gardening support and diabetes self-management courses, churches were thought to be a good partner for health nutrition awareness through programming and policy initiatives, and there was an interest in hiring a dietician for each county.
Exercise Highlights
Participants reported that exercise was perceived as a negative word, doctors tended to spend minimal time on promoting exercise, and patients were not asking the right questions about exercise. They suggested communication should begin with encouragement of any kind of movement such as low-impact exercise, but they also acknowledged the lack of options for exercise in the counties. They feel underinformed regarding exercise programs offered at a low cost in their communities such as those offered at the county extension offices, churches, or YMCAs. They wanted to know of any walking clubs and exercise they could do at home, hoping doctor offices would provide this information. They shared an interest in friendly walking competitions across the counties and the availability of exercise programs for disabled individuals living with diabetes including those for the blind and wheelchair-bound. They suggested encouraging business leaders to incentivize exercise for their employees.
Diabetes Care Highlights
Participants reported that there was a universal need for diabetes education that was easy to understand and family-friendly. They indicated they need education on various diabetes-specific diagnostic tests, and they need to know what to ask their doctors at their visits. Many reported being unaware of their Medicare health benefits related to their diabetic care, including the number of strips and educational classes covered. They also reported they needed more qualified primary care professionals and specialists in their county for many of them were going outside of their county for quality care. They reported that their primary care providers needed training on how to communicate the meaning of the tests or they needed educators in their offices or health teams to help communicate the meaning of the tests. Some noted that their county practices were staffed with transient doctors or doctors who only spent a day in their community who did not know the resources in the community to help prevent complications. They reported needing support meetings in their counties to aid their self-management practices and then subsequent marketing on these programs to increase awareness. They suggested that KRDC should partner with pharmaceutical companies and should offer self-management classes.
Smoking Highlights
Participants indicated the need for smoking cessation programs. They thought an education packet for doctor’s offices should be created and distributed. Public awareness campaigns were also discussed including personal testimonials, films, radio spots, or flyers to educate smokers and nonsmokers on the cost of smoking. They also thought businesses needed to be educated on the impact of a smoke-free ordinance on profits. A smoke-free ordinance at the community level was discussed but it was thought to be premature given both the strong history of tobacco farming in their counties and the lack of knowledge regarding the consequences of a smoke-free ordinance. It is important to note that during the need assessment and world café conversations, one county’s Board of Health was being sued by the county for implementing a community-level smoke-free ordinance.
Satisfaction Outcomes of County World Cafés
At the end of each county world café, participants were asked to rate their satisfaction with the experience on a rating scale from 1 (not at all) to 5 (very much so). The world café provided to be a rich experience of interaction between community members, as evidenced by the high level of satisfaction with the world café format (see Table 2). They noted the fact sheets were both easy to understand and informative, and they were not particularly surprised by the results shared in the fact sheets. The participants expressed an appreciation for the informal structure of the cafés; the physical room design, which supported listening to each other; and the small group approach. Overall the participants felt very comfortable sharing their ideas and thoughts with one another, reported being interested in hearing other’s ideas, and noticed connection among ideas from community participants.
Participant Reactions to the County-Specific World Cafés (N = 29)
Ranged from 1 (not at all) to 5 (very much so).
Outcomes and Impact of the World Cafés
Based on the four world café conversations, a final strategic plan for each topic area including possible evidence-based interventions was developed by the KRDC leadership team, which consisted of four university researchers, three county-specific community organizers, and KIPDA representatives. This world café–created strategic plan became the scorecard for which annual success was measured.
Approximately 77% of the areas of improvement noted in the county world cafés received significant attention in the final 3 years of the grant. The outcomes of the world café–driven strategic plan included a number of interventions ranging from individual-level interventions to environmental and policy interventions. Prior to implementation of KRDC’s strategic plan, there were no self-management classes or support groups for individuals living in Henry, Shelby, and Bullitt Counties and only a few smoking cessation classes were being offered across the counties. By Year 3 of the strategic plan implementation, 605 individuals living with diabetes participated in evidence-based and practice-based interventions focused on one or more of the areas identified in the world cafés, including healthy eating, exercise, blood glucose monitoring, psychological distress associated with diabetes, and communication with family members and health care professionals. The implemented programs include the Stanford Diabetes Self-Management Program led by lay leaders; American Diabetes Association’s Live Empowered Program for African American Churches; University of Kentucky’s Taking Ownership of Your Diabetes Program, Share Our Strength’s Cooking Matters Program for families on a tight budget; Biggest Loser Competitions; the KRDC Peer Mentoring Program (in-home, one-to-one program); Cooper-Clayton Method to Stop Smoking; and diabetes support groups. The standardized evaluations used across all grant-associated interventions noted significant changes in the participants’ self-efficacy related to the management of their diabetes. KRDC also hosted Annual Diabetes Education Days with professional speakers drawing 346 attendees over the last 3 years of the grant.
On a community and environmental level, a number of interventions targeting accessibility of healthy foods, exercise opportunities, smoke-free policies, and health care professional training were implemented. For example, the coalition collaborated with a local food pantry to provide both structural recommendations to food pantries to recruit healthier donations from the community, and training for volunteers in food pantries to provide healthier options to persons with diabetes. KRDC also participated in the design and development of two community gardens in two of the three counties. The coalition also organized two continuing education events drawing over 100 local and regional health care providers highlighting community resources that can support patients with diabetes, and distributed 2,500 “patient packets” for health care providers to offer to their patients that contained basic diabetes information and local community resources for people with diabetes. Annual walking competitions were initiated across the three counties with approximately 200 walkers attending each year. KRDC was also integral in a statewide advocacy effort that was led by the Kentucky Diabetes Network. In 2012, the designation for diabetes education funding for local and district health departments was removed, and the number of health departments in Kentucky that were providing diabetes education had dropped in half. KRDC advocated with the Kentucky Diabetes Network for diabetes education and prevention programs, resulting in the approval of a line-item designation for diabetes education in the state budget. The coalition’s efforts have continued past the end of the grant because of the sustainable structure of the coalition and the community buy-in that was established since the beginning of the grant.
Discussion
Given the escalating cost of diabetes to 322 billion annually (Dall et al., 2014), the health disparities, the aging population in rural areas, and the increased emphasis on the integration of primary care and public health promotion (Institute of Medicine, Committee on Integrating Primary Care and Public Health, Board on Population Health and Public Health Practice, 2012), there is value in using community participatory methods, like world cafés, to empower those affected by the barriers, including the residents and the local organizations, to strategize and advocate for a “culture of health” in their rural communities. Environmental strategies, which tend to have broad impact on the population health of people living in rural counties, require community mobilization to increase the public pressure required to implement them. Community participatory methods like world cafés and the coalition model help build infrastructure for community mobilization to create far-reaching, sustainable, environmental changes. The world cafés gave older adults, often a marginalized population, a voice in the health of their communities. The residents, the representatives from the community organizations, and the local governmental officials reported they appreciated the informal setting and reported feeling comfortable in sharing their ideas so having those with formal power did not dampen the older adults’ voices. The informal, small group approach of the world cafés allowed for cross-pollination of ideas, and as a result, collective wisdom evolved. This method brought residents and community organizations to collectively problem-solve regarding the health of their community, which would have not likely occurred. These cafés also encouraged residents and community organizations who had and had not been part of the coalition or its activities to either deepen their commitment to the coalition or consider joining the coalition’s efforts. The world cafés not only produced conversations and forged new relationships among the residents and organizations but also produced a strategic plan, which became both the road map and scorecard for the coalition’s efforts.
It was valuable to use a two-stage world café process. In the first three cafés, the participants represented the demographic focus of the grant—specifically, many of the participants had diabetes, were community residents, and were older adults—while the participants at the regional café mainly represented health-oriented organizations with interests spanning across counties. With the inclusion of the organizations, opportunities surfaced as resources and programs that were either gearing up to be implemented in a county or being piloted in our counties were considered for expansion in the coalition’s counties. Additionally, the objective of the first three county cafés was idea generation, while the final café allowed for regional and local partners to consider the preferred strategies and discuss collective capacity for implementation.
Greater participation from older adult residents and health care professionals would have been ideal in the county cafés. Certain barriers to participation in the world cafés represented larger barriers to system change in these communities: a lack of transportation for older adults in rural areas, a culture resistant to address smoke-free policies due to a history of tobacco farming, and a lack of local health care providers. These areas remained a challenge throughout the initiative, but because these gaps were identified during the world cafés and the needs assessments, efforts continue to address the gaps. Sustainable change in these areas will come from continued community advocacy and organizational efforts, making the community mobilization established through the world cafés and the coalition model all the more important. Future research is needed to determine the ways in which community-based participatory models affect system-level changes such as transportation, smoke-free policies, and availability of local quality health care providers.
Conclusion
Affecting positive change in the approach to addressing the health of older persons living in rural communities with type 2 diabetes required the community to drive the change. Participatory methods, such as the world cafés, were integral in building this community buy-in and coalition membership, as well as guaranteeing that grant and coalition efforts were truly community-driven. This collaborative and empowering methodology led to a stronger, more efficient and formalized support system of community partners and stakeholders for the rural, older adults living with diabetes. The world cafés provided a structure that allowed a diverse group of community residents, governmental leaders, and business leaders to come together to discuss topics that matter to their community, leading to the development of a strategic plan that provided the road map for community empowerment.
Footnotes
Authors’ Note:
Teresa McGeeney is now at REACH Evaluation, Louisville, KY, USA. Special acknowledgment goes to the community organizers, Amanda Strecker, Jessica Craddock, and Mona Huff, along with the coalition members, who used the world café results to lead the community transformations. Support for this research was provided by Cooperative Agreement 1U58DP002815-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.