From Evidence-Based Implementation Guides to Meaningful Action: Public Health Practitioners Use Readiness Assessments to Build Bridges to Successful Community Prevention Implementation

Abstract

Readiness has been cited as a determining factor in whether a community can effectively implement, support, and sustain an initiative. Through readiness assessments and technical assistance, public health practitioners can be the bridge between the gap of reaching goals outlined in Healthy People 2030, or another funder’s guides, and actionable, successful, implementation. Readiness assessments are practical tools for implementing change in public health. Here we discuss three readiness assessment activities that we developed for four Texas counties: a partnership mapping tool, an Ease and Impact score, and a round table discussion. Through the assessments, we ascertained both readiness and the relevance of Policy, Systems and Environment opportunities. We used readiness assessments to translate our funder’s implementation guide to meet the needs of four counties. Data allowed us to determine whether communities were ready to move forward with minimal technical assistance, needed further assessment to better understand relevance and feasibility within the community to implement the initiative, or whether this opportunity was not a good fit at the time. We adapted readiness tools based on components of the R = MC² framework so we could assess the readiness (motivation [M]; general organizational capacity [C]; and innovation-specific capacities [C]) of the participant groups and based on that assessment, we provided appropriate, tailored technical assistance. Public health practitioners and local supporters can use readiness tools and technical assistance to build a bridge from implementation guide(s) to effective community program implementation.

Keywords

readiness assessment implementation guides technical assistance community assessments community readiness translation practice

Background

Readiness is a determining factor in whether a community can effectively implement, support, and sustain an initiative (Edwards et al., 2000; Makoae et al., 2012; Scaccia et al., 2015). However, although funders offer recipients evidence-based interventions (EBIs) in their implementation guidelines, it is impossible to offer tailored implementation strategies that consider each recipient’s needs for adaptations and adjustments for context and readiness. If a community is not ready for the intervention due to lack of community support, contextual factors, or insufficient adaptation of the intervention, the results may be less than successful (Weiner et al., 2008). As many as 80% of health-related interventions are not successfully implemented (Khan et al., 2014; Kotter, 1996). Failure to accurately assess readiness accounts for around half of implementation failures (Centers for Disease Control and Prevention [CDC], 2022).

Weiner et al. (2008) recognized readiness as a precursor to change, initially defining it as the extent to which community members are mentally, emotionally, and behaviorally prepared to implement change. Insufficient implementation readiness was the reason that only 40% of all change projects fully reached their targets (Drzensky et al., 2012). Public health practitioners can be the bridge between the funder’s implementation guides and actionable, successful, implementation practice through readiness assessments and technical assistance. Readiness assessments are practical tools for implementing change in public health.

Healthy People, the set of national, data-driven, measurable objectives to improve health and well-being over the next decade, has challenges. For example, of the 42 health topic areas in Healthy People 2020, progress was only reported in 17 (40%), and targets met or exceeded in only 33.9% of the trackable objectives. Among these, 31% saw little or no change, and 14.3% actually got worse (HP2020; U.S. Department of Health and Human Services [HHS], 2020). For trackable objectives affecting persons with less than a high school education, only 39% of objectives were improved upon, met, or exceeded their targets (HHS, 2021). How can public health practitioners support communities to achieve the objectives of HP2030 and other initiatives? A community might be overwhelmed with the number of objectives in HP2030; they might read a funder’s implementation guide not knowing next steps. Readiness assessments and technical assistance can move communities toward actionable, successful implementation.

Numerous studies suggested that a critical or foundational facilitator for successful implementation is a community’s readiness for the initiative (Domlyn & Wandersman, 2019; Hall & Hord, 2006; Shea et al., 2017; Weiner et al., 2008). Weiner et al. (2008) and Weiner (2020) posited that change may fail due to an inability to recover from false starts, stalling in the face of increasing resistance, and outright failure due to low capacity. Implementation failures or stalls drain resources and weaken community engagement for future efforts (Domlyn et al., 2021; Weiner, 2020; Weiner et al., 2008). Readiness assessments and technical assistance can help ensure that communities are ready to implement initiatives.

A Readiness Framework

Scaccia et al. (2015) viewed readiness as a construct ensuring quality implementation throughout the life of the project. They expanded on Weiner’s model to introduce an R = MC² framework to describe and assess readiness. They assumed readiness (R) involves motivation (M), general organizational capacity (C), and innovation-specific capacities (C). Within this framework, projects not only improve health outcomes but also improve readiness outcomes in preparation for future efforts. Recognizing this, Health and Human Services/Assistant Secretary for Planning and Evaluation (ASPE) suggested practitioner organizations should assess a community’s readiness before implementing EBIs to provide more appropriate technical assistance and then continue to assess throughout the life cycle of the initiative (Dymnicki et al., 2014).

Technical Assistance

Technical assistance (TA) can bridge the gap between readiness of communities and funders’ standardized, evidenced-based implementation guides (Domlyn et al., 2021; Katz & Wandersman, 2016). Where appropriate, public health practitioners or other subject matter experts can provide this critical TA (Katz et al., 2016). A practitioner can use readiness tools to assess whether a community is ready to move forward with some technical assistance, to move forward after better understanding of the relevance and feasibility to implement the intervention, or whether an opportunity is not the right fit and the community should find something more appropriate.

Purpose/Aim

Participants in a CDC-funded High Obesity Program (HOP) in four counties along the Texas/Mexico border (Hudspeth, Maverick, Starr, and Webb Counties) recognized they required meaningful, relevant, community-based solutions that can be sustained long term. The success of a community-based approach depends on an engaged and active community that is ready for the initiative (Wallerstein & Duran, 2006; Weiner, 2009). We decided that community readiness assessment tools could be used to (1) engage the community and (2) identify implementation strategies that match community capacity and needs.

We assessed the community’s program readiness with user-friendly tools we adapted from readiness principles, such as those supporting R = MC² (Edwards et al., 2000; Scaccia et al., 2015). We provided tailored technical assistance to the four counties to bridge the gap between community readiness and our funder’s implementation guidelines, which included EBIs based on HP2020 goals (Domlyn et al., 2021; Edwards et al., 2000). We used the readiness assessment tools to translate the implementation guide into action, which allowed participants to move toward meaningful progress. In-depth methods like surveys and focus groups can be more time-consuming and expensive, but tools such as those as presented here (used within a half-day workshop) can facilitate wins and build trust more quickly (CDC, 2022). The case study presents the use of an adapted and simplified R = MC² framework to assess community health program readiness using a series of ease and impact assessments.

Methods

Participants

Participants were a convenience sample of 52 members of the four Working on Wellness Environment (WOWe) kickoff meetings held between March 2019 and June 2019. Meeting attendees (N = 52) included members of the WOWe coalition in Starr County, the Healthy Texas Coalition in Webb County, and the Family and Community Health committee in Maverick County. A mix of residents, community organization leaders, and government leaders participated in the process to identify opportunities that were feasible and sustainable. It was important to actively include stakeholders from all socioeconomic groups. These established groups were interested in or currently working on activities centered around improving the health and wellness of their communities. The Hudspeth County meeting was attended by a group of community supporters. The group was formed in response to opportunities with HOP funding from CDC. The methods were submitted to the Texas A&M University Institutional Review Board, which determined the data collection did not constitute research activities. Thus, informed consent was not required.

Data Collection and Assessment Tools

Semi-structured facilitations in each half-day workshop employed three activities: (1) partnership mapping, (2) Ease and Impact scores, and (3) round table discussions. These activities were aimed at identifying meaningful ways to gauge readiness and relevance of Policy, Systems and Environment (PSE) opportunities from the CDC’s Division of Nutrition, Physical Activity, and Obesity’s Implementation Guide for the Notice of Funding Opportunity: High Obesity Program (CDC-RFA-DP18-1809; Link: https://www.cdc.gov/nccdphp/dnpao/state-local-programs/pdf/HOP-Implementation-Guide-508.pdf; Centers for Disease Control and Prevention, 2018), referred to here as the Guide. As previously mentioned, the Guide is an evidence-based implementation guide aligned with HP2020 goals. Facilitators included two extension¹ subject matter experts (SMEs), one project manager, and one extension assistant. The R = MC² framework is a best practice approach in helping organizations/communities identify where they are in the PSE process. This framework was suggested to be used by public health organizations in combination with technical assistance by HHS/ASPE (Dymnicki et al., 2014).

Activity 1, Partnership Mapping, involved encouraging participants to identify organizations and agencies relevant to PSE work. Local supporters and SMEs created a visual construct of potential partners and systems to depict existing and potential capacity (capacity elements of R = MC²) and readiness for implementation (Figure 1).

Figure 1

Example of a Partnership Map Related to PSE Work

Activity 2, Ease and Impact, was an assessment of perceived ease and impact, and introduced coalition members to the Guide (CDC, 2018). The Ease and Impact activity is a 2 × 2 matrix adapted from work by Morrison et al. (2019). Known as a strategic doing matrix, it helps participants identify opportunities with the largest impact and those that are also the easiest to implement. Facilitators created a presentation to convey simplified key themes from the Guide, including examples of possible interventions, labeled as opportunities (CDC, 2018). Opportunities from the Guide presented to participants were based on previous PSE work in similar communities and were recommended by experts who supported our readiness assessment. Some opportunities (such as webinars and communication) were included to introduce and highlight best practice interventions to implement with community support (such as motivation and capacity). Opportunities were depicted with a title, description, visual, and indication of whether it was an education/empowerment intervention, a plan, an assessment, or policy/environmental change.

Through the Ease and Impact activity, SMEs gathered perceptions regarding the potential impact of opportunities and the relative ease of local implementation. These perceptions are components included in the R = MC² framework (Scaccia et al., 2015). Each participant got a worksheet (Figure 2) to score the Ease and Impact for each opportunity. This can help a community identify where to get started within the numerous suggestions in the Guide (CDC, 2018). Participants briefly discussed the selected opportunities (CDC, 2018). To assure that everyone understood how to complete the activity, coalition members practiced assigning Ease and Impact to a sample opportunity.

Figure 2

Example of Ease and Impact Scoring Worksheet

Activity 3, Round Table Discussions, explored perceived healthy eating and physical activity challenges, opportunities, and ongoing initiatives. Facilitators provided a list of questions (Table 1) and listened, answered questions, and clarified groups’ responses. Coalition members worked in self-selected groups primarily determined by what table they sat at when they arrived. Participants tended to sit with the organization they represented.

Table 1

Overview of Activities 1, 2, and 3

Activity	Facilitation prompts & link to framework (R = MC²)^a	Purpose of activity
Activity 1: Partnership Mapping	Using one blue square, clearly write the name of your Organization. Using as many yellow squares as needed, list organizations/agencies you partner and collaborate with. Please write one organization per square. Framework: CI & C2	Allowed each organization to identify relevant organizations and agencies. This activity created a snapshot of existing partners that allowed SMEs and local supporters to identify possible systems and to map out the existing social ecological model relevant to possible PSE interventions in their community.
Activity 2: Ease and Impact Adapted from Purdue Extension Strategic Doing (Morrison et al., 2019)	“Opportunities” have different relevance to different groups (their potential IMPACT). Framework=M And organizations have different readiness levels—that is, they require different levels and types of resources to get started or activated (EASE). Framework: C2 Please rank the ease and impact of each slide from 1–10 (with 10 being high).	Gathered perceptions of the potential impact of interventions along with the Ease of being able to implement them locally.
Activity 3: Round Table Discussion	List the nutrition and physical activity issues in your community that affect your organizations’ constituents the most. Framework: M List what challenges, if any, has your organizations have faced trying to address the following issues: Access to healthy food Connectivity to everyday places Built environment/location of services (parks, schools, work, stores, churches) Framework: M, C2 List the existing initiatives your organizations are involved in to help address these key issues: Access to healthy food Connectivity to everyday places Built environment/location of services (parks, schools, work, stores, churches) Framework: M, C1 List what, if any, existing health reports, studies, plans, or policies exist to address nutrition, connectivity, and built environment and/or related health issues. Framework: C1 List ways you think your organizations can participate in the Working on Wellness Environments effort to address these issues. Framework: M, C1	Explored healthy eating and physical activity challenges, opportunities, and ongoing initiatives via a self-guided worksheet.

Note. PSE = Policy, Systems and Environment.

Framework R = MC²—M: Motivation, C1: Organization, C2: Innovation Specific.

Data Analysis

To ensure readability and understanding, at least one facilitator reviewed partnership mapping data and round table discussion data. Data were captured via portable electronic devices and uploaded into a secure cloud folder immediately after each meeting. Data were transcribed into lists and organized by the indicators for each county and for each organization (Figure 1). Data were reviewed by SMEs to identify types of existing partners and potential for building system capacity relevant to the interventions. These data were also triangulated with Ease and Impact data.

After the meetings, Ease and Impact matrix data were entered into Excel, coded, and mapped by the extension assistant and student worker. Averages of each score were calculated to identify opportunities with the collective highest and lowest scores by county. Next, Ease and Impact scores were assessed for positive rankings in both areas. Figure 3 shows the Ease and Impact scores for one potential opportunity in Starr County, an Actively Friendly Routes (AFR) workshop. Ease and Impact data were graphed on X, Y grids in Excel to depict reported perceptions of ease and impact and to identify relationships. Data for Ease and Impact were filtered for each county and depicted by opportunity. The X, Y coordinate points depict participant scores labeled by the organization they represent. We reviewed data for patterns indicating high ease, high impact opportunities by organization type, number, and expertise.

Figure 3

Ease and Impact Group Scores for Potential AFR Workshop in Starr County

Roundtable discussion data were reviewed by SMEs to better understand local perspectives. In addition, data related to all high ease, high impact opportunities were reviewed collectively for context relevant to readiness as outlined in the R = MC² framework and subsequent technical assistance needs (Scaccia et al., 2015).

Results

Data were analyzed to better understand how to support communities in meaningfully moving forward within the context of their self-reported readiness context.

For the partnership mapping activity, the number of unique partners mapped ranged from 16 in the smallest county to 83 in the largest. Typical partners included local government/leadership, state agencies, service clubs, school districts, child care providers, health agencies, social services, faith-based organizations, county extension personnel, and community colleges and universities. Local individuals, such as a community champion, were also listed. This activity provided insight into capacity to implement a particular initiative. This activity can prompt participants to understand local capacity and identify meaningful and feasible future projects while saving money and time.

Ease and Impact scores are unique to each county cohort and are not standardized. Thus, thresholds vary between locations and interventions. However, three categories emerged from the review of the Ease and Impact matrix data. Note that these categories serve more as qualitative descriptors to assess and rank scores more so than a quantitative or definitive approach:

High Impact with relatively high Ease (Score 7 or higher out of a possible 10): Community perceives they are ready to move forward with technical assistance.

Recognized Impact and with some level of Ease Score >5 to <7): Community perceives a need for further assessment to better understand relevance and feasibility within the community and to identify level of and type of technical assistance needed.

Low Impact with mid to low Ease (Ease or Impact score below 5): This opportunity is not relevant to this community currently.

Cut points were based on natural breaks from the average scores from organizations within each county and in the community rated for each of the 15 opportunities. Scores varied based on partners, interventions considered, and local environments. Of the opportunities assessed, 18 had averages in the High Impact with relatively High Ease; 30 were Recognized Impact and with some level of Ease; and 12 were Low Impact with mid to low Ease. These were based on average scores by county, by intervention (60 total aggregate scores; 15 interventions scored by representatives in four counties). Number of opportunities in each category differed by county. Data were triangulated from the Ease and Impact scores for each county with their partnership mapping data, which further depicted capacity via connections. Collectively, this depicted capacity and interest among both number and type of partners. Finally, roundtable discussion comments were reviewed to gauge additional context related to the readiness assessments.

Case Study Result

As a case study of how one county was scored and rated on an activity, we present Starr County’s Active Friendly Routes (AFR). Partners and activities are unique to each county; therefore, it is not advisable to compare proposed activities across locations. The AFR Ease and Impact matrix (Figure 3, Table 2) indicated that partners from the Economic Development Council, Starr County, Family Community Health, high school, ACE Afterschool program, and health coalition in Starr County scored this opportunity similarly. The AFR workshop was considered a High Impact with relatively high Ease project because most key partners scored it above 7; those pulling the average down to 6.4 are not in the city, or their work is not relative to this opportunity area. Data were triangulated with their partnership mapping activity, which further depicted capacity via connections to the Texas Department of Transportation as well as city and county government. Collectively, this depicted capacity and interest among both number and type of partners.

Table 2

Average Ease and Impact Score for Starr County Active Friendly Routes Workshop

Ease ^a	Impact ^a	Total ^b	Difference ^c
6.4	8.1	14.5	1.7

Average score from 12 organizations. Original data depicted as dots in Figure 3, with the average represented as the orange dot. ^bTotal = sum of average Ease and Impact Scores. ^cDifference = difference between average Ease and Impact Scores.

For Starr County, participants indicated through their roundtable comments that there were both challenges and supporting factors related to implementation and technical assistance needs, such as:

Lack of transportation for the elderly; locked physical activity areas (such as restricted access); rural areas lacking reasonable walking distance and connectivity (such as no sidewalks) to stores, parks, and schools; and limited access to parks and trails were listed as existing challenges.

Supportive elements mentioned included ongoing health initiatives and bike parking availability at the school (such as some support for alternative transportation infrastructure).

Organizations indicated they could participate by spreading the word to constituents about healthy choices, promoting program availability and locations, writing potential policy, and incorporating activities into existing efforts.

Discussion

Through the adaptation of readiness tools based on components of the R = MC² framework, we assessed the readiness of the participant groups for various opportunities and provided appropriate, tailored technical assistance (Scaccia et al., 2015). Communities rated as high impact/high ease were deemed ready to implement with minimal technical assistance. Groups rating as high impact/some level of ease would probably be able to implement successfully given tailored technical assistance. Opportunities rated low impact/mid-to-low ease were considered not to be a good match. Data from this activity were used to guide the development of Action Institutes in each county detailing how to get started on the higher scoring opportunities. In addition, a Request for Assistance (RFA) application was released, which allowed local groups to request relevant technical assistance and funding based on their readiness. Interested groups were paired with SMEs and coaches to guide them through the RFA process and opportunity implementation.

Limitations

These processes are rarely without limitations. The Ease and Impact data are quantitative, based on subjective perceptions. Additional qualitative data may have provided further insights into these data. Findings were subject to bias based on the participants’ and the facilitators’ perspectives. As with many community meetings, this project represented a convenience sample of people invited to workshops based on their expertise. It demonstrated simple tools with plain language that support inclusive discussions to help identify impactful and sustainable future projects.

Future facilitation activities will have more explicit directions. The activities were adapted from tools previously available and continually evolving. For the partnership mapping activity, facilitators noted some participants did not include partners if they noticed other people already listed them. Although attempts were made to address this limitation, not all organizations revised their partner list. As a result, the maps do not always reflect the relative weight of partnerships or identify shared partners likely to initiate system change. It is also important to make sure that all stakeholders are represented.

Implications For Public Health Practice

This approach provided a road map for facilitators and SMEs to identify which opportunities best fit local organizational capacity, innovation-specific capacity, and motivation (Scaccia et al., 2015). In addition, the readiness assessment provided directions to facilitate initiating action steps and build capacity. Such readiness indicators can help communities achieve relevant and effective wins (Domlyn & Wandersman, 2019). Moreover, it provided an understanding of when technical assistance could possibly reduce local barriers to Ease and make the intended Impact doable (Morrison et al., 2019). By assigning a level of readiness, we were able to assign an appropriate type, amount, and level of technical assistance. Finally, it depicted which of the opportunities presented were not viewed as currently relevant or feasible by the organizations in attendance.

This approach provides a way to see where communities and their organizations have PSE opportunities. This may guide the allocation of resources and assistance to build capacity and increase likelihood for success among less ready communities. As more programs shift from education and knowledge gain toward the implementation of PSE, readiness is an essential component of project assessment and monitoring. Many assessment phases focus on what exists and what people want/need (motivation) when they also need to look at what they can do and sustain (capacity). Assessment grounded in R = MC² encourages adoption of the most feasible actions while building readiness for other activities (Scaccia et al., 2015). Similarly, it may indicate when the funding or program is not the best fit at a given time or for a specific community. Using readiness assessments throughout the project can help prevent frustration and burnout, as most will not stay engaged when the impact is not relevant or the ease is not within their innovation-specific capacity (Weiner, 2020; Weiner et al., 2008). It can also assist in allocating resources to communities or organizations by identifying relevant interventions and pairing them with meaningful technical assistance.

Implications For Practice

Including readiness components in funding announcements, program design, and evaluation can improve outcomes for work focusing on PSE. Understanding a community’s readiness before committing resources and time can assure that projects are realistic and relevant, thereby improving the return on investment for both funders and communities and building local readiness for long-term success. For effective implementation, public health practitioners can embed readiness concepts into PSE work and be prepared to use the tools available throughout the planning, implementation, and evaluation cycle process. Public health practitioners and local supporters can use readiness tools and technical assistance to build a bridge from implementation guide(s) to effective community program implementation.

Footnotes

Authors’ Note:

We would like to thank the four counties that participated in the program with Texas A&M AgriLife: Hudspeth, Maverick, Starr, and Webb. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors whose names are listed immediately below certify that they have NO conflict of interest related to this manuscript submission: Jamie Rae Walker is an Associate Professor and Extension Specialist focused on community parks and open spaces, capacity building, and policy and planning. Jenna D. Anding is a Professor and Extension Specialist focused on developing and evaluating food and nutrition education programs. Rebekka M. Dudensing is a Professor and Extension Economist focused on rural community development, capacity building, and business planning. S. René Lavinghouze is a Lead Senior Health Scientist at the Centers for Disease Control and Prevention/Division of Nutrition, Physical Activity, and Obesity. She is the translation team lead. Valeria Jauregui is a Program Director and Doctoral student studying Health Promotion and Behavioral Science at the University of Texas, Health Science Center School of Public Health, Kelsey Coats serves as a Project Specialist and recently completed her Masters in Regional Planning at Cornell University. Funding was provided to Texas A&M AgriLife Extension Service by Centers for Disease Control and Prevention High Obesity Prevention (HOP) Cooperative Agreement DP18-1809.

Supplement Note:

This article is part of the Health Promotion Practice supplement, “Reducing Chronic Disease through Physical Activity and Nutrition: Public Health Practice in the Field.” The purpose of the supplement is to showcase innovative, community-centered, public health actions of SPAN, REACH, and HOP programs to advance nutrition and physical activity among priority populations in various settings. The Society for Public Health Education is grateful to the Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity for providing support for the issue. The entire supplement issue is available open access at .

IRB Approval

The methods used, and data collected were determined to be non-research activities by the Texas A&M University Institutional Review Board.

Prior Publication

NO part of this manuscript submission, including tables and figures, has been published previously.

ORCID iDs

Jamie Rae Walker

S. René Lavinghouze

Notes

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