1. Lesson 1B Moving Toward the MAPP Model
Community Health Analysis MPH607
REVISED: 01/2010

2. Lesson 1B Objectives
Understand the development of the MAPP process by examining earlier models of health improvement.
Identify the steps key concepts underlying each model
Review models:
Precede/Proceed
PATCH
APEXPH
IOM CHIP Model
MAPP

3. Models for Public Health Planning
PROGRAM
PRECEDE /PROCEED
PATCH
APEXPH
CHIP (IOM)
MAPP SYSTEM
MAPP – Mobilizing for Action through Planning and Partnerships was preceded by a number of models of planning for use in public health.
Evolution of the Models as one moves from Precede/Proceed to MAPP:
Increasingly emphasize the cyclical nature of health improvement
Move from program/intervention focus to system improvement.
Greater emphasis on performance/quality improvement
Common elements to the approaches in all of the models:
Engage the “participant” in process
Focus on assessment/diagnosis
Involve prioritization of health issues
Focus on measurement and evaluation
Use of objectives to measure process, impact and outcomes

4. PRECEDE -PROCEED Developers: L. Green, M. Krueter
Years of origin for PRECEDE, late 1980s for PROCEED.
Principles:
Success in achieving change is enhanced by the active participation of members of the target audience.
  The important role of the environmental factors as determinants of health and health behavior such as media, industry, politics, and social inequities
The Precede-Proceed model was developed for Health Promotion program planning.
It emphasized the participation of the target audience in development of the program planning.
It also looked beyond individual factors that played a role in behavior change and included a broader view of determinants in the change process.
PRECEDE:
Focus: Health Education
Process for development and evaluation of health education programs.
In theory it held that
health education is dependent on voluntary cooperation and participation of the client in a process – behavior change is voluntary
health and health behaviors have multiple causations which must be evaluated in order to assure appropriate intervention.
this theory applies to health education in various settings e.g. such as school, clinic/patient, community education
Source: THE PRECEDE/PROCEED MODEL.

5. PRECEDE -PROCEED
PRECEDE is an acronym for Predisposing, Reinforcing, Enabling, Causes in, Educational Diagnosis and Evaluation.
PROCEED is an acronym for Policy, Regulatory, Organizational Constructs in Educational and Environmental Development.
(You do not need to memorize these! These are somewhat convoluted and contrived!)
In health education and health promotion planning, this model’s first step was to “precede” (with assessment) and the “proceed” with policy and planning.

6. PRECEDE - 5 “Diagnosis” Phases
1 Social: identify and evaluate the social problems which impact the quality of life 2 Epidemiological: identify specific health problems and non-health factors 3 Behavioral: analysis of behavioral links to the problems identified in the first phases Environmental: parallel analysis of factors in the social/physical environment 4 Education & Organizational: looks at the specifics that hinder or promote behaviors 5 Administrative & Policy: assessment of policy resources, circumstances that could impact implementation.
PRECEDE consisted of 5 Diagnosis phases. The “Diagnosis” phases parallel ‘Assessment’ from a planning perspective.
Each of the elements were assessed in developing the program plan. Note that the scope is broader than epidemiologic outcomes and measures alone.

7. PROCEED PROCEED: added to the framework .
Recognition of the need for health promotion interventions that goes beyond traditional educational approaches to changing health behaviors.
Flows from the PRECEDE:
to promote the plan or policy, regulate the environment, and organize the resources and services, as required by the plan or policy.  
Proceed was added later to the Precede. Following the “diagnosis”, policy and planning for community health promotion strategies which were broader than student/client education – targeting social norms (e.g. societal norms about smoking, seat belt use, etc), as means of behavior change.

8. PROCEED – Action/Evaluation
6 IMPLEMENTATION
7 PROCESS EVALUATION  evaluates:
the process by which the program is being implemented.
8 IMPACT EVALUATION measures
effectiveness related to intermediate objectives
changes in predisposing, enabling, and reinforcing factors.  
9 OUTCOME EVALUATION measures
change in overall objectives and
changes in health and social benefits or the quality of life.
The emphasis in proceed was on implementing the plan and evaluating the results at the process, impact and outcome levels.
Aspects of this model are present in subsequent models of health improvement (e.g. APEXPH).

9. PRECEDE-PROCEED Framework
Phase 5
Administrative
Policy
Assessment
Phase 4
Educational &
Ecological
Assessment
Phase 3
Behavioral &
Environmental
Assessment
Phase 2
Epidemiologic
Assessment
Phase 1
Social
Assessment
Predisposing
factors
Health services
Behavior &
lifestyle
Health Education
Health Promotion
Policy, Regulation
Reinforcing
factors
Quality
of life
Health
The overall model of Precede Procede.
Environment
Enabling
factors
Phase 7
Process
Evaluation
Phase 8
Impact
Evaluation
Phase 9
Outcome
Evaluation
Phase 6
Implementation

10. Planned Approach to Community Health (PATCH)
Developed 1983; by CDC
Program focus.
Assist local health agencies to partner with local communities
Evaluate health promotion/prevention programs
Improve linkages within/between communities, health depts, universities, etc
PATCH was developed to provide a model to assist state and local public health agencies, in their partnerships with local communities, to plan, conduct, and evaluate health promotion and disease prevention programs.
PATCH was also intended to serve as a mechanism to improve links both within communities and between communities and state health departments, universities, and other agencies and organizations.

11. PATCH STEPS 1) mobilizing the community,
2) collecting and organizing data,
3) choosing health priorities,
4) develop comprehensive intervention plan
5) evaluation.
The focus of PATCH was on gaining community participation in the development of the public health programming. It emphasized community engagement. It also required collection of data to support priorities and plans. Finally it included an evaluation component.
PATCH required:
Time to complete the process – up to a year or more
Having adequate time and resources to gather and interpret data
Requires actively engaging community members
Developing cohesion among stakeholder organizations.
PATCH is an example of a model that not only tested the application of theory, but has also facilitated the link between research and practice in community health education and health promotion.
It still had an emphasis on public health program interventions – not focused on a true strategic, systems approach.

12. PATCH Benefits Strengths: Tested the application of theory
PATCH increases community
(1) organizing and data use skills,
(2) awareness and interest in health,
(3) networking and ability of groups and organizations to work together, and
(4) the number of health promotion interventions activities.
Strengths:
Tested the application of theory
Facilitated the link between research and practice in community health education and health promotion.
Practical/user friendly approach
However, PATCH planning sometimes leads to a priority problem for which resources are available. In some cases if the selected problem is not a priority of the government entity, the community may have to choose between shifting focus to a health issue for which there are available resources, or go without. Since the process focuses on an organizational approach rather than a systems approach, the ability to implement priorities not aligned with (public health) agency resources was limited.

13. Assessment Protocol for Excellence in Public Health (APEXPH)
A collaborative project of
The American Public Health Association
The Association of Schools of Public Health
The Association of State and Territorial Health Officials
The Centers for Disease Control
The National Association of County Health Officials
The United States Conference of Local Health Officers
Funded through a Cooperative Agreement between the Centers for Disease Control and the National Association of County Health Officials (NACCHO)
APEXPH was the result of a broad collaborative during the late ‘80s and early ’90s.
APEXPH: Public Health Leadership
Emphasized the leadership role of governmental public health
Local health departments have a responsibility to take a key role in local efforts to improve the conditions that affect health 
Health departments must lead their communities in assessing health problems, setting appropriate policies, and assuring that health problems are effectively addressed.
It moved the focus beyond program planning to addressing community health priorities with a focus on broader strategy and community participation.

14. APEXPH – 3 Part Process Part I, Organizational Capacity Assessment
an internal review of a local health department.
an assessment of department's basic administrative capacity and to undertake Part II.
Part II, The Community Process
involving key members of a community and department staff
assessing the health of the community and identifying the role of the health department in relation to community strengths and health problems.
use of objective health data
use of community's perceptions of community health problems.
Part III, Completing the Cycle
integrates the plans developed during Part 1 and Part II
into the ongoing activities of a health department and the community it serves.
discusses policy development, assurance, monitoring, and evaluation of plans
The APEXPH process was comprised of 3 parts:
Part 1 was focused on the public health agency – the local health department’s capacity.
Part 2 was the community based assessment and planning process.
Part 3 was the implementation phase of the plan.

15. STEPS: APEX PARTS I & II
INTERNAL
1. Prepare for the organizational capacity assessment
2. Score indicators for importance and current status
3. Identify strengths and weaknesses
4. Analyze and report strengths
5. Analyze weaknesses
6. Rank problems in order of priority
7. Develop and implement action plans
8. Institutionalize the assessment process
EXTERNAL
1. Prepare for the community process
2. Collect and analyze health data
3. Form a community health committee
4. Identify community health problems
5. Prioritize community health problems
6. Analyze community health problems
7. Inventory community health resources
8. Develop a community health plan
The APEXPH model was much more comprehensive process that previous models. It also shifted the process outside of the health department. The priorities that were to be determined were derive from a process involving community input and prioritization.
APEXPH was used as the model that was (is) required for Illinios’ IPLAN and part of the Illinois public health certification rules:
“The local health department shall, at least once every five years perform an organizational capacity self-assessment that meets the requirements set forth in Section The process shall involve community participation in the identification of community health problems, priority-setting, and completion of the community health needs assessment and community health plan.”
The IPLAN version of this process is modified slightly. These essential steps are nearly identical but the IPLAN version calls for the formation of a community health committee as the first step of the process. Below are the steps in the IPLAN version of this process.
Convening the Community Health Committee
Analysis of Health Problems and Health Data
Prioritize Community Health Problems
Conduct Detailed Analysis of Community Health Problems
Inventory Community Health Resources
Develop a Community Plan

16. APEXPH Strengths: Challenges: Strengthened health department’s role
True organizational assessment
Adaptable to fit local situations and resources.
Limit size/scope of effort.
Focused on community as partners in health improvement
Challenges:
Commitment of time and resources
Priorities may not align with program funding
Lacked environmental health component

17. IOM: Community Health Improvement Process (CHIP)
Focuses on a broader definition of health:
Health is a state of well-being and the capability to function in the face of changing circumstances” (IOM 1997).
Underlying themes:
The origins of good health are multiple and cross- sectorial.
A focus on the origins of health:
emphasizes the need for cross-sectorial assumptions of responsibilities
creates multiple options for intervention
The Institute of Medicine model for Community Health Improvement (CHIP) emphasized a broader health view of health. APEXPH was focused on health problems defined by health status indicators of disease, death or disability.
The IOM process expanded the view of health to include both the health outcomes and risk factors but also the systems that enable people to be healthy. It also placed more of the responsibility for health on entities other than the public health department alone or the health sectors alone. This enabled interventions to focus on more than medical interventions – opening opportunities for social and economic interventions as well.

18. Determinants of Health
It expanded the view of determinants of health beyond the biologic environment and individual behavior, to include social and physical environment factors that play a role in health – the social determinants of health. These were indirect factors -- outside of the direct cause-effect pathway. However they exert an impact on the ability of individuals to respond to health hazards and potential detrimental behavioral choices.
A model of the determinants of health. Source: Reprinted from R.G. Evans and G.L. Stoddart, 1990, Producing Health, Consuming Health Care, Social Science and Medicine 31:1347–1363

19. IOM: Community Health Improvement Process (CHIP)
Two Cycles:
Problem Identification and Prioritization
Analysis and Implementation
Emphasizes ongoing nature of community improvement process
The CHIP process involves an initial problem identification and prioritization cycle . This phase focuses on bringing community stakeholders together in a coalition, assessing community-level health indicators, and identifying specific health issues as community priorities.
The priorities are addressed in the second kind of CHIP cycle—an analysis and implementation cycle. This cycle’s components are analyzing a health issue, assessing resources, determining how to respond and who should respond, and selecting and using stakeholder-level performance measures together with community-level indicators to assess whether desired outcomes are being achieved.
More than one analysis and implementation cycle may be ongoing at once if a community is responding to multiple issues.

20. CHIP: Problem Identification Cycle
Focuses on bringing community stakeholders together in a coalition Monitoring community-level health indicators Identifying specific health issues as community priorities.

21. CHIP: Analysis & Implementation Cycle
Analyzing a health issue (for determinants )
Assessing resources
Determining:
How to respond
Who should respond
Assess outcomes
Performance monitoring
Community indicators

22. What is meant by Performance Monitoring in Health Improvement?
Continuing and evolving process – measure along the way
Shared responsibility and accountability
Not outcomes (disease) alone:
using a limited number of indicators that can track critical processes AND outcomes over time and among accountable stakeholders;
collecting and analyzing data on those indicators;
making the results available to inform assessments of the effectiveness of an intervention AND the contributions of accountable entities.
Move toward “systems” approach.
Performance monitoring is a key component of the CHIP process and later models (i.e. MAPP).
Each stakeholder establishes performance measures as part of implementation. These are monitored and tracked. Stakeholders are held accountable for measures.
Increasing movement away from accountability by one agency/entity to a systems approach.

23. Mobilizing for Action through Planning and Partnerships (MAPP)
Developed by the National Organization of City and County Health Officials (NACCHO) and CDC
a community-wide strategic planning tool for improving public health,
an action oriented process to help communities prioritize public health issues, identify resources, take action

24. Three Keys to MAPP Strategic Thinking Community Driven Process
Focus on the Local Public Health System
MAPP is based on strategic planning concepts, requires creative, long-term strategic thinking.
It is a community driven process that relies on participation from a wide range of individuals, groups, and constituencies in the community. Since the community drives the process, the process has credibility, ensures buy-in and creates sustainability over time. It can also create greater advocacy for public health.
The third key to making MAPP successful is the use of a broad definition of the Local Public Health System. Recognizing that public health is provided by more than just the local health department promotes a shift from silos to systems.

25. Strategic Thinking Requires broad-scale information gathering
Encourages exploration of alternatives
Places emphasis on future implications of present decisions
Facilitates communication and participation
Accommodates divergent interests and values
MAPP is different from previous public health planning tools in that it introduces strategic thinking into public health planning efforts. Strategic thinking requires broad-scale information gathering
An exploration of alternatives
And an emphasis on the future implications of present decisions. 
It can facilitate communication and participation,
And accommodate divergent interests and values, and foster orderly decision-making and successful implementation.
For example, in traditional public health planning you may have just taken into consideration community perceptions and data – and then used that information to determine priority public health issues. But thinking strategically means looking at multiple sources of information - such as
local perceptions about health and the community,
public health data and trends,
information about how the public health system is operating and gaps in services, and
forces of change, such as the fact that new legislation is being implemented or state funding for public health has been decreasing or the kinds of things that may happen if certain solutions are implemented.
It also maxmizes input from individuals representing diverse organizations and perspectives.
This approach - looking at multiple sources of information, incorporating future implications of decisions, and using broad input, a stronger community health improvement plan emerges that has a better likelihood for success and sustainability.

26. Community Driven Process
Mobilizing and engaging the community
Action with and by the community
Planning driven by the community
Partnerships to strengthen the community
MAPP is a community driven process. MAPP serves as a tool for including diverse portions of the community and thereby maximizes the creative resources of the community. It expands ownership of the problems and solutions to a broad base of the community. Ths assists in making efforts sustainable, actions that are built on collective wisdom, and incorporates resources from throughout the community to contribute to health improvement.

27. Local Public Health System
The third component that makes MAPP unique. It is MAPP’s emphasis on system-wide involvement, and a broader definition of public health.
The local public health system includes all public, private and voluntary entities, as well as individuals and informal associations that contribute to public health services.
No single organization provides public health services in a community. MAPP recognizes the important contributions of all entities involved in the local public health system and provides a process for coming together and planning how to provide better public health.

28. MAPP Overview Phases Organize for Success and Partnership Development
Who should we include
Who is part of the public health system in our community?
Visioning
What will the public health system look like if it is substantially providing the Ten Essential Public Health Services
What will our community look like?
What will our community’s health look like?
What would we like to see?
What mission and values drive this process?
There are six phases in the MAPP process.
The first phase involved organizing and preparing to implement MAPP (Organize for Success and Partnership Development). This phase allows for planning it assure that there will be a process that builds commitment, engages participants, uses their time well, and results in a plan that can be implemented successfully.
The second phase is Visioning. This phase seeks to establish a shared vision and common values provide a framework for pursuing long-range community goals. During this phase, the community answers questions such as “What would we like our community to look like in 10 years?”

29. MAPP Overview (cont.) Four MAPP Assessments
Community Themes and Strengths
“What is important to our community?”
Local Public Health System
“How are the Essential Services being provided?”
Community Health Status
“How healthy is are our residents?”
Forces of Change
What is occurring or might occur that affects the health of our community or LPHS?”
Next, the four MAPP Assessments are conducted, providing critical insights into challenges and opportunities throughout the community
The Community Themes and Strengths Assessment provides a deep understanding of the issues residents feel are important by answering the questions, “What is important to our community” and “How is quality of life perceived in our community?” and “What assets do we have that can be used to improve community health?”
The Local Public Health System Assessment is a comprehensive assessment of all of the organizations and entities that contribute to the public’s health. This assessment answers the questions, “What are the activities, competencies, and capacities of our local public health system?” and “How are the Essential Services being Provided to our community?”
The Community Health Status Assessment identifies priority issues related to community health and quality of life. Questions answered during the phase include, “How healthy are our residents?” and “What does the health status of our community look like?”
The Forces of Change Assessment focuses on the identification of forces such as legislation, technology, and other issues that affect the context in which the community and its public health system operates. This answers the questions, “What is occurring or might occur that affects the health of our community or the local public health system?” and “What specific threats or opportunities are generated by these occurrences?”

30. MAPP Overview (cont.) Identify Strategic Issues
Focus on issues, not programs and services
Not limited to health outcomes
Formulate Goals and Strategies
Goals and objectives
Responsibilities and accountability
Action Cycle
Plan
Implement
Evaluate
Once a list of challenges and opportunities has been generated from each of the four assessments, the next step is to
Identify Strategic Issues. During this phase, participants identify linkages between the MAPP assessments to determine the most critical issues that must be addressed for the community to achieve its vision.
After issues have been identified, participants Formulate Goals and Strategies for addressing each issue.
The final phase is the Action Cycle during which participants plan, implement, and evaluate. These activities build upon one another in a continuous and interactive manner and ensure continued success.

31. MAPP Connects with National Frameworks and Initiatives
National Public Health Performance Standards (NPHPSP) – (“model standards”) is used within MAPP to assess the local public health system
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10 Essential Services framework ensures a comprehensive picture of public health
MAPP can help address Healthy People 2020 objectives
MAPP incorporates national models and standards of public health practice and community health improvement.
It incorporates the local instrument of the NPHPSP (National Public Health Performance Standards Program). This instrument examines the provision of the 10 Essential Public Health Services by the local public health system, by assessing the system’s performance of model practice standards.
Healthy People objectives aligns community improvement plans and actions with national health improvement targets. Using Healthy People objectives also assists with interpreting health status and prioritizing health problems.

32. Summary
Public Health community health improvement planning has evolved from program oriented process to system level processes.
Incorporates strategic planning principles
Broadened definition of health and determinants
Increasing emphasis on community input and shared responsibility for public health
Focus on evidence based planning – link to standards and measures

33. REFERENCES
THE PRECEDE/PROCEED MODEL. Retrieved 1/15/2010, 2010, from
PATCH: Its origin, basic Concepts/Links to health policy. Retrieved 1/15/2010, 2010, from
APEXPH:Assesment protocol for excellence in public health. Retrieved 1/18/2010, 2010, from
Mobilizing for action through planning and partnerships (MAPP) | NACCHO. Retrieved 1/18/2010, 2010, from