• By Louise Morpeth
  • Posted on Thursday 03rd December, 2009

But what if communities really struggle to care?

It is the end of the training. The folks from Communities that Care have skilfully compressed their nine-day training into two. The team from the Casey Foundation and I have a solid grasp of the what and the how of the CtC system, and tomorrow we’ll see what it looks like when the rubber hits road.Thanks to the quality of the written products, it’s pretty easy to learn about the system. All the materials – and there are lots of them – are freely available on the web (see http://ncadi.samhsa.gov/features/ctc/resources.aspx). So what do you get from the training session that you can’t get from reading?The obvious difference is that you get to ask questions. When doesn’t CtC work? What is the maximum and minimum size of a CtC community? How do you make it sustainable? What do you do for out-of-school youth? What next for CtC? and so on. A more important difference is the opportunity to experience the process and hear about it first hand from people in the community. Dalene Dutton, the CtC coordinator from Five Town Communities that Care in Maine told us how she got involved.“I was a High School teacher and was getting really concerned about the things that our young people were getting into – like early sex, drugs and drinking. Then in one year we lost five of our students and all the deaths were preventable. Our school was asked what we were going to do about it. We were being held partly responsible. I found it difficult to cope with what had happened and took a year out. It was then that I saw the advert for a CtC co-ordinator. As a science teacher, I was drawn to the scientific approach.”Dalene’s community has proved to be an exemplar of CtC. As she said, “I’ve seen it work – we have achieved things in five years that we didn’t think were possible”. Our conversations helped me realise the importance of the CtC co-ordinator and what an unusual mix of skills and traits they need. She understands prevention science, she values data, as a former teacher she has credibility and understands the politics of children’s services agencies. She is a great communicator and has an infectious enthusiasm for improving the lives of young people. I wondered how important it was to find a ‘Dalene’ and how much of the success of projects can be explained by the quality of the co-ordinator.All that said, Dalene’s community is small – 13,000 people - and not particularly poor. There is resource within the community in terms of peoples’ skills and time that can be harnessed by the project. Would these skills exist where the need is greater? None of the exemplar CtC sites combined diversity, poverty and an urban setting. Would it be possible to replicate the effects in this context?The public health approach, upon which, CtC is built, requires the definition of the problem, the identification of risk and protection, selection of interventions, and implementation and evaluation. Kevin Haggerty (Assistant Director at Social Development Research Group – the Seattle developers of CtC) bemoaned the fact that when asked about the risk factors for heart disease we can all reel off lack of exercise, poor diet, stress, genetic vulnerability and family history, but the same level of understanding of the risks for problematic behaviour have not seeped into general knowledge in the same way. CtC provides a list of factors proven to be risks for problematic behaviour and a way of measuring their prevalence. This way a community can focus their efforts on a small number of risks. They are pushed to express these as targets, for example “we will increase levels of commitment to school by 10% over 4 years”. They can then hold themselves to account by measuring their progress against the target.Left to their own devices, or simply with the CtC manual, it is unlikely that a community would successfully get through all these steps let alone go on to implement programmes with fidelity. Technical assistance appears to be a critical component. To achieve fidelity to the CtC model, technical assistance (training and coaching) is probably essential.Work in Pennsylvania, where CtC is more widely used and there is limited availability of technical assistance, suggests, despite wide variation in its use community level, that change in attainment and delinquency is apparent. So, technical assistance is probably necessary but a relatively small dose is sufficient.As part of the training we got to experience what it is like to take a number of risk factors and find appropriate evidence based programmes. We used the CtC Prevention Strategies Guide, a cleverly designed book comprising 56 programmes. Participants on the training repeatedly commented how the printed materials, particularly the worksheets, helped to make what looks like a complex process manageable. The tools that got the most oohs and aahs were surprisingly simple. The ‘Coordinating Resources Worksheet’ is a good example. It is a one-page sheet with a 5 x 8 table. It lists down one column the things that are needed to implement a programme: staff, supplies, equipment, administration, technical assistance and transport. Across the top it lists: description, costs, agency that will provide and gaps. Completing the table forces an analysis of what is available and what is needed. In response to my question about when CtC didn’t seem to work, Kevin Haggerty explained that the manuals, resources and worksheets were in effect the lessons learnt over 30 years of developing the method. So, in response to concerns about sustainability, a worksheet was prepared to analyse political willingness to share or re-direct resources. This helped communities shift from thinking that the only way of getting funding was by bringing in new money to considering the redeployment of existing funds.It would seem from our discussions over two days that there is potential for further developments, particularly in understanding how CtC has and can bring about system change, and how federal and state dollars may be more easily identified for evidence-based programmes.It will be particularly interesting to see if and how CtC can work in more challenging settings and with larger populations.

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