Why do some diabetes programs thrive while others never get off the ground? In this episode of Diabetes Care Conversations, Angela Forfia speaks with Dr. Linda Stanley about the Community Readiness Model and how organizations, teams, and communities move through stages of change. From “go slow, to go fast” to building sustainable programs beyond a single champion, this conversation offers practical insights for anyone working to advance diabetes prevention, care, and management.
Angela Forfia
Hello, and welcome to our ADCES podcast, Diabetes Care Conversations. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm Angela Forfia, Director of Prevention and Public Health Initiatives at the Association of Diabetes Care and Education Specialists. As part of my role at ADCES, I work on the Diabetes Match Initiative. Through this national public health initiative, I work with colleagues here at ADCES and at the Emory Centers for Training and Technical Assistance to understand how to support and sustain diabetes prevention, care, and management programs, and explore what makes diabetes programs stick in care teams, health and hospital systems, and communities.
Thanks to Mesh, I reconnected with our guest today, Dr. Linda Stanley. I first met Linda more than 15 years ago as I was working on creating healthier school environments for children and youth. Today, Linda will be talking about the community readiness model, how this work started, and how you can apply this to your own teams and organizations. Linda, welcome.
Linda Stanley
Thank you. Happy to be here.
Angela Forfia
So before we get into today's discussion, would you like to tell our audience a bit more about yourself?
Linda Stanley
Sure. I am a senior research scientist at the Tri-Ethnic Center for Prevention Research, which is kind of a mouthful. That is the center within the psychology department at Colorado State University. I've worn many hats here, but one of those hats has to do with community readiness. I've conducted many community readiness trainings nationally and internationally. I've managed over probably 200 community readiness assessments, and I have provided extensive technical assistance to those groups out there that are conducting their own assessments. a long history, probably more than 20 years history with community readiness.
Angela Forfia
Excellent. So you are here today to talk exactly about that, about the community readiness model. But for those who haven't heard about community readiness before, could you give us just a brief overview of what that is?
Linda Stanley
You bet. One of the things I find is that if you learn about the community readiness model, it starts pervading everything that you think about. You can see it in a readiness kind of way. So, sometimes talking to an audience of public health professionals and health professionals who work with people with pre-diabetes and diabetes, you probably all know about the stages of change model.
The individuals go through stages of change as they want to undertake behavioral changes. That might be quitting smoking, making changes to our feeding, getting more physically active. It would be nice if we could all just hit that switch and just make that change. But I'm sure we've all been through it. The process can be difficult at times to make that change. And that's really a key point. This is a process, not a single event.
We don't flip a switch from not doing something to doing something. With the community readiness model, it's really the same thing. But now we're talking about maybe teams of people, departments, organizations. And in my work, a lot of times, whole communities being ready to make a change. And how can they move through that process to make it easier?
Angela Forfia
So what would you say led to the development of this model of sort of taking what we've learned from working with individuals and applying it to groups or systems or communities?
Linda Stanley
I'd like to say that it just came to us at some point in time that we needed to use a community readiness model or that we needed to devise a community readiness model. But in fact, it came out of frustration and failures. Here at the center, we've done a lot of prevention work over time. many times, I'd like to say those were all successes, but many times those ended up in failures at a community level.
And so we've worked with prevention of alcohol use amongst youth. We've worked with prevention of HIV AIDS, prevention of sexual violence. We've gone into communities with a program and a program that has been evidence-based and thought, all we have to do is implement this program. But in fact, we would find that sometimes communities would do it and it would be great and it would last a long time. And sometimes the communities would not even get to the starting line really with that program. And the same can be said if people think about, our audience members think about people that they have worked with. You probably would have two individuals who look very similar and they have very similar medical histories. But one of them really gets into that program. They come back to the group, they take their medication, they use their glucose monitor, they make positive changes. And another person may simply not show up again. They may not make those changes. And they were at different stages of readiness to make those changes. So the same thing happens at an organizational level, at a community level. You may try to get a national diabetes prevention program lifestyle change program started. And in one health center, it'll work great. In another one, it may not even get off the ground. Why is that?
Usually, those organizations were at a different level of readiness. So people, when they've used the individual readiness model, they have come up with different strategies for people and how to, if you're in a different stage, you'll use a different strategy. Well, our director, Gene Edding, at this time started putting the pieces together and looked at the individual stages of change and some other community models and said, okay, how can we measure really where a community is in terms of their readiness to make a change? You know, we oftentimes get a vibe of where people are at. We know when somebody is going to make a change, we can see that enthusiasm, but we need to really measure that.
And that's where the Katratnik Center for Prevention Research came in. They came up with a community readiness model and a technique for measuring where a community may be at and then what can we do about that? How can we get that community to be more ready to make that change?
Angela Forfia
Yeah, that's one of the pieces of the community readiness model that really stayed with me. I think I can speak for every public health professional in our audience, every health professional in our audience by saying that, wow, we really developed that sort of vibe or intuition about people and places, about whether they're ready to change. But it's truly that connection, that recognition that these individual stages of change are very similar to the stages of change that organizations go through. So if I am remembering correctly from my latest motivational interviewing training, the individual stages of change are denial, contemplation, preparation, action, maintenance. Can you talk us through what that looks like when we move from the individual to the community?
Linda Stanley
Yeah, well, good memories there. They look a lot similar. One of the main differences is that we have more stages of readiness under the community readiness model. And that's simply because communities, they're more complex. There's many more individuals and different motivations within those individuals. So when we talk about the nine levels of readiness with our community readiness model, we oftentimes focus on those lower levels of readiness because that's where you see a lot of organizations and communities when you're going in to implement a program. If the programs are already there and they're working great, those are the communities or organizations that are at those higher levels of readiness that we typically don't, for at least in my work, need to do a whole lot about. They're doing a great job. But oftentimes what I have found is that communities are in those first four levels, the ones that I'm working with, where level one is really no awareness, and some individuals may not be aware that this is an issue. And so if we look at diabetes care, you may find some communities who really don't think that this is an issue in their community or that it's something that they should be dealing with.
You had mentioned denial as one of the stages with individual level of readiness. And that's true here. Denial is a stage and really level two is what we call denial, but level one and level two are very much related to one another. With denial, it may be that doesn't affect our community or there may be a resistance to trying to do anything. At level three, this is where you can see a community that has some vague awareness. And that's what it's called, vague awareness. People know there's a problem. They don't have a plan, they don't know where to start, they just know, hmm, this is going on in our community, maybe we should do something about it. So it may be an organization that says, yeah, this is going on within a specific community, where do we start? What do we do? They may not know that if you're talking about an individual person in the vague awareness stage, they may not know that a local hospital has the DSMES services or how they get referred to them. So at level four, we're at a pre-planning stage. And this is where we find a lot of our communities, organizations, and teams. We know that we have to do something. We know that this is an issue in our community. We are just now getting to a point of trying to figure out what that is but we're not focused yet, we're not really detailed in what our plans are going to be. This is probably where we put together a team to do something, to put together the plan that we will ultimately implement in our community. So I'm sure that everyone who's listening today can think of something in their team, organization, or community at each of these levels. If we're talking about diabetes as an issue, some people may think, what's something that is between a medical doctor and a patient, and it's not necessarily the concern of the community. So even though they see that it's an individual problem, they don't see it as something that, well, the community can't do anything about that. They may be at a very low level of readiness, and you may see a lot of people within that organization thinking the same thing. In that case, you're going to have to do some work, right? You're going to have to bring the level of readiness up so that you can start doing some community level programs. If you were to try to start those community level programs, you're really going to get a lot of resistance to that because at this point in time, it's not the community's problem. But slowly, as we'll talk about, I'm sure, a little bit later on in this podcast, we need to take some steps to raise that readiness level so that we can do that community work.
Angela Forfia
Yeah, I can really relate to that. Sometimes when we talk about that, like lack of awareness or denial, it's not necessarily that a health or hospital system or a community is denying that diabetes exists, but they're just, they don't see themselves as having an important role or they put that at a lower priority than other things that they should be doing. But the result is the same. Is there not ready for you to drop in a diabetes self-management education or support program or a national diabetes prevention program into that environment because they haven't seen their role in doing that and they haven't made this work a priority within their system. Would you say that's kind of fair to say?
Linda Stanley
I that's a great point. So we talk about that in terms of readiness. They're not at that readiness level and it doesn't mean that they can't be brought up to a readiness level, especially when you have such wonderful programs that are evidence-based that can do such a great job in a community.
Angela Forfia
Yeah, I'm having flashbacks to my career in public health, to a lot of the places I've worked, as well as a lot of like schools and community-based organizations and health centers, federally qualified health centers, other organizations that I've worked with as partners, where it seemed like there was just one passionate person who was making something happen.
And here at ADCES, it might be that one passionate diabetes care and education specialist. In our public health work, it might be that one passionate person that's trying to get a program started within their community. But as soon as that person moved on to another job or retired or left for some other reason, the entire program would fall apart.
And it was so discouraging to have such a champion for these programs, but have it not be able to be sustained over time.
Linda Stanley
Yeah, my goodness, yes. I am sure you are describing the reality of many, many programs out there that are community-based. We take a three-dimensional view of community readiness where we want to speak to many different people that are involved or that know about this issue in order to try to figure out where they are on that readiness scale what readiness level are they at? If I only speak to that one passionate person, it might seem like they are at a high level of readiness, everybody's ready to go, and this has already been done, we're doing it. But if then if I talk to somebody in a different department or in a different role, I may get a completely different story. When we conduct a community readiness assessment, we do in-depth interviews with a variety of people.
So we might do them with a hospital CFO or CMO, an endocrinologist, a primary chair provider, a director of population health, a social worker, a community health worker, people that are living with diabetes and other members of the GSMS team. This gives us a simply much broader view. It does not rely upon that one individual person. And through all of these conversations, we get a sense about the community climate, the attitude of leadership, the community knowledge, what's going on out there right now, where are the resources being allocated. So we have these different dimensions of community readiness and what we're trying to get is a picture from the entire community really of these different dimensions and where they may be at.
It allows us to score. We actually come up with a number. We score a community or we score an organization or a team at a specific level of readiness. And then we can work from there to see where do we go. It gives us a place where everybody can be on the same page at what do we need to do from here in order to make sure that we can have a successful implementation of our program.
Angela Forfia
So it sounds in a way very similar to what we might do with an individual of having like a person centered approach to care that instead of just having a vibe about that person, you're maybe doing a readiness assessment of that individual. You are seeing if they have social determinants of health needs, you might be thinking about their family context or their social context. So it's a three dimensional view of that person, not just from the first conversation that you have. But it sounds like with a community, that's pretty intense to do all of those interviews, to be talking to the CFO and to be talking to a community health worker. Is it as intense as it sounds to me right now or should we be nervous about doing such an intense assessment?
Linda Stanley
That is a very good point. I have to say that when I'm doing trainings, like the first two hours, everybody is really into it and, my gosh, this makes so much sense. And this answers a lot of the things that I've seen. And then you start getting into the methodology and people become maybe a little more nervous or it looks like it's quite an intense process. And it can be, we try to interview say 10 people.
And not every project can take the time to interview those people and to code the interviews and to score all of the interviews and to really take a deep dive into community readiness. Sometimes it's worth it to do that entire process because you have a very large initiative. Maybe you're planning for a million dollar grant or you have a really large hospital initiative. I recommend going slow to go fast. Take your time to do this, you will get so much good information out of it that then you can build a foundation on which you will be successful in the end. But if you're not doing, you know, a million dollar project and you have limited resources, we do have a brief assessment. You could conduct it with a focus group. And again, we have questions that you can ask those focus group members and you will get some really great information on how to begin making sure that your community is ready to hear what you have to say. So whether you do an intensive assessment or a brief assessment, the important thing is what you do with the information. How do you use that information? What can we do differently? What do we do next? What now?
Angela Forfia
This is a great segue because at heart I am a program person. I'm like, you may not be able to see this if you are a podcast listener, but I'm like rolling up my sleeves. I'm ready to get to work. And so I want to know what do I do with this information? If I get a sense and I've scored how ready my team is or my organization is or my community is, what do I do then?
Linda Stanley
Well, I get you. I'm being a program person and you just want to get in there and you want to start this program. But by knowing your organization or your community's level of readiness, you could tailor your approach and you really need to tailor your approach. And this has been one thing that's difficult for me because I am a person that I just want to jump right in. And let's just go with this program.
But again, remember that we may have to go slow at the beginning. So for organizations with low levels of readiness, especially in that one and two level, we need to focus on relationship building and on impactful education. education that's easy for people to take in and that they want to hear where they want to hear things. So personal stories, visuals, and then you can throw in some facts about diabetes.
You need to build those relationships one-on-one, many times with community leaders. When you get out into the community, and you need to talk to and listen to the smaller groups, maybe interest groups that don't have their focus is not diabetes, their focus may be, my mom goes to a yap and knit group. So maybe it's the yap and knit group that you go to. And you do it in such a way that you're not really pressing this.
You're not trying to just get out your accent figures. You can put information in things like church bulletins, at school newspapers, social media groups. You could take your show on the road internally by presenting to your own community wellness team, the healthcare professionals and others. And again, what you say will depend upon your audience. And that's one thing that communications and marketing people have always taught us. It's your audience that will tell you what you're able to do and how much you should get into the nitty-gritty. And at these stages, these lower levels of readiness, make sure that you're making this really interesting to folks. And you can host your own event, but keep it fun. Make sure you're giving people something that they value. Give them a good meal. And then maybe they'll take the chance to listen to you, but not for an hour, maybe for five minutes, maybe just very briefly, or have somebody tell a story, their own personal story.
Angela Forfia
Yeah, I love that food always helps. If the grant you have received allows you to purchase food, that's such a great way to draw people in and sharing food together or having some food to take home. I remember we did a community diabetes education event where we got $55 rotisserie chickens and everyone who came out to our little learning event got to go home with a chicken and got to go home with some recipes for healthy eating with diabetes. And sometimes I would do events at a health center and we would have $5 gift cards as prizes for the doctors or PAs or nurse practitioners who answered trivia questions or who referred the highest percentage of their patients to our program you know, something to know about doctors, they're pretty competitive. And so they would just march up to the front of the room and so happy to get a $5 Starbucks card. But from my perspective, it was getting the results that I needed and having people referred to my program or having people come out and learning about diabetes so I could recruit them into a diabetes prevention program or a diabetes self-management program. So fun is really the name of the game was some of these early interventions that you do in the community. Yeah
Linda Stanley
Exactly. I love those examples. I just think those are great. And the thing is, people will remember those. As we move into those higher levels of readiness, though, you know, we can start offering some more information, but we want to keep that energy. We want to continue doing all of the things we were doing. But now maybe we will find some champions for ideas who know how to talk to those key audiences and to influence them we maybe will sponsor a community picnic that before nobody would show up to because they didn't know who we were unless we had really great food. And if you're out of fun ideas, get together a focus group to think about some new ways to approach the issue, especially if you feel stuck. You may not want to have that community meeting. I know I've ran across a lot of folks out there in communities when I'm doing a training that we'll talk about sponsoring a community meeting or even it's something, a two day conference about something. my goodness, how many people showed up? Those that were passionate, two or three or four or five maybe, but not very many. So just always be thinking about who are my audience members? Do they really want to hear this? What do they want to hear? And how can I make it worth their while to hear it?
Angela Forfia
Yeah, that's such a great question. I had that on a survey that I did of if you had a community meeting about X, whatever topic that was, how many people would show up? And one of the responses was just me. Fewer than five people, you know, and if you are answering just me or fewer than five people, that's an indicator that you have some work to do before you do that community meeting. Community meeting is a great idea, but you have to build up the energy and readiness to get there.
Linda Stanley
When you get into those higher levels of readiness, maybe after a level up to a level five where you're really planning and starting to implement those actions, then you start building on that energy. And that's where it's like a snowball that picks up speed, where it becomes much easier to do things because you do have more people involved and you begin to get more resources and more ideas and just more energy. It is that those beginning stages where just remember that it will all pay off in the end. If go slow to go fast, it will pay off.
Angela Forfia
Well, this has been so great. I feel like we've covered a lot of ground. Do you have any final thoughts or final takeaways that we can take out of this conversation and put into practice in our own lives?
Linda Stanley
You know, I think I'm going to sound like a broken record here, but I think it bears repeating. I'm speaking to a lot of people here. I'm sure they're passionate about what they do. And I am the same way. So sometimes I jump right in and try to make something happen before I really understand whether or not the person that I'm working with or the team or community is actually ready for me and for what I'm trying to do. So by using this model, even if you just use a short assessment, the brief assessment, you can make sure you're using your knowledge and your passion to truly meet people where they are and to meet whole systems where they're at. And then to get the outcomes you want to see in your organization and community. It may take you a little bit longer. And I know that can be a problem when we have grants that say, you have to have this done within one year or two years, but if we don't do it, we always know we won't succeed. If we do do this, then at least we have a much better chance of succeeding in the end.
Angela Forfia
Yeah, it's almost like channeling that jump right in energy into doing something that will lay the foundation for that energy to actually get the impact that you want to achieve. I need to sometimes talk to myself about that. Like, have to make sure people are ready for me before I just come storming in to have this conversation or try to make this intervention happen.
Linda Stanley
I love the words that you used late the foundation. That's actually what this is.
Angela Forfia
I am certainly inspired and I have been inspired for more than 15 years by this work and by the community readiness model. And I love the idea of meeting our teams, our organizations, our systems, where they are in the same way that we meet individual people who are living with prediabetes and diabetes where they are. So thank you again, Linda, for this great conversation. I hope that our listeners are able to take those takeaways with them and put them in place in their own work. Today or sometime soon.
Linda Stanley
Thank you so much.
Angela Forfia
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