1. Community Capacity Inventory 1
• Gifts of the head: (things I know something about and would enjoy
talking about or teaching other about, e.g., birds, local history,
music).
• Gifts of the hands (things I know how to do and enjoy doing, e.g.,
carpentry, sports, planting, cooking, – be specific).
• Gifts of the heart (things I care deeply about, e.g., children, older
people, community history, environment).
Adapted from World Learning, 1989

2. CORE Group Spring Meeting
May, 2012
Strengthening and Measuring Community
Capacity for Sustained Health Impact
Gail Snetro-Plewman, Save the Children
gsnetro@savechildren.org

3. Background
Contributors:
David Marsh, MD, Senior Child Survival Advisor, Save the Children
Carol Underwood, PhD, Johns Hopkins University, Center for
Communication Programs (CCP)
Mark Boulay, PhD, Johns Hopkins University, CCP

4. Definitions of Community Capacity
• “the characteristics of communities that affect their ability to
identify, mobilize, and address social and public health
problems (Goodman, et.al, 1998; Poole, 1997)
• “the set of assets or strengths that residents individually and
collectively bring to the cause of improving the quality of life:
(Easterling, Gallagher, Drisko, & Johnson, 1998.)
• “the ability of people and communities to do the work needed
in order to address the determinants of health for those
people in that place” (Bopp, GermAnn, et.al, 2000)

5. Why measure community capacity?
• We predict that increased capacity helps improve health &
social change outcomes.
• We predict that this capacity will help sustain positive health &
social change outcomes in the future.
• We know that SC projects increase community capacity (CC)
through its community mobilization (and other) approaches -
but how much?

6. Why measure community capacity?
• SC devotes a lot of effort to strengthening CC.
• SC thinks we are good at strengthening CC.
• But we cannot prove it because we lack systematic
way to measure CC.
• Yet, it seems reasonable that strengthened CC:
– Helps increase the use of interventions.
– Sustains this use.
– Promotes “development” more broadly.

7. State of the Art -
Measuring Community Capacity
• Limited research undertaken globally to date testing impact of
capacity building on social change outcomes – but field is
growing.*
• No agreed upon theoretical framework from social scientists.
• Few indicators from literature have ever been tested for
validity and reliability.
• Myriad, unsystematic, project-specific indicators from
programmers.
• ‘Who’ should develop & measure? institutional vs.
community?
*Sources: “What is the evidence on effectiveness of empowerment to improve health.”, Feb. 2006, WHO/HENS; Johns Hopkins, Communication for Social
Change, World Bank

8. Community-capacity interventions
as a means and as an end
SOCIAL CHANGE
Participation
Social capital
COMMUNITY Social cohesion
CONTEXT Empowerment
Collective Efficacy
- Material
resources
- Social COMMUNITY Health
resources CAPACITY Status
- Disease
burden
- Experience HEALTH
- etc. COMPETENCE
Consistent &
appropriate health
behavior
Community capacity designed to improve health
behavior and health status via social change

9. SC/US Generic Results Framework
GOAL: Status Improved
SO: Use of Key Practices and
Services Improved
IR 1 IR 2 IR 3 IR 4
Access and Quality Knowledge and Social and
Availability of Key of Key Acceptance of Key Policy
Services and Services Practices and Environment
Supplies Increased Services Enabled
Increased Increased

10. SC/US Generic Results Framework
GOAL: Status Improved
SO: Use of Key Practices and
Services Improved
IR 1 IR 2 IR 3 IR 4
Access and Quality Knowledge and Social and
Availability of Key of Key Acceptance of Key Policy
Services and Services Practices and Environment
Supplies Increased Services Enabled
Increased Increased

11. CM Terminology
Sustained Behavior Change
Community Sustained Social Change,
Mobilization Including Enhanced Community
Capacity
Sustained Societal Change

12. SC Community Action Cycle and
“Rock-Hop” JHU
Integrated Model of Communication for Social Change
Catalyst
Internal Change Mass
Agent Innovation Policies Technology Media
Stimulus
Explore &
Prioritize Community Dialogue
Recognition of Identification and Clarification Expression of Vision
a Problem Involvement of of Individual of
Leaders and Perceptions and Shared the Future
Stakeholders Interests
Conflict-Dissatisfaction
Disagreement
Prepare
Organize Plan Action Plan
Consensus Options for Setting Assessment of
to on Action Action Objectives Current Status
Mobilize
Collectiv e Action
m
C
V
p
n
o
e
u
a
v
r
I
t
f
Assignment of
i
l
Mobilization of
C
S
E
Participator
y
p
u
d
o
a
n
e
s
x
Responsibilities Organizations Implementation Outcomes
r
t
i
l
Evaluation
• Individuals
• Existing Community • Outcomes vs.
• Media
Groups Objectives
• Health
• New Community • Education
Task Forces • Religious
Prepare Evaluate Act • Others • Other
for Scale
Indiv idual Change Social Change
• Ski ll s • Leadership
• Ideation • Degree and Equity of Participation
Knowledge, Attitudes, Perceived • Information Equity
Risk, Subjective Norms, Self -Image, • Collective Self-Efficacy
Emotion, Self -Efficacy, Social • Sense of Ownership
Influence, and Personal Advocacy • Social Cohesion
• Intention • Social Norms
• Behavior
SOCIETAL IMPACT
Figueroa and Kincaid, 6/2001

13. Community Action Cycle
• Implemented by the community
• Fosters equity through participation of those
most interested and affected by health issue
• Instills ownership and works towards
sustainability
• Iterative – not linear
• Builds community capacity for managing
health and development

14. Measuring Community Capacity –
Efforts to Date
• Measuring Community Capacity - Partners Learning Forum: Lusaka,
Aug ‘06 - HCP– learning, change, planning
• Literature Review of measuring community capacity research efforts
to date
• Meta-Analysis of CC domains and indicators to validate
• Hypothesis-testing research testing the effect of CC on
achieving health outcomes in Uganda, Zambia, Vietnam, Nicaragua
• Quantitative and Qualitative measurement tools

15. Literature Review: 30 C x 210 R matrix
Domains of Community Capacity by Researcher*
*L=Laverack; W =World Bank; H=Hastings (proxy of Bopp); G =Goodman; F=Figueroa; R=Rifkin; C =Chaskin; B=Bopp;
E =Easterling; S1= Study 1; S 2=Study 2; S3= Study 3; S4=Study 4; S5=Study 5; S6=Study6; S7=Study 7; S8=Study8;
S9=Study 9; S10=Study10; S11=Study11; T12= Tool12; T13=Tool 13; T14=Tool 14; T15= Tool 15; S16= Study 16; T17=
Tool 17; T18= Tool 18
Researcher
# Domain Sub-Domain
L W H G F R C B E S1 S2 S3 S4 S5 S6 S7 S8 S
1 Participation small groups, larger organizations X
2 Participation strong participant base X
3 Participation diverse network to enable different interests to act X X
4 Participation benefits over-ride costs of participation X X
5 Participation citizen involvement in defining and resolving needs X X X
6 Participation Citizen participation and control
7 Participation Environement
8 Participation Attracting and keeping volunteers
9 Participation broad, representative range of community X
10 Participation engage diverse members of community in process of consultation,
collective analysis & decision-making X
11 Participation, degree & equity of access to participation X
12 Participation, degree & equity of extent and level of participation X
13 Culture of Openness & Learning openess between indiv; comfort to listen & speak X
14 Sense of ownership importance of issue or program to participants X
15 Sense of ownership sense of responsibility for program X
16 Sense of ownership contribution to the program X
17 Sense of ownership benefit from program X
18 Sense of ownership sense of ownership of "credit/blame" for outcome X X
19 Sense of ownership personal identification with program X
20 Leadership organizes groups X
21 Organizational level context Commitment to community Organizational culture and climate X
22 Organizational level context Organizational structure, procedures and authority X
23 Organizational level context Organizational effectiveness and/or sustainability X

16. Long story short
 CC Outcomes:10 domains with 54 sub-domains

17. Long story short
 CC Outcomes:10 domains with 54 sub-domains
1. Community history
2. Networks
3. Participation
4. Leadership
5. Social cohesion
6. Ownership
7. Collective efficacy
8. Resource mobilization
9. Information equity
10. Critical thinking

18. Long story short
 CC Outcomes:10 domains with 54 sub-domains
1. Community history
2. Networks
1. Extent 3. Participation
2. Equity and diversity 4. Leadership
3. Flexibility 5. Social cohesion
4. Skills to maintain dialogue 6. Ownership
5. Vision and innovation 7. Collective efficacy
6. Trustworthiness 8. Resource mobilization
7. Exercise of power 9. Information equity
10. Critical thinking

19. # (%) groups effectively*
formed around
Suggested SC Community Capacity health/development issue.
*60/40 rule to include
Indicators – “Quantitative” marginalized populations,
including women; clear
roles/responsibilities of
Explore &
members; rotating leadership…
Prioritize
# (%) community members
exploring the
health/development issue and
setting priorities
Prepare
Organize Plan # (%) written community
to action plans in place
Mobilize
# (%) communities completing
70% of action plan on time
Prepare Evaluate Act
for Scale
# (%) communities using data
for decision through
community bulletin boards, or
health records

20. Who should measure what?
Community or externally measured indicators?
“Top-down”
vs.
“Bottom-up”

21. Measuring Community Capacity
in Zambia - Context
• Strengthening Community Capacity and Engendering Behaviour Change - Health
Communication Partnership (HCP) -Zambia
• Project Goal: To use strategic communication approaches at scale to support households
and communities to take positive health action.
• 5 Year – 2004-2009, $31 million Cooperative Agreement with Johns Hopkins University –
Save the Children Lead in Zambia - In’tl HIV/AIDS Alliance – sub.
• HCP focused on hard to reach districts; low health progress; inactive Neighbourhood
Health Committees, weak community capacity
 Community systems strengthened to focus on health priorities they identified through
community-level dialogue, and application of Community Action Cycle as a mobilizing tool
for collective action
 Interventions integrated across health areas (Malaria, RH,
Child health, HIV and AIDS, Maternal Health)

22. CM at Scale - Context
Continued…
Total Population Covered: 2,848,520
• 22 Districts out of 71 country-wide (presence in all 9
provinces)
• 22 District Level Health Center Partners
• 1800 Community Core Groups’ -Neighborhood Health
Committees (NHCs)
• Application of the Community Action Cycle
• 1341 with Community Action Plans
• 1063 communities completed at least one activity from
their action plan
• 65 Safe Motherhood Action
Groups formed as part of NHC’s.

23. HCP Program Framework ( 2005 – 2009)
HCP Enabling Intermediate Health
Interventions
Behaviour
Environment Effects
• Mobilising and • Increased community • Increased knowledge Illustrative:
empowering • Reduced high risk • FP use
capacity
individuals/families Social cohesion behaviours • Birth planning
communities Collective efficacy • Increased individual • Delivery at a health
• Engaging leaders Conflict management /collective efficacy for facility
• Empowering youth Leadership health action • Exclusive breast-
• Harmonising health Effective leadership • More equitable feeding
messages Individual efficacy gender and social • ITN use
• Increased exposure to norms • HIV protective
health messages behaviours
Drama
TV/video
Print materials

24. Endline Evaluation assessed:
• The effect of the project activities to foster
improvements in the community capacities required
for social dialogue and action
• Increases in individuals’ knowledge, attitudes, and
behaviors
• Associations between program exposure & knowledge,
attitudes, and behaviors
• The reach of program messages through community-
based and mass-media channels

25. Survey Design Con’t
Phase I - Measuring Community Capacity Study
• Qualitative approach for community-generated domains and
sub-domains
• Most Significant Change technique*
Phase II – Measuring Community Capacity Study
• Survey to test and validate indicators
• Principal Components Analysis (PCA) & Cronback’s alpha (a)
tests used to develop and assess the scales to measure
community capacity domains (validate indicators)
Phase III – Quantitative Population Based Endline Evaluation
Significant Change Technique, Dart and Davies, 2003

26. Description of Community Capacity
Domains and Indicators for Endline:
(1) Social Cohesion - Description of Domain:
Seeks to measure the extent to which target
communities were able to work together towards
a perceived common good.
Indicators:
• Repay debts to others
• Did not help each other in times of need
(reversed)
• Did not trust one another (reversed)
• Strong relationships
• Able to discuss problems

27. Domains and Indicators…
(2) Collective Efficacy- Description of Domain
Seeks to measure the extent to which target groups
shared belief in its conjoint capabilities to attain their
goals and accomplish desired task. It involves the
“belief or perception that an effective collective
action is possible to address a social or public health
problem”.
Indicators:
• Work hard to accomplish a project
• Confidence in community problem solving
• Committed to the same collective goals
• Solutions to problems

28. Domains and Indicators…
(3) Conflict Management – Description of Domain
Seeks to measure the extent to which target communities
were able to handle conflicts in a way that was fair and
allowed for continued participation of its members
towards positive health action
Indicators:
• Quick resolution to conflict
• Trouble dealing with conflict (reversed)
• Feuding for a long time (reversed)
• Getting involved to resolve issue

29. Domains and Indicators…
(4) Leadership – Description of Domain
Seeks to measure the extent to which target
communities had leaders with the capacity to engage
the diversity of sectors and levels within community
life in processes of learning and action for health.
Indicators:
• Women leaders
• Leaders treat people equally
• Leaders listen
• Leaders lead by example
• Leaders are good at resolving disagreements

30. Domains and Indicators….
(5) Effective Leadership – Description of Domain
Seeks to measure the extent to which the community has
the capacity to engage the diversity of sectors and
levels within community life in processes of learning and
action for health.
Indicators:
• Participation in meetings
• Setting goals & objectives
• Developing a plan
• Assigning tasks fairly
• Obtain money from outside

31. Domains and Indicators…
(6) Participation – Definition of Domain
Seeks to measure the extent to which target
communities can engage its own diverse
membership in constructive processes of
consultation, collective analysis and decision
making.
Indicators:
• Skills and knowledge
• Confidence to solve it
• I can participate

33. % reporting that community worked together in past year
to solve a health problem - by number of capacities

34. Percentage of NHCs reporting having 50% or more female
members by intevention and comparison districts (N=89)
80
73
70
60
54
50
Percentage
40
30
20
10
0
Intervention District Comparison District

35. Percentage of females in NHC leadership
positions by intervention and comparison
districts
50
43 42
40
Percentage
30
Intervention District
20 18 17Comparison Districts
11
10 4
0
Chairperson V.Chaireperson Secretary
Key Positions

36. Table 4: Adjusted odds ratios from logistic regression models predicting selected health behaviors
Adjusted Odds Ratios
Current use of a Received HIV test in Youngest child under 5
contraceptive past year and know years slept under a bed
method 1
results1 net the past night2
Community worked to address health
problem in past year 1.00 1.00 1.00
No 2.14*** 1.76*** 1.54***
Yes
Capacity Score
First quintile (lowest) 1.00 1.00 1.00
Second quintile 1.17 1.17 2.49***
Third quintile 0.95 1.06 2.58***
Fourth quintile 1.31* 1.17 2.35***
Fifth quintile (highest) 1.09 1.26 2.21***
Community Type
Comparison 1.00 1.00 1.00
Non-intensive 0.97 0.87 0.93
Intensive activity 1.05 0.92 1.07
Gender
Female 1.00 1.00
Male 1.08 0.46***
Age
15-24 1.00 1.00 1.00
25-34 1.39*** 1.20* 1.71***
35 and over 1.38*** 0.99 2.05***
Education
Primary or less 1.00 1.00 1.00
Secondary or more 1.16 1.31*** 0.96
Use media weekly
No 1.00 1.00 1.00
Yes 1.42*** 1.27** 1.39*
Type of residence
Rural 1.00 1.00 1.00
Urban 1.09 1.18* 1.05
Province
Central 1.00 1.00

37. Results!
 Community Capacity was measured through six domains:
- Participation
- Collective Efficacy
- Conflict Management
- Leadership
- Effective Leadership
- Social Cohesion
 Significant change in 6 domains of community capacity found in all intervention
districts compared to comparison districts
 Respondents living in an HCP Intervention District scored higher on more capacity
scales than respondents in Comparison Districts.
 Community capacity score was directly related to the community-led collective
action.
 Respondents living in communities with a greater level of community capacity were
more likely to indicate that their community had worked together in the past year
to solve a problem.
 Communities that ‘worked together’ were:
- 2 x use a modern contraceptive method
- 1.8 times more likely to have received a HIV test and know results
- 1.5 x more likely to have their youngest child sleep under a ITN

38. Results Con’t
• Overall 30% of community action was mediated by increases in
community capacity (controlling for age; ed; media use. – Baron
and Kenny, 1986).
• Increases in community capacity mediated the effect on health
behaviors:
- 63% of contraceptive use was mediated by community action
- 11% of bed net use among young children was mediated by
community action
- No direct or indirect effect on HIV testing

39. Conclusions:
 Community-generated capacity indicators were identified, validated and
used to measure improved capacity
 First time community capacity index validated and applied to a
population based endline survey
 Significant changes in community capacity measured in intervention
areas over comparison areas
 Changes in community capacity directly attributed to increased
community collective action for health
 Greater community capacity was significantly related to an increase in
specific health outcomes!
 Strengthening community capacity, in this instance, was both a means
to an end – improved health behaviors and reported collective action
for health – and an end-in-itself, both of which are vital to social
development.

40. Still work to be done!
• Test these measures in other settings
• Simplify measurement tools and approaches
• Standardizing the integration of measuring
community capacity into practice
Please join us in the challenge!

41. Thank you!

42. Web & Other Recent CM
References
• How to Mobilize Communities for Health and Social Change
– http://www.hcpartnership.org/Publications/Field_Guides/Mobilize/htmlDocs/cac.ht
• “Rock Hop”
– http://www.comminit.com/strategicthinking/stcfscindicators/sld-1500.html
• Effects of a participatory interventions with women’s groups on birth
outcomes (India), Lancet, April 3, 2010, T. Tripathy, et. al.
• Community Participation: Lessons Learned for Maternal and Child
Health, M. Rosato, G. Laverack, L Howard-Grabman, et.al, Lancet,
2008: 372: 962-71
• An Evaluation of the Community Action Cycle, T.Kabore, HIV/AIDS
Care and Support Program, Ethiopia, May, 2009.

43. More References:
• Measuring Community Capacity for Better Health and Social Outcomes -
paper by Save the Children. Detailed overview of initiative to measure
community capacity in Uganda, Nicaragua, Vietnam and Zambia.
• Zambia Phase 1 PR Discussion Outline - qualitative tool to elicit
community generated capacity indicators, Save the Children/HCP
• HCP/ZambiaEndlineSurvey - WomenQuestionnaire - quantitative endline
household instrument. Section 1 A: Perception of Community includes
the community generated indicators that had been validated, Save the
Children/HCP
• Community Observation Checklist – to validate CC findings, Save the
Children/HCP

44. •What experience has your organization on measuring CC?
•What tools/materials do you use?
What do you think?
•Would you be interested in further measuring CC? If yes, what support/materials/tool would be helpful?
1. What experience does your organization have
on strengthening CC?
2. What tools/materials do you use?
3. What experience has your organization on
measuring CC?
4. What tools/materials do you use?
5. Would you be interested in further measuring
CC?
6. If yes, what support/materials/tool would be
helpful?

45. Endline Survey Design
– Baseline (2005); Endline (2009)
– Sample Size: Baseline (3,000); Endline (4,000)
– Endline fielded in 21 intervention districts (Kalabo
dropped) 13 comparison districts
– External evaluation conducted by DCDM (Baseline); Glow
Consultancy (Endline)
– Probability Sample
– One male & female respondent from each sample
household; over 80% sample coverage rate
– Stratified into intervention and comparison districts; urban/
rural
– Intervention districts refer to where HCP directly
implemented programs