Policy, Systems, and Environmental Change: A Planning Tool for Community Health Implementation

Interventions that change the context for individual behavior are more effective than direct education efforts alone (Frieden, 2010). Extension educators across the United States are therefore being asked to expand their direct education efforts to include community engagement around the policy, systems, and environmental (PSE) elements that support health-promoting lifestyle behaviors (Braun et al., 2014; Smathers et al., 2019). However, in a survey of 379 Extension professionals, only about half of the respondents agreed that they would be comfortable developing a PSE action plan if asked to do so by a supervisor (Smathers et al., 2019). To address this gap, professional development opportunities and tools are needed to familiarize Extension professionals with PSE elements, build their capacity to implement PSE change, and make the process relevant to their work (Leeman et al., 2015; Smathers & Lobb, 2015).

In July 2019, Tennessee State University Extension, University of Tennessee Extension, and University of Kentucky Extension partnered to offer Extension educators from all three institutions a professional development workshop on implementing PSE changes in their communities (Sneed et al., 2020). The 2-day workshop, which we developed, ended with a call to action, during which participants worked individually and with their peers to develop comprehensive action plans to guide their PSE change efforts (Sneed et al., 2020). After the planning activity, participants shared their action plans with the larger group, an activity that provided an opportunity for peer education from the diverse perspectives and experiences of those in the room.

In planning the workshop, we understood that developing an action plan for PSE change can be challenging, especially for educators unfamiliar with PSE change approaches. Therefore, we created the PSE Change Action Planning tool to facilitate the process (available by request from our lead author). It comprises a stepwise process for health educators transitioning from a needs assessment phase to an implementation phase (see the appendix for an example of a completed version of the tool). Tool development was guided by relevant research and technical practice manuals (Golden, McLeroy, Green, Earp, & Lieberman, 2015; Leeman et al., 2012; Moore, Villalobos, Gardner, Staples, & Shafir, 2019).

During the workshop planning activity, participants were provided a hard copy of the Be More Implementation Guide developed by University of Tennessee as part of the Centers for Disease Control and Prevention's 1416 High Obesity Cooperative Agreement. The Be More Implementation Guide contains PSE change strategies and resources for several different contexts, including for promoting physical activity and healthful nutrition in worksites, with faith-based groups, in senior centers, in schools, and in food retail establishments. For the workshop activity, participants were instructed to (a) select PSE change strategies that fit an identified opportunity in their counties, using the Be More Implementation Guide, and (b) work through the PSE Change Action Planning tool, both individually and with their peers, as a capacity-building exercise (Leeman et al., 2015). Participants were provided with the Be More Implementation Guide and other physical resources (books, websites) to assist with the planning activity, although those materials are not required to effectively use the tool. Similar resources are readily available at the national or local levels (e.g., from SNAP-Ed Library). Technical assistance from other Extension professionals, including specialists, was also provided.

The PSE Change Action Planning tool engaged participants through four steps:

1. Participants selected a strategy and were directed to think about the strategy in their community context. They were asked to brainstorm ideas about existing community strengths and opportunities related to the selected strategy as well as champions and community partners they would need to work with to implement it.
2. Participants were instructed to identify barriers and challenges as well as any additional resources (e.g., external funding) they would need to be successful.
3. After an explanation of how to create a SMART (specific, measurable, attainable, relevant, timely) goal (Bovend'Eerdt, Botell, & Wade, 2009), participants created several goals for implementing the strategy.
4. Participants identified what success would look like and what measurable outcomes they could report. They were also asked to consider how they could ensure that their project was equitable for everyone in their community.

Others interested in using the PSE Change Action Planning tool may benefit from the following recommendations:

• Emphasize equity. The intended goal of any health-related PSE change is to create a culture of health by mitigating preventable factors related to poor health outcomes. Historically, most policies, systems, and environments have purposely disenfranchised entire communities of people on the basis of their race, ethnicity, or other demographic or cultural characteristics (Alexander, 2020; Bailey et al., 2017; Quijada & Murakami-Ramalho, 2009; Ross & Leigh, 2000; Simovska, Kane, Elia, & Tokunaga, 2015; Wallace, Crear-Perry, Richardson, Tarver, & Theall, 2017). Moreover, communities where health inequities are most persistent are often not the beneficiaries of equitable PSE changes (Kumanyika, 2018). For PSE changes to have the intended impact, there must be intentional engagement of all stakeholders in the process, not only those who are traditionally engaged (Liburd, Giles, & Jack, 2013).
• Allow for peer education. Participants in our workshop reported in the workshop evaluation that having time to discuss and troubleshoot their action plans with their peers and more experienced colleagues was very helpful. Educators should reach out to other Extension professionals, partners, or coalitions for assistance with action plan development (Haller, Gallagher, Weldon, & Felder, 2000).
• Encourage reflection. It is important to reflect on the completed action plan with other stakeholders. Critical reflection stimulates creativity and provides a framework for authentic implementation of PSE changes. Consistent reflection during implementation improves buy-in from the community and acceptability of the changes being implemented (Hills & Mullett, 2000; Raelin, 2001).

Through the use of the tool presented here, Extension educators will be able to develop an action plan for PSE interventions tailored to the needs of the communities they serve. Using the tool not only benefits Extension educators in mapping their PSE engagements but also can help Extension educators communicate their PSE change plans to community partners, including the steps necessary for achieving those plans. Given the continued conversations nationally regarding PSE interventions, this PSE change tool holds potential for scaling use by Extension educators to the national level.

Author Note

Lauren Kennedy was employed as a health specialist with Tennessee State University Extension during the development of this article but began working as a community behavioral health specialist with Michigan State University Extension during the review process.

References

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Appendix

Sample Policy, Systems, and Environmental (PSE) Change Action Plan

Health Issue: Example: Healthful Food Access

Step 1: Use the Be More Implementation Guide, other available resources, and your community partners to select PSE change strategies that address your identified opportunity. Use the table below to brainstorm how you will implement your chosen strategy(ies).

Step 2: Identify barriers and challenges and any additional resources you will need to be successful.

Step 3: Identify several SMART goals for implementing your strategy.

Step 4: How will you know that you have been successful with your PSE change? What are some of the measurable outcomes you can report? How will you ensure that what you are doing is equitable?

Example: Each of the four targeted stores participates in the program, store owners report increased POS purchase of fruit, etc.