Planning and Implementation of Community Readiness Assessment: Experience and Lessons Learned by a Health System

Planning and Implementation of Community Readiness Assessment: Experience and Lessons Learned by a Health System | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Planning and Implementation of Community Readiness Assessment: Experience and Lessons Learned by a Health System Yun T. Tran, Bushra Tahir Khan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6505495/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction A Community Readiness Assessment (CRA) that also evaluated Collaboration Readiness and Organizational Literacy was planned and implemented as part of our health system’s effort to improve health equity through funding collaborative community interventions. A crucial step following the Community Health Needs Assessment (CHNA), the CRA aimed to inform grant strategy because communities with higher readiness tend to have better intervention outcomes. Method The CRA tool detailed by Tri-Ethnic Center for Prevention Research at Colorado State University was modified. Each key informant determined the issue that should be addressed. A community where at least three informants discussed the same issue received an average CRA score. Those affiliated with relevant community organizations were also surveyed on Collaboration Readiness and Organizational Literacy. Results Seventy-two key informants from 15 communities were interviewed. Average CRA scores were calculated in 10 communities where the most common issues were “access to health care” and “behavioral health.” Most readiness fell on “vague awareness” and “preplanning.” Majority of the organizations surveyed on Collaboration Readiness and Organizational Literacy were already (a) collaborating with partners and (b) helping people, including those of diverse cultures and linguistic backgrounds and those with disabilities, find, understand and use information and services provided by their organizations. Conclusions The CRA results were used to inform grant strategy. Future considerations have been described to enhance the process. Community Readiness Assessment Collaboration Readiness Organizational Literacy Grant Strategic Decision Making Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION A Community Readiness Assessment (CRA), with components of Collaboration Readiness Assessment and Organizational Literacy Assessment, was conducted in 2023 by a team of public health student interns of our organization, a health system serving North Texas, as part of our effort to improve health equity through collaborative community engagement. Optimal health status is unevenly distributed across the socioeconomic spectrum. Individuals of lower income, education, or occupational status tend to experience worse health and die earlier than their counterparts. For example, within Tarrant County, life expectancy ranges from 68 to 75.6 in ZIP code 76119 where the median household income is $ 44,605, while it ranges from 78.9 to 83.1 in ZIP code 76109 where the median household income is $ 99,102 [ 1 – 3 ]. For individuals of lower socioeconomic status, health care access is more difficult, and protective resources such as employment opportunities and transportation are less accessible. They are often the last to receive the benefits of new scientific and medical developments. Unmet social needs, environmental factors, and barriers to obtaining health care contribute to worse health outcomes [4]. Not only does a healthcare system have the moral obligation to address health disparities by improving the health outcomes of the more vulnerable populations, but it also makes economic sense as we are in the era of value-based care where payment for services provided by a healthcare system is tied to health outcomes of those served by the system [5]. It is also important to attend to the uninsured population. For example, because food insecurity is associated with more emergency room visits and hospitalizations, reducing food insecurity for the uninsured population could help hospitals avoid costs related to unreimbursed care [6]. Because each community has unique issues, resources, opportunities, and readiness, achieving health equity involves understanding and addressing the numerous factors contributing to health disparities. The voices of the communities must be considered to ensure solutions adopted will create a more equitable future for all. This is the impetus for conducting a Community Readiness Assessment. Community Readiness Assessment (CRA) Background Our organization is a private nonprofit healthcare system consisting of multiple hospitals and outpatient clinics serving 16 North Texas counties. We also award grants to collaborative community interventions operated by organizations such as school districts and nonprofit agencies that provide health and/or social services. The CRA results would serve as a factor in determining which intervention proposals to fund. For example, if a community was vaguely aware of a health issue, then a grant might be awarded to a proposal to raise awareness; and if a community already had a long-standing effort to address a health issue, then a grant might be awarded to a proposal to evaluate and modify the effort [7]. The CRA was a crucial step following the 2022 Community Health Needs Assessment (CHNA), which identified high-need communities and their priority issues. When multiple communities are competing for limited funding, a grant may be awarded to the community with a higher CRA score because they tend to be more receptive of community-based interventions and have better outcomes [8, 9]. The Community Readiness Handbook published by the Tri-Ethnic Center for Prevention Research at Colorado State University served as the basis of our CRA [10]. Although there have been multiple models developed to assess community readiness, the Community Readiness Model developed by Oetting et al. in 1995 is the seminal work and foundation for the Community Readiness Handbook, and it is the most commonly used model by organizations and researchers to create their own CRA instruments for a variety of issues such as substance use, obesity prevention, and youths with serious emotional needs [11–14]. The Community Readiness Model was based on (a) the Transtheoretical Model Stages of Change Theory that identified the process through which an individual changes their behavior and (b) the work done in the field of community development especially the social action process that identified stages of change on the community level [15, 16]. In the Community Readiness Handbook, the community readiness to change was assessed on five dimensions. Each dimension was given a score on one of the nine stages of readiness based on the informant’s response to certain questions. The scores for each dimension were averaged by the number of informants. The averages for all five dimensions were averaged again for the CRA Score for the issue in that community. A program planner may focus efforts on the dimension that has the lowest readiness score. See Tables 1 and 2 . From our organization’s past experience, the many multiple-choice questions contained in the Community Readiness Handbook led to fatigue and confusion for the key informants. Indeed, the time-intensive nature of the original survey was cited as a reason by other researchers to develop their own process, and the specific needs of an organization would require changes as well [14]. Components of Collaboration Readiness Assessment and Organizational Literacy Assessment of key informants’ organizations were added to our CRA. According to Haq [17], most health care professionals do not have the “skills, time, or resources to address the social determinants of health” that directly impact health equity, so collaboration with other community organizations is vital. Many community organizations, health-related or not, play a significant role in helping community members access health care and health promotion activities [18]. Therefore, it is essential that these organizations are helping community members find, understand, and use information and services they provide. The literature on Collaboration Readiness Assessment is sparse. A study by Western Carolina University described a self-administered quantitative survey to nonprofits in North Carolina about their attitude on collaboration with local governments [19]. Neuhoff et al. also published a report of a nationwide survey of nonprofits and grant makers regarding their frequency of, desire for, and barriers to collaboration [20]. Neither study assessed the readiness of organizations in a community to collaborate with one another. Butel et al. described that “…a tool has not been developed to measure readiness levels of multiple organizations intending to collaborate…” and subsequently developed a Collaboration Readiness Assessment Tool for agencies and partners supporting Supplemental Nutrition Assistance Program-Education (SNAP-Ed) program [21]. Their assessment tool was a nine-item self-administered quantitative survey. We adapted this tool to develop a question for Collaboration Readiness Assessment in our CRA. There is also relatively little literature regarding general Organizational Literacy, an organization’s effort to help people find, use, and understand information and services they provide. The Centers for Disease Control and Prevention defined Organizational “Health” Literacy as “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others [22].” Kowalski et al. described that although there was an increasing amount of research on personal health literacy and shifting of attention to organizational health literacy, “there is no instrument for measuring the degree of implementation” of efforts to promote organizational health literacy [23]. Kowalski et al. then developed a 10-item self-administered survey for breast cancer hospitals and patients in Germany to assess the 10 attributes of a health literate health care organization described by Brach et al. [24]. See Table 3 . For organizational literacy assessment on an organization not providing health services, there are no existing tools. Therefore, we developed original survey questions for Organizational Literacy Assessment. METHOD Development of Survey Questions The survey tool in the Community Readiness Handbook was modified and pilot-tested with our leaders for face validity (Tri-Ethnic Center for Prevention Research, 2014). A team of public health student interns were trained to use this survey with two rounds of mock interviews. The survey questions were further refined based on feedback from our leaders, pilot test participants, and the student interns. There were four main modifications to the original survey: Style of questions : The many multiple-choice questions used to score each dimension in the original survey were converted to a few open-ended questions to reduce fatigue and confusion for the key informants. The challenge of scoring narrative responses was mitigated by adding mapped questions and criteria to the original rating tool. See Appendices A and B. Number of informants : The original tool recommended at least six key informants per community, or at least four if the community is small. For our CRA, we decided to have a minimum of three key informants per community due to limitation in the time allotted (six weeks) to schedule and complete interviews. Determination of survey issue : The original tool was designed for the interviewer to pre-determine a survey issue prior to the interview. To listen to the voices of the key informants, we opted to have each key informant determine the survey issue for their community instead. An additional benefit was to assess whether the priority issues identified in the CHNA were still valid. Addition of Collaboration Readiness and Organizational Literacy Assessment : Questions were added to assess the informant’s organizational readiness to collaborate and their organizational literacy defined as their effort in helping people find, understand, and use the information and services they provide. The Collaboration Readiness Assessment question was adapted from the tool developed by Butel et al. (2018). That tool also served as a framework to develop our original Organizational Literacy Assessment questions. Because most informants did not provide health information or services, a general assessment on organizational literacy rather than organizational “health” literacy was completed. Determining the Communities and Key Informants The 16 counties served by our organization were structured into five regions. Using the 2022 CHNA findings, the five region directors and their respective program managers determined 15 communities and 72 key informants for the survey. The key informants were existing or potential partners and included public government employees such as council members and fire department chiefs, school representatives such as superintendents and counselors, leaders of non-profit service organizations and faith communities, and individuals recognized as trusted advocates from within the communities. Of the 72 key informants, the program managers identified 59 to be surveyed on Collaboration Readiness Assessment and Organizational Literacy Assessment components. The other 13 informants were community members who were not part of relevant organizations. (For example, one informant was a resident who lived in our survey community but worked outside of it.) The UT Southwestern Human Research Protection Program (HRPP) reviewed this project and determined that it did not meet the definition of research and therefore did not require IRB approval or oversight. All methods were carried out in accordance with relevant guidelines and regulations. There were no experiments or experimental protocols to be reviewed. Data confidentiality was discussed and informed consent was obtained verbally from all the key informants. The interviews were conducted via Microsoft Teams video conferencing. Determining the Survey Issue There were four types of issues in our data collection and analysis: Issues first mentioned were those answered by key informants in response to Question 2.1: “What do you think is the issue that your community is the most concerned about?” 2022 CHNA Priority Issues were those published in the 2022 CHNA. See Table 4 . CHNA Issues chosen by program managers : In three regions, the program managers chose one issue from 2022 CHNA Priority Issues . In two regions, the program managers chose three. See Table 4 . Survey Issue : When one of the Issues first mentioned was the same as one of the CHNA Issues chosen by program managers , that issue was automatically the Survey Issue , and Questions 2.1 c-e were to be omitted. (When Issues first mentioned had multiple matches in regions with three CHNA Issues chosen by program managers , the informant was asked to choose one.) Otherwise, the interviewer asked Questions 2.1 c-e, and the informant chose whether to use one of their Issues first mentioned or one of the CHNA Issues chosen by program managers for the survey. See Fig. 1 for the algorithm. Data Analysis We first determined the agreement between the Issues first mentioned and 2022 CHNA Priority Issues , and the agreement between Issues first mentioned and CHNA Issues chosen by program managers . As long as there was one match, they were deemed to be in agreement. We then determined whether the discussion of CHNA Issues chosen by program managers influenced the Survey Issue . For example, one of the Issues first mentioned might be “access to health care,” but when the interviewer discussed “behavioral health” because it was the CHNA Issue chosen by program managers , the informant decided to focus on “behavioral health” as the Survey Issue . In this case, the discussion of CHNA Issue chosen by program managers changed the issue for the survey. Two raters then scored the five dimensions of the CRA. See Appendix B for scoring instructions and the Rating Tool for the Five Dimensions of Community Readiness Assessment (CRA). Each rater determined the score independently based on the responses to certain questions. In cases where the response to questions designed for scoring was missing, ambiguous, or inconsistent, including “I don’t know” or similar, we used responses to other questions to gather clues and determine the best score. If this was not able to be completed, we gave a score of “1” because that was the lowest possible score for each dimension. Using this method, all the data could be used in the practical sense instead of being discarded. For communities with only three informants, it was especially necessary to keep all the data. This is consistent with the spirit of the original tool developed by the Tri-Ethnic Center for Prevention Research (2014, p. 26) which recommended looking across the responses to the entire survey before scoring each dimension. The two raters’ scores were then compared. In 70% of the time, the two raters either agreed or had an absolute score difference of one. For scores that differed by one, the scores were averaged to get the consensus. For others, we reached consensus by carefully reviewing the entire survey responses and scoring instructions. See Table 5 for how the consensus scores were recorded. Each issue in each community received a separate table. The average CRA Score was calculated if the community had at least three informants for a Survey Issue. Additionally, themes from the informants’ responses to all the questions were extracted and recorded for qualitative analysis. Scoring of Collaboration Readiness was based on the response to a question that asked the informant to select one of six choices that corresponded to their organization’s status in collaboration. Scoring of Organizational Literacy was based on the responses to three questions that asked for the organization’s status in terms of their effort to help people, including those of diverse cultures and linguistic backgrounds and those with disabilities, find, understand, and use the information and services they provide. Each informant selected one of six choices for each of the questions and provided narrative comments which were analyzed for broad themes. RESULTS There were 72 key informants from 15 communities. The Issues first mentioned were the same as the 2022 CHNA Priority Issues in 56 (78%) cases. The Issues first mentioned were the same as the CHNA Issues chosen by program managers in 37 (51%) cases. The CHNA Issues chosen by program managers were discussed in 46 cases. In 35 cases, they were discussed according to algorithm. In 11 cases, they were discussed when the algorithm was not followed by the interviewer. Of these 46 cases, discussion of CHNA Issues chosen by program managers changed the issue for the survey in 21 (46%) cases. In total, the Issues first mentioned in response to question 2.1 were the Survey Issues in 51 (71%) cases. If the algorithm had been strictly followed, then the Issues first mentioned would have been the Survey Issue in 62 (86%) cases. “Access to Health Care” was the most common Survey Issue, followed by “behavioral health.” See Fig. 2 . Table 6 shows communities and issues that were able to have CRA scores calculated. The majority of CRA scores fell between “vague awareness” and “preplanning.” The blackened boxes indicate issues that did not have CRA scores due to not having at least three informants discussing an issue. Five communities did not receive CRA scores. Table 7 shows themes from qualitative analysis of the CRA. Fifty-nine key informants were surveyed on Collaboration Readiness Assessment and Organizational Literacy Assessment of their organizations. Of those, 46 (78%) were actively collaborating with other organizations; 49 (83%) were actively helping people find, understand, and use information and services provided by their organizations; 45 (76%) were actively outreaching to people of diverse cultures and linguistic backgrounds; and 39 (66%) were actively outreaching to people with disabilities. See Figs. 3, 4 , 5 and 6 . Table 8 contains themes from qualitative analysis of how community members access and understand information (from the CRA dimension Community Knowledge of Efforts) and how organizations help community find, understand, and use information and services they provide (from Organizational Literacy Assessment). CONCLUSIONS As part of our effort to improve health equity and increase the likelihood of success of interventions, we listened to the voices of the key informants by conducting a CRA to help us reduce our bias in funding decisions. For example, in a community with “vague awareness” of the priority issue, the focus may shift to raising awareness instead of simply funding needed services. For a community at preplanning, where there is clear recognition that something must be done but efforts are not focused or actively planned, the funding priority is to use the results of the Collaboration Readiness Assessment and bring potential partners together to start planning for an intervention. Further, the results of the Organizational Literacy Assessment, along with data from the CRA dimension “Community Knowledge of Efforts” about how community members access and understand information, contributed to strategies on how to help community members become aware of and access services, including those provided by the interventions we are funding. Proposed strategies include efforts to increase public Wi-Fi hotspots and to promote a centralized website for referral to nonprofit organizations because most people find information through word of mouth, referrals, and social media/websites. CRA Process Limitations and Recommendations In some communities, there were not enough key informants to calculate a meaningful average CRA score for an issue. This was especially a problem for those communities with only three informants. Although all interviewers were trained, there were still errors in following the survey algorithm. This resulted in some key informants changing their issues, and incomplete data for some communities. Due to the small number of informants, incomplete data could not be discarded. For an issue that was discussed by only three informants in a community, discarding one informant’s incomplete data would result in inability to calculate an average CRA score for the issue in that community. Reviewing the entire survey responses could help the raters determine a score in these situations, but there were still times when this approach was ineffective. Another challenge for our CRA was to give a quantitative score to narrative responses of open-ended questions, which were more suited for qualitative analysis. We recommend that a healthcare system select a priority issue from their CHNA to conduct the CRA instead of asking each key informant to determine the CRA issue. The priority issues identified in the 2022 CHNA were also issues first mentioned by the key informants in the 2023 CRA 78% of the time, indicating a high agreement and that the CHNA results were valid. We also recommend using a combination approach of emailing instructions to at least six informants in each community to complete CRA scoring on their own using the rating tool without the survey questions, and then following up with three of them to probe for more details (Tri-Ethnic Center for Prevention Research, 2014, p. 30). The larger sample size of informants to assess their community should minimize skewing of the score by the response of one informant. The combination approach could also reduce time and effort in gathering data and eliminate the challenging task of scoring narrative responses. It will still maintain the ability for key informants to elaborate on the specific context and needs of their community. Declarations Yun Tran conducted the work while being an MPH student at University of North Texas Health Science Center. She is currently a staff physician at John Peter Smith Health Network and assistant professor at Texas Christian University Burnett School of Medicine. Bushra Tahir Khan conducted the work while being an MPH student at Baylor University. She is currently a doctoral student at A.T. Still University Missouri School of Dentistry & Oral Health. Other than the expertise and resources provided by the internship supervisor and support staff at the healthcare institution, no funding was received to assist with the work conducted or the preparation of this manuscript. The authors have no competing interests to declare that are relevant to the content of this article. 1. Corresponding author: Yun Tran 2. Country affiliation for Yun Tran: United States 3. Country affiliation for Bushra Tahir Khan: United States 4. Clinical trial number: not applicable. 5. Consent to Participate declaration. Every human participant has provided their consent. 6. Funding Declaration: There was no Funding. 7. Clinical trial number: not applicable. 8. Human Ethics and Consent to Participate declarations: not applicable. 9. Consent to Publish declaration: not applicable. 10. Data availability: The data collected were proprietary to the health system and not openly available. Author Contribution Y.T. wrote the main manuscript text and prepared the tables, figures, and appendices. B.K. contributed to literature review for the introduction section. Both authors planned and implemented the project up to and including data collection. Y. T. carried out the data analysis and reporting. Both authors reviewed the manuscript. Acknowledgement AcknowledgementThis work was part of a Texas health system initiative and could not have been accomplished without the support and leadership of their community health improvement team. Data Availability The data collected were proprietary to the health system and not openly available. References City Health Dashboard. (n.d.). Fort Worth, TX. Retrieved September 13, 2024, from https://www.cityhealthdashboard.com/TX/Fort%20Worth/metric-detail?metricId=37&dataPeriod=2015 U.S. Census Bureau. (n.d.-a). ZIP code tabulation area: 76119. Retrieved September 16, 2024, from https://data.census.gov/profile/ZCTA5_76119?g=860XX00US76119 U.S. Census Bureau. (n.d.-b). ZIP code tabulation area: 76109. Retrieved September 16, 2024, from https://data.census.gov/profile/ZCTA5_76109?g=860XX00US76109 Thompson, T., McQueen, A., Croston, M., Luke, A., Caito, N., Quinn, K., Funaro, J., & Kreuter, M. W. 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Retrieved January 29, 2024, from https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/community-readiness/main Ehlers, D. K., Huberty, J. L., & Beseler, C. L. (2013). Is school community readiness related to physical activity before and after the Ready for Recess intervention? Health Education Research, 28 (2), 192-204. https://doi.org/10.1093/her/cys102 Millar, L., Robertson, N., Allender, S., Nichols, M., Bennett, C., & Swinburn, B. (2013). Increasing community capacity and decreasing prevalence of overweight and obesity in a community based intervention among Australian adolescents. Preventive Medicine, 56 (6), 379-384. https://doi.org/10.1016/j.ypmed.2013.02.020 Tri-Ethnic Center for Prevention Research. (2014). Community Readiness for Community Change . https://tec.colostate.edu/wp-content/uploads/2018/04/CR_Handbook_8-3-15.pdf Oetting, E. R., Donnermeyer, J. F., Plested, B. A., Edwards, R. W., Kelly, K., & Beauvals, F. (1995). 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C., & Norcross, J. C. (1992). In search of how people change. American Psychologist, 47 (9), 1102-1114. https://doi.org/10.1037//0003-066x.47.9.1102 Haq, C. (2017). The path to health equity through multidisciplinary collaboration. Journal of Patient-Centered Research and Reviews, 4 (4), 208-210. https://doi.org/10.17294%2F2330-0698.1615 Woodard, N., Bors, D., Hussain, A., Huq, M. R., & Knott, C. L. (2022). Motives driving non-healthcare community organizations to engage in health promotion activities. Journal of Community Health, 47 (5), 765-773. https://doi.org/10.1007%2Fs10900-022-01108-1 Western Carolina University. (2015). 2015 Nonprofit collaboration survey: Nonprofit collaborations with local governments in North Carolina . https://www.wcu.edu/WebFiles/Nonprofit-Survey-15.pdf Neuhoff, A., Milway, K. S., Kiernan, R., & Grehan, J. (2014, December). Making sense of nonprofit collaborations. https://www.bridgespan.org/getmedia/f5d1a314-a277-4a5f-a13c-8483360fac25/MakingSenseOfNonprofitCollaborations_1.pdf Butel J. A., Banna, J. C., Novotny, R., Franck, K. L., Parker, S. P., & Stephenson, L. (2018). Validation of a collaboration readiness assessment tool for use by Supplemental Nutrition Assistance Program-Education (SNAP-Ed) agencies and partners. Journal of Nutrition Education and Behavior, 50 (5). https://doi.org/10.1016/j.jneb.2017.11.002 Centers for Disease Control and Prevention. (n.d.). What is health literacy? Retrieved March 7, 2024, from https://www.cdc.gov/healthliteracy/learn/index.html Kowalski, C., Lee, S. D., Schmidt, A., Wesselmann, S., Wirtz, M. A., Pfaff, H., & Ernstmann, N. (2015). The health literate health care organization 10 item questionnaire (HLHQ-10): development and validation. BMC Health Services Research, 15 : 47 . https://doi.org/10.1186/s12913-015-0707-5 Brach, C., Keller, D., Hernandez, L. M., Baur, C., Parker, R., Dreyer, B, Schyve, P., Lemerise, A. J., & Schillinger, D. (2012, June 19). Ten attributes of health literate health care organizations. National Academy of Medicine. https://nam.edu/perspectives-2012-ten-attributes-of-health-literate-health-care-organizations/ Tables Table 1 Community Readiness Assessment Dimensions Dimension Definition Community knowledge of issue How much do community members know about the causes and consequences of the issue, and the impact on the community? Community knowledge of efforts to address the issue How much do community members know about existing local programs that address the issue? Leadership How much do community leaders support addressing the issue? Community climate How much do community members in general support addressing the issue? Resources What local resources – funding, donation, space, volunteers, expertise – are available? Source: 7. Community Tool Box. (n.d.). Section 9. Community Readiness . Retrieved January 29, 2024, from https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/community-readiness/main Table 2 Stages of Readiness (Assessed on each dimension and then averaged.) Stage Definition No awareness Community members and leaders are generally unaware that the issue is a problem. Denial/ resistance Only a few community members or leaders recognize that the issue is a problem, but most do not know or admit it is occurring locally. Vague awareness Most in the community know the issue is a problem, but there is no motivation to address it. Preplanning There is clear recognition that something must be done, but efforts are not focused or actively planned. Preparation There are leaders and community members actively planning and preparing to implement programs to address the issue. Initiation Programs have been newly implemented to address the issue. Stabilization Programs with experienced staff are supported community leaders and members. Confirmation/ expansion Community members feel comfortable using programs and they support expansions. High level of community ownership Community members have detailed knowledge about prevalence, causes, and consequences. Evaluation guides new directions of programs. Source: 7. Community Tool Box. (n.d.). Section 9. Community Readiness . Retrieved January 29, 2024, from https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/community-readiness/main Table 3 10 Attributes of Health Literate Health Care Organizations Has leadership that makes health literacy integral to its mission, structure, and operations. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement. Prepares the workforce to be health literate and monitors progress. Includes populations served in the design, implementation, and evaluation of health information and services. Meets the needs of populations with a range of health literacy skills while avoiding stigmatization. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. Provides easy access to health information and services and navigation assistance. Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. Addresses health literacy in high-risk situations, including care transitions and communications about medicines. Communicates clearly what health plans cover and what individuals will have to pay for services. Source: 24. Brach, C., Keller, D., Hernandez, L. M., Baur, C., Parker, R., Dreyer, B, Schyve, P., Lemerise, A. J., & Schillinger, D. (2012, June 19). Ten attributes of health literate health care organizations. National Academy of Medicine. https://nam.edu/perspectives-2012-ten-attributes-of-health-literate-health-care-organizations/ Table 4 Region Priorities and CHNA Issues Region (Number of communities assessed) 2022 CHNA Issues* CHNA Issues chosen by program managers (discussed with informants only if their Primary/Other Issues do not fall in these categories) Region 1 (2 communities) access to health care chronic disease behavioral health behavioral health physical health access to health care Region 2 (2 communities) access to health care behavioral health behavioral health Region 3 (3 communities) access to health care food chronic disease chronic disease, specifically hypertension and diabetes Region 4 (5 communities) behavioral health food access to health care behavioral health Region 5 (3 communities) access to health care social determinants of health (such as food, housing, transportation, financial stability) behavioral health access to health care social determinants behavioral health Note. The first column shows 5 regions and the number of communities involved in the 2023 Community Readiness Assessment. The second column shows the priority issues identified by the 2022 Community Health Needs Assessment. The third column shows the issues chosen by program managers for the 2023 Community Readiness Assessment. Access to health care is any issue regarding cost or lack of health insurance, providers/hospitals, transportation, knowledge to navigate health care system. Behavioral health is any issue regarding mental disorder or access to behavioral health services. For chronic disease, the focus is diabetes and hypertension. Table 5 Sample Table for Recording of Scores and Calculation of Average CRA Score Community Name: ____ Survey Issue: ____ Community Knowledge of Survey Issue Community Knowledge of Efforts (Programs to Address Survey Issue) Leadership Community Climate Resources Informant #1 Informant #2 Informant #3 Average by Dimension Average CRA Score: ______ Note. All the white spaces were to be filled in with data, including Community Name, Survey Issue, rating of each dimension by informant and on average, and the average CRA score. The average CRA Score was calculated by adding the average of each dimension, and then dividing the sum by 5. Table 6 Communities and Issues with CRA Scores Region Community Number of Informants Survey Issue (Number of informants) Average CRA Region 1 Community 1 7 Access to health care (4) 3.7 Behavioral health (3) 3.1 Community 2 7 Access to health care (4) 2.9 Behavioral health (2) Resources (1) Region 2 Community 3 7 Access to health care (3) 3.2 Behavioral health (3) 4.7 Food (1) Community 4 6 Behavioral health (3) 4.3 Access to health care (2) Resources (1) Region 3 Community 5 6 Access to health care (3) 4.4 Chronic disease (3) 3.6 Community 6 4 Access to health care (2) Food (2) Community 7 3 Chronic disease (2) Access to health care (1) Region 4 Community 8 3 Behavioral health (3) 4.1 Community 9 3 Behavioral health (2) Food (1) Community 10 3 Behavioral health (2) Food (1) Community 11 3 Behavioral health (3) 4.3 Community 12 5 Behavioral health (4) 4.9 Access to health care (1) Region 5 Community 13 6 Access to health care (4) 4.7 Housing (1) Food (1) Community 14 3 Housing (2) Access to health care (1) Community 15 6 Access to health care (3) 3.4 Food (3) 4.4 Note. “Resources” refers to the general lack of services (or lack of knowledge regarding the services) that address various health and social needs. Table 7 Common Themes from Qualitative Analysis of the CRA across 5 Regions Themes Details Access to health care is the most common issue of concern with one or more factors. Affordability (lack of insurance and high cost of services) Availability (lack of providers and hospitals, especially public county hospitals) Transportation Health literacy (lack of knowledge about resources to get care; issues like behavioral health are not existing concepts in some cultures) Behavioral health issue is often a problem about access to care as well. Stigma is a major obstacle for every issue that affects health. People tend not to ask for help with anything because getting assistance is associated with shame and guilt. There is a culture to not discuss personal problems especially behavioral health issues. Lack of funding for outreach hinders awareness of issues and programs that address them. Many people still rely on word of mouth and community engagement events for information. Information online is not centralized and hard to find. Print materials are often in places where people do not visit regularly (city hall, jail lobbies, doctor’s office, etc.) Many people, including target populations, ignore information despite outreach. The target populations prioritize other life demands. (Example: School events planned for parents to address behavioral health are poorly attended.) General community members are not aware or concerned about issues. ( “It doesn’t affect me.” ) Politics affects community health improvement efforts. Politics influences what information is available and whether programs are implemented. It is vital to frame issues and communicate programs in ways that will be accepted by general community members. Table 8 Common Themes from Qualitative Analysis of Community Knowledge of Efforts and Organizational Literacy Community members find information mostly through word of mouth , referrals , and social media/websites . To reach the general public, most organizations use plain language and have multiple modes of communication . Some organizations have effort to outreach to those from diverse cultural and linguistic backgrounds, but such effort is often limited to Spanish. Most organizations can accommodate those with disabilities, but do not have a structured outreach effort to help those with disabilities find their programs or understand the information they provide. Some organizations partner with school districts (with their existing structures to serve all children) to reach those from diverse cultural backgrounds and those with disabilities. However, this channel does not reach those without children in schools. Lack of funding and qualified staff are the biggest barriers for targeted outreach. Additional Declarations No competing interests reported. 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Tran","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYFCD4w0MzMSqZWwAU2cOkKzlRgKRWgxu5B5/XFFzJ5rv5hvDzwUVNgz87d0JBLTkJTaeOfYsd+btHGPpGWfSGCTOnN1AQEuOYWMD2+HcDbdzDKR52w4zGEjkEqPlH1DLzTPGv4nX0tgG1HKDx4w4WyTPvDGc2dh3OHfmmbQya54zaTwE/cJ3PMfgY8O3w7l9xw9vvs1TYSPH396LX4vCATiTwwBE8uBVDgLyDXAm+wOCqkfBKBgFo2BkAgBP11GFk4qASgAAAABJRU5ErkJggg==","orcid":"","institution":"University of North Texas Health Science Center College of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Yun","middleName":"T.","lastName":"Tran","suffix":""},{"id":462376387,"identity":"b626d9fe-2100-4017-809d-0f26e34df65c","order_by":1,"name":"Bushra Tahir Khan","email":"","orcid":"","institution":"Baylor University Robbins College of Health \u0026 Human Sciences Department of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Bushra","middleName":"Tahir","lastName":"Khan","suffix":""}],"badges":[],"createdAt":"2025-04-22 14:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6505495/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6505495/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83628804,"identity":"ea1107d8-5355-488c-b656-5e53e2e005e5","added_by":"auto","created_at":"2025-05-29 18:08:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83254,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAlgorithm for Determining Survey Issue\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/bbbee26780c64ac9b031d578.png"},{"id":83629219,"identity":"8b14d2bd-ffa2-4160-bab6-9d87e6f260b1","added_by":"auto","created_at":"2025-05-29 18:16:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":91904,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSurvey Issues (Count)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Across all 5 regions, “access to health care” was the Survey Issue for 28 key informants, and “behavioral health” was the Survey Issue for 25 key informants. 9 informants selected food-related issues (food insecurity, lack of access to healthy food). 5 informants selected chronic disease, specifically diabetes. 5 informants chose other issues—3 chose housing, and 2 chose “resources”. “Resources” refers to the general lack of services (or lack of knowledge regarding the services) that address various health and social needs.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/b84866cdade71964e926f1bb.jpg"},{"id":83628807,"identity":"d5d49411-dcea-4f92-8020-314b2ec443f8","added_by":"auto","created_at":"2025-05-29 18:08:04","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":126405,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCollaboration Readiness (Count of Status across 5 Regions)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/df1c0858aa38a730921ba5ce.jpg"},{"id":83628805,"identity":"caef8a82-1c5f-4723-bc24-e0dde2eafae9","added_by":"auto","created_at":"2025-05-29 18:08:04","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":135590,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOrganizational Literacy, General (Count of Status across 5 Regions)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/a77f6c37637e113a239d7fd4.jpg"},{"id":83629220,"identity":"1493e37a-7687-4d99-84a6-ffd3614931e6","added_by":"auto","created_at":"2025-05-29 18:16:04","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":133025,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOrganizational Literacy, Linguistic and Cultural Inclusion (Count of Status across 5 Regions)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/82a6f42ab199d0284e7dac63.jpg"},{"id":83628808,"identity":"5d530d6f-55a6-4bb8-8b99-9c824e853803","added_by":"auto","created_at":"2025-05-29 18:08:04","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":128046,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOrganizational Literacy, Disabilities Inclusion (Count of Status across 5 Regions)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/1743c22402c01b2e391d4b69.jpg"},{"id":93560663,"identity":"95e21cb7-6816-43aa-a197-b0245304fc9b","added_by":"auto","created_at":"2025-10-15 07:32:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2105940,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/32149d95-fbde-40c1-8f0c-ec45ff6c3332.pdf"},{"id":83628809,"identity":"b3b60db1-303d-4bba-865f-2e04a9b711c0","added_by":"auto","created_at":"2025-05-29 18:08:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":49727,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIX.docx","url":"https://assets-eu.researchsquare.com/files/rs-6505495/v1/739b8fad176c28a7b2327bcf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Planning and Implementation of Community Readiness Assessment: Experience and Lessons Learned by a Health System","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eA Community Readiness Assessment (CRA), with components of Collaboration Readiness Assessment and Organizational Literacy Assessment, was conducted in 2023 by a team of public health student interns of our organization, a health system serving North Texas, as part of our effort to improve health equity through collaborative community engagement. Optimal health status is unevenly distributed across the socioeconomic spectrum. Individuals of lower income, education, or occupational status tend to experience worse health and die earlier than their counterparts. For example, within Tarrant County, life expectancy ranges from 68 to 75.6 in ZIP code 76119 where the median household income is \u003cspan\u003e$\u003c/span\u003e44,605, while it ranges from 78.9 to 83.1 in ZIP code 76109 where the median household income is \u003cspan\u003e$\u003c/span\u003e99,102 [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For individuals of lower socioeconomic status, health care access is more difficult, and protective resources such as employment opportunities and transportation are less accessible. They are often the last to receive the benefits of new scientific and medical developments. Unmet social needs, environmental factors, and barriers to obtaining health care contribute to worse health outcomes [4].\u003c/p\u003e \u003cp\u003eNot only does a healthcare system have the moral obligation to address health disparities by improving the health outcomes of the more vulnerable populations, but it also makes economic sense as we are in the era of value-based care where payment for services provided by a healthcare system is tied to health outcomes of those served by the system [5]. It is also important to attend to the uninsured population. For example, because food insecurity is associated with more emergency room visits and hospitalizations, reducing food insecurity for the uninsured population could help hospitals avoid costs related to unreimbursed care [6].\u003c/p\u003e \u003cp\u003eBecause each community has unique issues, resources, opportunities, and readiness, achieving health equity involves understanding and addressing the numerous factors contributing to health disparities. The voices of the communities must be considered to ensure solutions adopted will create a more equitable future for all. This is the impetus for conducting a Community Readiness Assessment.\u003c/p\u003e\n\u003ch3\u003eCommunity Readiness Assessment (CRA) Background\u003c/h3\u003e\n\u003cp\u003eOur organization is a private nonprofit healthcare system consisting of multiple hospitals and outpatient clinics serving 16 North Texas counties. We also award grants to collaborative community interventions operated by organizations such as school districts and nonprofit agencies that provide health and/or social services. The CRA results would serve as a factor in determining which intervention proposals to fund. For example, if a community was vaguely aware of a health issue, then a grant might be awarded to a proposal to raise awareness; and if a community already had a long-standing effort to address a health issue, then a grant might be awarded to a proposal to evaluate and modify the effort [7]. The CRA was a crucial step following the 2022 Community Health Needs Assessment (CHNA), which identified high-need communities and their priority issues. When multiple communities are competing for limited funding, a grant may be awarded to the community with a higher CRA score because they tend to be more receptive of community-based interventions and have better outcomes [8, 9].\u003c/p\u003e \u003cp\u003eThe Community Readiness Handbook published by the Tri-Ethnic Center for Prevention Research at Colorado State University served as the basis of our CRA [10]. Although there have been multiple models developed to assess community readiness, the Community Readiness Model developed by Oetting et al. in 1995 is the seminal work and foundation for the Community Readiness Handbook, and it is the most commonly used model by organizations and researchers to create their own CRA instruments for a variety of issues such as substance use, obesity prevention, and youths with serious emotional needs [11\u0026ndash;14]. The Community Readiness Model was based on (a) the Transtheoretical Model Stages of Change Theory that identified the process through which an individual changes their behavior and (b) the work done in the field of community development especially the social action process that identified stages of change on the community level [15, 16]. In the Community Readiness Handbook, the community readiness to change was assessed on five dimensions. Each dimension was given a score on one of the nine stages of readiness based on the informant\u0026rsquo;s response to certain questions. The scores for each dimension were averaged by the number of informants. The averages for all five dimensions were averaged again for the CRA Score for the issue in that community. A program planner may focus efforts on the dimension that has the lowest readiness score. See Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFrom our organization\u0026rsquo;s past experience, the many multiple-choice questions contained in the Community Readiness Handbook led to fatigue and confusion for the key informants. Indeed, the time-intensive nature of the original survey was cited as a reason by other researchers to develop their own process, and the specific needs of an organization would require changes as well [14].\u003c/p\u003e \u003cp\u003eComponents of Collaboration Readiness Assessment and Organizational Literacy Assessment of key informants\u0026rsquo; organizations were added to our CRA. According to Haq [17], most health care professionals do not have the \u0026ldquo;skills, time, or resources to address the social determinants of health\u0026rdquo; that directly impact health equity, so collaboration with other community organizations is vital. Many community organizations, health-related or not, play a significant role in helping community members access health care and health promotion activities [18]. Therefore, it is essential that these organizations are helping community members find, understand, and use information and services they provide.\u003c/p\u003e \u003cp\u003eThe literature on Collaboration Readiness Assessment is sparse. A study by Western Carolina University described a self-administered quantitative survey to nonprofits in North Carolina about their attitude on collaboration with local governments [19]. Neuhoff et al. also published a report of a nationwide survey of nonprofits and grant makers regarding their frequency of, desire for, and barriers to collaboration [20]. Neither study assessed the readiness of organizations in a community to collaborate with one another. Butel et al. described that \u0026ldquo;\u0026hellip;a tool has not been developed to measure readiness levels of multiple organizations intending to collaborate\u0026hellip;\u0026rdquo; and subsequently developed a Collaboration Readiness Assessment Tool for agencies and partners supporting Supplemental Nutrition Assistance Program-Education (SNAP-Ed) program [21]. Their assessment tool was a nine-item self-administered quantitative survey. We adapted this tool to develop a question for Collaboration Readiness Assessment in our CRA.\u003c/p\u003e \u003cp\u003eThere is also relatively little literature regarding general Organizational Literacy, an organization\u0026rsquo;s effort to help people find, use, and understand information and services they provide. The Centers for Disease Control and Prevention defined Organizational \u0026ldquo;Health\u0026rdquo; Literacy as \u0026ldquo;the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others [22].\u0026rdquo; Kowalski et al. described that although there was an increasing amount of research on personal health literacy and shifting of attention to organizational health literacy, \u0026ldquo;there is no instrument for measuring the degree of implementation\u0026rdquo; of efforts to promote organizational health literacy [23]. Kowalski et al. then developed a 10-item self-administered survey for breast cancer hospitals and patients in Germany to assess the 10 attributes of a health literate health care organization described by Brach et al. [24]. See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. For organizational literacy assessment on an organization not providing health services, there are no existing tools. Therefore, we developed original survey questions for Organizational Literacy Assessment.\u003c/p\u003e "},{"header":"METHOD","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eDevelopment of Survey Questions\u003c/h2\u003e \u003cp\u003eThe survey tool in the Community Readiness Handbook was modified and pilot-tested with our leaders for face validity (Tri-Ethnic Center for Prevention Research, 2014). A team of public health student interns were trained to use this survey with two rounds of mock interviews. The survey questions were further refined based on feedback from our leaders, pilot test participants, and the student interns.\u003c/p\u003e \u003cp\u003eThere were four main modifications to the original survey:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStyle of questions\u003c/b\u003e: The many multiple-choice questions used to score each dimension in the original survey were converted to a few open-ended questions to reduce fatigue and confusion for the key informants. The challenge of scoring narrative responses was mitigated by adding mapped questions and criteria to the original rating tool. See Appendices A and B.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eNumber of informants\u003c/b\u003e: The original tool recommended at least six key informants per community, or at least four if the community is small. For our CRA, we decided to have a minimum of three key informants per community due to limitation in the time allotted (six weeks) to schedule and complete interviews.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDetermination of survey issue\u003c/b\u003e: The original tool was designed for the interviewer to pre-determine a survey issue prior to the interview. To listen to the voices of the key informants, we opted to have each key informant determine the survey issue for their community instead. An additional benefit was to assess whether the priority issues identified in the CHNA were still valid.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eAddition of Collaboration Readiness and Organizational Literacy Assessment\u003c/b\u003e: Questions were added to assess the informant\u0026rsquo;s organizational readiness to collaborate and their organizational literacy defined as their effort in helping people find, understand, and use the information and services they provide. The Collaboration Readiness Assessment question was adapted from the tool developed by Butel et al. (2018). That tool also served as a framework to develop our original Organizational Literacy Assessment questions. Because most informants did not provide health information or services, a general assessment on organizational literacy rather than organizational \u0026ldquo;health\u0026rdquo; literacy was completed.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eDetermining the Communities and Key Informants\u003c/h3\u003e\n\u003cp\u003eThe 16 counties served by our organization were structured into five regions. Using the 2022 CHNA findings, the five region directors and their respective program managers determined 15 communities and 72 key informants for the survey. The key informants were existing or potential partners and included public government employees such as council members and fire department chiefs, school representatives such as superintendents and counselors, leaders of non-profit service organizations and faith communities, and individuals recognized as trusted advocates from within the communities. Of the 72 key informants, the program managers identified 59 to be surveyed on Collaboration Readiness Assessment and Organizational Literacy Assessment components. The other 13 informants were community members who were not part of relevant organizations. (For example, one informant was a resident who lived in our survey community but worked outside of it.)\u003c/p\u003e \u003cp\u003eThe UT Southwestern Human Research Protection Program (HRPP) reviewed this project and determined that it did not meet the definition of research and therefore did not require IRB approval or oversight. All methods were carried out in accordance with relevant guidelines and regulations. There were no experiments or experimental protocols to be reviewed. Data confidentiality was discussed and informed consent was obtained verbally from all the key informants. The interviews were conducted via Microsoft Teams video conferencing.\u003c/p\u003e\n\u003ch3\u003eDetermining the Survey Issue\u003c/h3\u003e\n\u003cp\u003eThere were four types of issues in our data collection and analysis:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e were those answered by key informants in response to Question 2.1: \u0026ldquo;What do you think is the issue that your community is the most concerned about?\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e2022 CHNA Priority Issues\u003c/span\u003e were those published in the 2022 CHNA. See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e: In three regions, the program managers chose one issue from \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2022 CHNA Priority Issues\u003c/span\u003e. In two regions, the program managers chose three. See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSurvey Issue\u003c/span\u003e: When one of the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e was the same as one of the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e, that issue was automatically the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSurvey Issue\u003c/span\u003e, and Questions 2.1 c-e were to be omitted. (When \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e had multiple matches in regions with three \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e, the informant was asked to choose one.) Otherwise, the interviewer asked Questions 2.1 c-e, and the informant chose whether to use one of their \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e or one of the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e for the survey. See Fig.\u0026nbsp;1 for the algorithm.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe first determined the agreement between the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2022 CHNA Priority Issues\u003c/span\u003e, and the agreement between \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e. As long as there was one match, they were deemed to be in agreement.\u003c/p\u003e \u003cp\u003eWe then determined whether the discussion of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e influenced the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSurvey Issue\u003c/span\u003e. For example, one of the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e might be \u0026ldquo;access to health care,\u0026rdquo; but when the interviewer discussed \u0026ldquo;behavioral health\u0026rdquo; because it was the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issue chosen by program managers\u003c/span\u003e, the informant decided to focus on \u0026ldquo;behavioral health\u0026rdquo; as the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSurvey Issue\u003c/span\u003e. In this case, the discussion of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issue chosen by program managers\u003c/span\u003e changed the issue for the survey.\u003c/p\u003e \u003cp\u003eTwo raters then scored the five dimensions of the CRA. See \u003cspan refid=\"Sec19\" class=\"InternalRef\"\u003eAppendix B\u003c/span\u003e for scoring instructions and the Rating Tool for the Five Dimensions of Community Readiness Assessment (CRA). Each rater determined the score independently based on the responses to certain questions. In cases where the response to questions designed for scoring was missing, ambiguous, or inconsistent, including \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo; or similar, we used responses to other questions to gather clues and determine the best score. If this was not able to be completed, we gave a score of \u0026ldquo;1\u0026rdquo; because that was the lowest possible score for each dimension. Using this method, all the data could be used in the practical sense instead of being discarded. For communities with only three informants, it was especially necessary to keep all the data. This is consistent with the spirit of the original tool developed by the Tri-Ethnic Center for Prevention Research (2014, p. 26) which recommended looking across the responses to the entire survey before scoring each dimension.\u003c/p\u003e \u003cp\u003eThe two raters\u0026rsquo; scores were then compared. In 70% of the time, the two raters either agreed or had an absolute score difference of one. For scores that differed by one, the scores were averaged to get the consensus. For others, we reached consensus by carefully reviewing the entire survey responses and scoring instructions. See Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e for how the consensus scores were recorded. Each issue in each community received a separate table. The average CRA Score was calculated if the community had at least three informants for a Survey Issue. Additionally, themes from the informants\u0026rsquo; responses to all the questions were extracted and recorded for qualitative analysis.\u003c/p\u003e \u003cp\u003eScoring of Collaboration Readiness was based on the response to a question that asked the informant to select one of six choices that corresponded to their organization\u0026rsquo;s status in collaboration. Scoring of Organizational Literacy was based on the responses to three questions that asked for the organization\u0026rsquo;s status in terms of their effort to help people, including those of diverse cultures and linguistic backgrounds and those with disabilities, find, understand, and use the information and services they provide. Each informant selected one of six choices for each of the questions and provided narrative comments which were analyzed for broad themes.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere were 72 key informants from 15 communities. The \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e were the same as the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2022 CHNA Priority Issues\u003c/span\u003e in 56 (78%) cases. The \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e were the same as the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e in 37 (51%) cases. The \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e were discussed in 46 cases. In 35 cases, they were discussed according to algorithm. In 11 cases, they were discussed when the algorithm was not followed by the interviewer. Of these 46 cases, discussion of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCHNA Issues chosen by program managers\u003c/span\u003e changed the issue for the survey in 21 (46%) cases. In total, the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e in response to question 2.1 were the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSurvey Issues\u003c/span\u003e in 51 (71%) cases. If the algorithm had been strictly followed, then the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIssues first mentioned\u003c/span\u003e would have been the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSurvey Issue\u003c/span\u003e in 62 (86%) cases. \u0026ldquo;Access to Health Care\u0026rdquo; was the most common Survey Issue, followed by \u0026ldquo;behavioral health.\u0026rdquo; See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows communities and issues that were able to have CRA scores calculated. The majority of CRA scores fell between \u0026ldquo;vague awareness\u0026rdquo; and \u0026ldquo;preplanning.\u0026rdquo; The blackened boxes indicate issues that did not have CRA scores due to not having at least three informants discussing an issue. Five communities did not receive CRA scores. Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e shows themes from qualitative analysis of the CRA.\u003c/p\u003e \u003cp\u003eFifty-nine key informants were surveyed on Collaboration Readiness Assessment and Organizational Literacy Assessment of their organizations. Of those, 46 (78%) were actively collaborating with other organizations; 49 (83%) were actively helping people find, understand, and use information and services provided by their organizations; 45 (76%) were actively outreaching to people of diverse cultures and linguistic backgrounds; and 39 (66%) were actively outreaching to people with disabilities. See Figs.\u0026nbsp;3, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e contains themes from qualitative analysis of how community members access and understand information (from the CRA dimension Community Knowledge of Efforts) and how organizations help community find, understand, and use information and services they provide (from Organizational Literacy Assessment).\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eAs part of our effort to improve health equity and increase the likelihood of success of interventions, we listened to the voices of the key informants by conducting a CRA to help us reduce our bias in funding decisions. For example, in a community with \u0026ldquo;vague awareness\u0026rdquo; of the priority issue, the focus may shift to raising awareness instead of simply funding needed services. For a community at preplanning, where there is clear recognition that something must be done but efforts are not focused or actively planned, the funding priority is to use the results of the Collaboration Readiness Assessment and bring potential partners together to start planning for an intervention. Further, the results of the Organizational Literacy Assessment, along with data from the CRA dimension \u0026ldquo;Community Knowledge of Efforts\u0026rdquo; about how community members access and understand information, contributed to strategies on how to help community members become aware of and access services, including those provided by the interventions we are funding. Proposed strategies include efforts to increase public Wi-Fi hotspots and to promote a centralized website for referral to nonprofit organizations because most people find information through word of mouth, referrals, and social media/websites.\u003c/p\u003e\n\u003ch3\u003eCRA Process Limitations and Recommendations\u003c/h3\u003e\n\u003cp\u003eIn some communities, there were not enough key informants to calculate a meaningful average CRA score for an issue. This was especially a problem for those communities with only three informants. Although all interviewers were trained, there were still errors in following the survey algorithm. This resulted in some key informants changing their issues, and incomplete data for some communities. Due to the small number of informants, incomplete data could not be discarded. For an issue that was discussed by only three informants in a community, discarding one informant\u0026rsquo;s incomplete data would result in inability to calculate an average CRA score for the issue in that community. Reviewing the entire survey responses could help the raters determine a score in these situations, but there were still times when this approach was ineffective. Another challenge for our CRA was to give a quantitative score to narrative responses of open-ended questions, which were more suited for qualitative analysis.\u003c/p\u003e \u003cp\u003eWe recommend that a healthcare system select a priority issue from their CHNA to conduct the CRA instead of asking each key informant to determine the CRA issue. The priority issues identified in the 2022 CHNA were also issues first mentioned by the key informants in the 2023 CRA 78% of the time, indicating a high agreement and that the CHNA results were valid. We also recommend using a combination approach of emailing instructions to at least six informants in each community to complete CRA scoring on their own using the rating tool without the survey questions, and then following up with three of them to probe for more details (Tri-Ethnic Center for Prevention Research, 2014, p. 30). The larger sample size of informants to assess their community should minimize skewing of the score by the response of one informant. The combination approach could also reduce time and effort in gathering data and eliminate the challenging task of scoring narrative responses. It will still maintain the ability for key informants to elaborate on the specific context and needs of their community.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eYun Tran conducted the work while being an MPH student at University of North Texas Health Science Center. She is currently a staff physician at John Peter Smith Health Network and assistant professor at Texas Christian University Burnett School of Medicine.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBushra Tahir Khan conducted the work while being an MPH student at Baylor University. She is currently a doctoral student at A.T. Still University Missouri School of Dentistry \u0026amp; Oral Health.\u003c/p\u003e\n\u003cp\u003eOther than the expertise and resources provided by the internship supervisor and support staff at the healthcare institution, no funding was received to assist with the work conducted or the preparation of this manuscript. The authors have no competing interests to declare that are relevant to the content of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. Corresponding author: Yun Tran\u003cbr\u003e\u0026nbsp;2. Country affiliation for Yun Tran: United States\u003cbr\u003e\u0026nbsp;3. Country affiliation for Bushra Tahir Khan: United States\u003c/p\u003e\n\u003cp\u003e4. Clinical trial number: not applicable.\u003cbr\u003e\u0026nbsp;5. Consent to Participate declaration. Every human participant has provided their consent.\u003cbr\u003e\u0026nbsp;6. Funding Declaration: There was no Funding.\u003cbr\u003e\u0026nbsp;7. Clinical trial number: not applicable.\u003cbr\u003e\u0026nbsp;8. Human Ethics and Consent to Participate declarations: not applicable.\u003cbr\u003e\u0026nbsp;9. Consent to Publish declaration: not applicable.\u003c/p\u003e\n\u003cp\u003e10. Data availability: The data collected were proprietary to the health system and not openly available.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.T. wrote the main manuscript text and prepared the tables, figures, and appendices. B.K. contributed to literature review for the introduction section. Both authors planned and implemented the project up to and including data collection. Y. T. carried out the data analysis and reporting. Both authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eAcknowledgementThis work was part of a Texas health system initiative and could not have been accomplished without the support and leadership of their community health improvement team.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data collected were proprietary to the health system and not openly available.\u003c/p\u003e"},{"header":"References","content":"\u003col class=\"decimal_type\"\u003e\n\u003cli\u003eCity Health Dashboard. (n.d.). \u003cem\u003eFort Worth, TX.\u003c/em\u003e Retrieved September 13, 2024, from https://www.cityhealthdashboard.com/TX/Fort%20Worth/metric-detail?metricId=37\u0026amp;dataPeriod=2015\u003c/li\u003e\n\u003cli\u003eU.S. Census Bureau. (n.d.-a). ZIP code tabulation area: 76119. 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Validation of a collaboration readiness assessment tool for use by Supplemental Nutrition Assistance Program-Education (SNAP-Ed) agencies and partners. \u003cem\u003eJournal of Nutrition Education and Behavior, 50\u003c/em\u003e(5). https://doi.org/10.1016/j.jneb.2017.11.002\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. (n.d.). \u003cem\u003eWhat is health literacy?\u003c/em\u003e Retrieved March 7, 2024, from https://www.cdc.gov/healthliteracy/learn/index.html \u003c/li\u003e\n\u003cli\u003eKowalski, C., Lee, S. D., Schmidt, A., Wesselmann, S., Wirtz, M. A., Pfaff, H., \u0026amp; Ernstmann, N. (2015). The health literate health care organization 10 item questionnaire (HLHQ-10): development and validation. \u003cem\u003eBMC Health Services Research, 15\u003c/em\u003e:\u003cem\u003e47\u003c/em\u003e. https://doi.org/10.1186/s12913-015-0707-5\u003c/li\u003e\n\u003cli\u003eBrach, C., Keller, D., Hernandez, L. M., Baur, C., Parker, R., Dreyer, B, Schyve, P., Lemerise, A. J., \u0026amp; Schillinger, D. (2012, June 19). \u003cem\u003eTen attributes of health literate health care organizations.\u003c/em\u003e National Academy of Medicine. https://nam.edu/perspectives-2012-ten-attributes-of-health-literate-health-care-organizations/ \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cem\u003eCommunity Readiness Assessment Dimensions\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.5769%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64.4231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.5769%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity knowledge of issue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64.4231%;\"\u003e\n \u003cp\u003eHow much do community members know about the causes and consequences of the issue, and the impact on the community?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.5769%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity knowledge of efforts to address the issue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64.4231%;\"\u003e\n \u003cp\u003eHow much do community members know about existing local programs that address the issue?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.5769%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeadership\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64.4231%;\"\u003e\n \u003cp\u003eHow much do community leaders support addressing the issue?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.5769%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity climate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64.4231%;\"\u003e\n \u003cp\u003eHow much do community members in general support addressing the issue?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.5769%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64.4231%;\"\u003e\n \u003cp\u003eWhat local resources \u0026ndash; funding, donation, space, volunteers, expertise \u0026ndash; are available?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSource: 7.\u0026nbsp;\u003c/strong\u003eCommunity Tool Box. (n.d.). \u003cem\u003eSection 9. Community Readiness\u003c/em\u003e. Retrieved January 29, 2024, from https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/community-readiness/main\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cem\u003eStages of Readiness (Assessed on each dimension and then averaged.)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo awareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003eCommunity members and leaders are generally unaware that the issue is a problem.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDenial/ resistance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003eOnly a few community members or leaders recognize that the issue is a problem, but most do not know or admit it is occurring locally.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVague awareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003eMost in the community know the issue is a problem, but there is no motivation to address it.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreplanning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003eThere is clear recognition that something must be done, but efforts are not focused or actively planned.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreparation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003eThere are leaders and community members actively planning and preparing to implement programs to address the issue.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitiation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003ePrograms have been newly implemented to address the issue.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStabilization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003ePrograms with experienced staff are supported community leaders and members.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConfirmation/ expansion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003eCommunity members feel comfortable using programs and they support expansions.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh level of community ownership\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1923%;\"\u003e\n \u003cp\u003eCommunity members have detailed knowledge about prevalence, causes, and consequences. Evaluation guides new directions of programs.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSource: 7.\u0026nbsp;\u003c/strong\u003eCommunity Tool Box. (n.d.). \u003cem\u003eSection 9. Community Readiness\u003c/em\u003e. Retrieved January 29, 2024, from https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/community-readiness/main\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003e\u003cem\u003e10 Attributes of Health Literate Health Care Organizations\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eHas leadership that makes health literacy integral to its mission, structure, and operations.\u003c/li\u003e\n \u003cli\u003eIntegrates health literacy into planning, evaluation measures, patient safety, and quality improvement.\u003c/li\u003e\n \u003cli\u003ePrepares the workforce to be health literate and monitors progress.\u003c/li\u003e\n \u003cli\u003eIncludes populations served in the design, implementation, and evaluation of health information and services.\u003c/li\u003e\n \u003cli\u003eMeets the needs of populations with a range of health literacy skills while avoiding stigmatization.\u003c/li\u003e\n \u003cli\u003eUses health literacy strategies in interpersonal communications and confirms understanding at all points of contact.\u003c/li\u003e\n \u003cli\u003eProvides easy access to health information and services and navigation assistance.\u003c/li\u003e\n \u003cli\u003eDesigns and distributes print, audiovisual, and social media content that is easy to understand and act on.\u003c/li\u003e\n \u003cli\u003eAddresses health literacy in high-risk situations, including care transitions and communications about medicines.\u003c/li\u003e\n \u003cli\u003eCommunicates clearly what health plans cover and what individuals will have to pay for services.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSource:\u0026nbsp;\u003c/strong\u003e24.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eBrach, C., Keller, D., Hernandez, L. M., Baur, C., Parker, R., Dreyer, B, Schyve, P., Lemerise, A. J., \u0026amp; Schillinger, D. (2012, June 19). \u003cem\u003eTen attributes of health literate health care organizations.\u003c/em\u003e National Academy of Medicine. https://nam.edu/perspectives-2012-ten-attributes-of-health-literate-health-care-organizations/\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003e\u003cem\u003eRegion Priorities and CHNA Issues\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7311%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegion (Number of communities assessed)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.479%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2022 CHNA Issues*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.7899%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHNA Issues chosen by program managers (discussed with informants only if their Primary/Other Issues do not fall in these categories)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7311%;\"\u003e\n \u003cp\u003eRegion 1 (2 communities)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.479%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eaccess to health care\u0026nbsp;\u003c/li\u003e\n \u003cli\u003echronic disease\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ebehavioral health\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.7899%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ebehavioral health\u003c/li\u003e\n \u003cli\u003ephysical health\u003c/li\u003e\n \u003cli\u003eaccess to health care\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7311%;\"\u003e\n \u003cp\u003eRegion 2 (2 communities)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.479%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eaccess to health care\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ebehavioral health\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.7899%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ebehavioral health\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7311%;\"\u003e\n \u003cp\u003eRegion 3 (3 communities)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.479%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eaccess to health care\u0026nbsp;\u003c/li\u003e\n \u003cli\u003efood\u0026nbsp;\u003c/li\u003e\n \u003cli\u003echronic disease\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.7899%;\"\u003e\n \u003cul\u003e\n \u003cli\u003echronic disease, specifically hypertension and diabetes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7311%;\"\u003e\n \u003cp\u003eRegion 4 (5 communities)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.479%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ebehavioral health\u0026nbsp;\u003c/li\u003e\n \u003cli\u003efood\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eaccess to health care\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.7899%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ebehavioral health\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7311%;\"\u003e\n \u003cp\u003eRegion 5 (3 communities)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.479%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eaccess to health care\u0026nbsp;\u003c/li\u003e\n \u003cli\u003esocial determinants of health (such as \u003cem\u003efood, housing, transportation, financial stability)\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003ebehavioral health\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.7899%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eaccess to health care\u003c/li\u003e\n \u003cli\u003esocial determinants\u003c/li\u003e\n \u003cli\u003ebehavioral health\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e The first column shows 5 regions and the number of communities involved in the 2023 Community Readiness Assessment. The second column shows the priority issues identified by the 2022 Community Health Needs Assessment. The third column shows the issues chosen by program managers for the 2023 Community Readiness Assessment. Access to health care is any issue regarding cost or lack of health insurance, providers/hospitals, transportation, knowledge to navigate health care system. Behavioral health is any issue regarding mental disorder or access to behavioral health services. For chronic disease, the focus is diabetes and hypertension.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u0026nbsp;\u003c/strong\u003e\u003cem\u003eSample Table for Recording of Scores and Calculation of Average CRA Score\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.2276%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommunity Name: ____\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9717%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurvey Issue: ____\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6578%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.4019%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4835%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.2276%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9717%;\"\u003e\n \u003cp\u003eCommunity Knowledge of Survey Issue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003eCommunity Knowledge of Efforts (Programs to Address Survey Issue)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6578%;\"\u003e\n \u003cp\u003eLeadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003eCommunity Climate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.4019%;\"\u003e\n \u003cp\u003eResources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4835%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.2276%;\"\u003e\n \u003cp\u003eInformant #1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9717%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6578%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.4019%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4835%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.2276%;\"\u003e\n \u003cp\u003eInformant #2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9717%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6578%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.4019%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4835%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.2276%;\"\u003e\n \u003cp\u003eInformant #3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9717%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6578%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.4019%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4835%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.2276%;\"\u003e\n \u003cp\u003eAverage by Dimension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9717%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6578%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.4019%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4835%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAverage CRA Score: ______\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e All the white spaces were to be filled in with data, including Community Name, Survey Issue, rating of each dimension by informant and on average, and the average CRA score. The average CRA Score was calculated by adding the average of each dimension, and then dividing the sum by 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6\u0026nbsp;\u003c/strong\u003e\u003cem\u003eCommunities and Issues with CRA Scores\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Informants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvey Issue (Number of informants)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage CRA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRegion 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to health care (4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioral health (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to health care (4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eBehavioral health (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eResources (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRegion 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to health care (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioral health (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eFood (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioral health (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eAccess to health care (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eResources (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRegion 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to health care (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic disease (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eAccess to health care (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eFood (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eChronic disease (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eAccess to health care (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRegion 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioral health (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eBehavioral health (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eFood (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eBehavioral health (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eFood (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioral health (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioral health (4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eAccess to health care (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRegion 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to health care (4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eHousing (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eFood (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eHousing (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eAccess to health care (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eCommunity 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to health care (3)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e \u0026ldquo;Resources\u0026rdquo; refers to the general lack of services (or lack of knowledge regarding the services) that address various health and social needs.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7\u0026nbsp;\u003c/strong\u003e\u003cem\u003eCommon Themes from Qualitative Analysis of the CRA across 5 Regions\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eThemes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 590px;\"\u003e\n \u003cp\u003eDetails\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003eAccess to health care is the most common issue of concern with one or more factors.\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 590px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAffordability (lack of insurance and high cost of services)\u003c/li\u003e\n \u003cli\u003eAvailability (lack of providers and hospitals, especially public county hospitals)\u003c/li\u003e\n \u003cli\u003eTransportation\u003c/li\u003e\n \u003cli\u003eHealth literacy (lack of knowledge about resources to get care; issues like behavioral health are not existing concepts in some cultures)\u003c/li\u003e\n \u003cli\u003eBehavioral health issue is often a problem about access to care as well.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eStigma is a major obstacle for every issue that affects health.\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 590px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePeople tend not to ask for help with anything because getting assistance is associated with shame and guilt.\u003c/li\u003e\n \u003cli\u003eThere is a culture to not discuss personal problems especially behavioral health issues.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eLack of funding for outreach hinders awareness of issues and programs that address them.\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 590px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eMany people still rely on word of mouth and community engagement events for information.\u003c/li\u003e\n \u003cli\u003eInformation online is not centralized and hard to find.\u003c/li\u003e\n \u003cli\u003ePrint materials are often in places where people do not visit regularly (city hall, jail lobbies, doctor\u0026rsquo;s office, etc.)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003eMany people, including target populations, ignore information despite outreach.\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 590px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eThe target populations prioritize other life demands. (Example: School events planned for parents to address behavioral health are poorly attended.)\u003c/li\u003e\n \u003cli\u003eGeneral community members are not aware or concerned about issues. (\u003cem\u003e\u0026ldquo;It doesn\u0026rsquo;t affect me.\u0026rdquo;\u003c/em\u003e)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003col start=\"5\"\u003e\n \u003cli\u003e\u003cstrong\u003ePolitics affects community health improvement efforts.\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 590px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePolitics influences what information is available and whether programs are implemented.\u003c/li\u003e\n \u003cli\u003eIt is vital to frame issues and communicate programs in ways that will be accepted by general community members.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8\u0026nbsp;\u003c/strong\u003e\u003cem\u003eCommon Themes from Qualitative Analysis of Community Knowledge of Efforts and Organizational Literacy\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 623px;\"\u003e\n \u003col\u003e\n \u003cli\u003eCommunity members find information mostly through \u003cstrong\u003eword of mouth\u003c/strong\u003e,\u003cstrong\u003e\u0026nbsp;referrals\u003c/strong\u003e, and \u003cstrong\u003esocial media/websites\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003eTo reach the general public, most organizations \u003cstrong\u003euse plain language\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003ehave multiple modes of communication\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003eSome organizations have effort to outreach to those from diverse cultural and linguistic backgrounds, but such effort is often \u003cstrong\u003elimited to Spanish.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eMost organizations can accommodate those with disabilities, but \u003cstrong\u003edo not have a structured outreach effort to help those with disabilities\u003c/strong\u003e find their programs or understand the information they provide.\u003c/li\u003e\n \u003cli\u003eSome organizations \u003cstrong\u003epartner with school districts\u0026nbsp;\u003c/strong\u003e(with their existing structures to serve all children) to reach those from diverse cultural backgrounds and those with disabilities. However, this channel does not reach those without children in schools.\u003c/li\u003e\n \u003cli\u003eLack of \u003cstrong\u003efunding\u003c/strong\u003e and \u003cstrong\u003equalified staff\u0026nbsp;\u003c/strong\u003eare the biggest barriers for targeted outreach.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Community Readiness Assessment, Collaboration Readiness, Organizational Literacy, Grant Strategic Decision Making","lastPublishedDoi":"10.21203/rs.3.rs-6505495/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6505495/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eA Community Readiness Assessment (CRA) that also evaluated Collaboration Readiness and Organizational Literacy was planned and implemented as part of our health system\u0026rsquo;s effort to improve health equity through funding collaborative community interventions. A crucial step following the Community Health Needs Assessment (CHNA), the CRA aimed to inform grant strategy because communities with higher readiness tend to have better intervention outcomes.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThe CRA tool detailed by Tri-Ethnic Center for Prevention Research at Colorado State University was modified. Each key informant determined the issue that should be addressed. A community where at least three informants discussed the same issue received an average CRA score. Those affiliated with relevant community organizations were also surveyed on Collaboration Readiness and Organizational Literacy.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeventy-two key informants from 15 communities were interviewed. Average CRA scores were calculated in 10 communities where the most common issues were \u0026ldquo;access to health care\u0026rdquo; and \u0026ldquo;behavioral health.\u0026rdquo; Most readiness fell on \u0026ldquo;vague awareness\u0026rdquo; and \u0026ldquo;preplanning.\u0026rdquo; Majority of the organizations surveyed on Collaboration Readiness and Organizational Literacy were already (a) collaborating with partners and (b) helping people, including those of diverse cultures and linguistic backgrounds and those with disabilities, find, understand and use information and services provided by their organizations.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe CRA results were used to inform grant strategy. Future considerations have been described to enhance the process.\u003c/p\u003e","manuscriptTitle":"Planning and Implementation of Community Readiness Assessment: Experience and Lessons Learned by a Health System","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-29 18:07:59","doi":"10.21203/rs.3.rs-6505495/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a000f464-8587-4aaf-bc03-740c5a004af7","owner":[],"postedDate":"May 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-15T07:24:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-29 18:07:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6505495","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6505495","identity":"rs-6505495","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}