Table 2.

Action Strategies for Citizen Health Care

Action Strategy	Rationale
1. Get buy-in from key professional leaders & administrators; “stakeholders”.	These are the gatekeepers who must support the initiation of a project based on its potential to meet the goal(s) of the community. Key point to emphasize to stakeholders: you want to move interdisciplinary collaboration from treating one individual at a time to collaborating with families and communities to effect change on a larger scale. It is best to request little or no budget, beyond a small amount of staff time, in order to allow the project enough incubation time before being expected to justify its outcomes. Play it Forward!: University researchers talked with several City Mayors and Parks and Recreation Directors to discuss the Citizen Health Care approach to collaboration and to identify potential “pressure points”. The Mayor and Parks and Recreation Director of Burnsville were very supportive of the pressure point and the Citizen Health Care CBPR model. This component of the CBPR process included several meetings (about two per City) with four different Mayors of Cities in the Twin Cities, MN. Ultimately Burnsville was the best fit for the project.
2. Identify a health issue that is of great concern to both professionals and members of a specific community (e.g., clinic, neighborhood, cultural group in a geographical location).	Citizen Health Care begins with the notion that all personal health problems can also be seen as public problems. The health issue must be one that a community of citizens actually cares about—not just something we think they should care about. Additionally, professionals must care about the issue and have enough passion for it to sustain their efforts over time. It must be a “pressure point”. For example, childhood obesity is a pressure point because it can be viewed in terms of its consequences for individuals, families and the surrounding community. Play it Forward!: The “pressure point” of childhood obesity prevention was an issue that all stakeholders were passionate about. The pressure point was reframed as child health and wellness. This component of the CBPR process took four meetings to clearly define the pressure point. Pilot study ideas were also discussed from the beginning of the partnership.
3. Identify potential community leaders who have personal experience with the health issue & who have relationships with the professional team.	Leaders should be ordinary members of the community who in some way have mastered the selected health issue in their own lives & have a desire to give back to their community. “Positional” leaders who head community agencies are generally not the best group to engage at this stage—they bring institutional priorities & constraints. Play it Forward!: After several meetings (4 meetings) with the Mayor, Parks and Recreation Director and university researchers, there was consensus to move forward with the pressure point. The Mayor, Parks and Recreation director and university researchers created criteria for characteristics of parents who would be a good fit for the Citizen Action Group (CAG). This component of the CBPR process took three meetings.
4. Invite a small group of community leaders (three or four people) to meet several times with the professional team to explore the issue & see if there is a consensus to proceed with a larger community project.	These preliminary discussions help determine whether a Citizen Health Care project is feasible & begin creating a professional/citizen leadership group. Ultimately you want to access a community resource that is largely untapped: the knowledge, lived-experience, wisdom, and energy of individuals and their families who face challenging health issues in their everyday lives. Play it Forward!: The Mayor, Parks and Recreation director and university researchers created criteria for the CAG and recruitment of CAG members (3 meetings). Ultimately, the Mayor allowed her Parks and Recreation director to officially represent the City of Burnsville and she stepped out of the official CAG process. However, the Mayor did attend several Play it Forward! events to reinforce her involvement in the project. Flat hierarchies were employed from the beginning of the CBPR process, but the concept of a flat hierarchy was discussed at length at this key turning point when the CAG was about to be recruited.
5. Strategize how to invite a larger group of community leaders (10–15) to begin the process of generating the project.	You must have a larger group invested in the process to facilitate a larger “We” focus. Ordinary “citizens” become assets in health care as they work alongside their neighbors and others as co-producers of health for themselves and their communities. Play it Forward!: The Mayor and Parks and Recreation Director of Burnsville had an email list of families who had attended city parks and recreation activities and events. These potential families fit the criteria the researchers and leadership at Burnsville City had collaboratively created. All families on the email list were invited to a launch event to see if they would be interested in becoming CAG members. This component took one month to carry out. About 15 parents attended the launch event. Ultimately, 9 parents were invited to participate in the CAG. These community parents were representative of the overall Paha Sapa neighborhood. There was a mix of male and female parents of children ages 6–12 years.
6. Over the next six months have biweekly meetings using community organizing principles.	The following key steps are crucial, but can be slow & messy: (a) explore the community & citizen dimensions of the issue; (b) create a name & mission statement for the initiative; (c) conduct one-on-one interviews with a range of stakeholders; (d) generate potential action initiatives & process them in regards to the Citizen Health Care model & existing community resources; (e) decide on a specific action initiative & implement it. Play it Forward!: CAG members met bi-weekly to carry out a needs assessment. Each CAG member approached 5–10 neighbors who lived in the Paha Sapa neighborhood and who had children between the ages of 6–12 years. Based on their interview findings, a name and mission statement was created and potential action initiatives were created. CAG members used interview themes to create the intervention.
7. Employ Citizen Health Care processes throughout the project.	The following steps will keep the initiative focused, strong, & increase sustainability: (a) democratic planning & decision making at every step; (b) mutual teaching & learning among community members; (c) creating ways to fold new learnings back into the community; (d) identifying & developing leaders; (e) using professional expertise selectively—“on tap,” not “on top”; (f) forging a sense of larger purpose. Play it Forward!: University researchers and Paha Sapa community members collaborated throughout every step of the needs assessment, intervention development, intervention delivery and pilot study data collection, analyses and presentation of results.