Presenting Research Findings

http://hpp.sagepub.com/ Health Promotion Practice

http://hpp.sagepub.com/content/10/1/24 The online version of this article can be found at:

DOI: 10.1177/1524839906289048

2009 10: 24Health Promot Pract Katz

Kari A. Hartwig, Richard Louis Dunville, Michael H. Kim, Becca Levy, Margot M. Zaharek, Valentine Y. Njike and David L. Promoting Healthy People 2010 Through Small Grants

Published by:

http://www.sagepublications.com

On behalf of:

Society for Public Health Education

can be found at:Health Promotion PracticeAdditional services and information for

http://hpp.sagepub.com/cgi/alertsEmail Alerts:

http://hpp.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

http://hpp.sagepub.com/content/10/1/24.refs.htmlCitations:

What is This?

- Dec 30, 2008Version of Record >>

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

Promoting Healthy People 2010 Through Small Grants

Kari A. Hartwig, DrPH Richard Louis Dunville, MPH

Michael H. Kim, MPH Becca Levy, PhD

Margot M. Zaharek, MS Valentine Y. Njike, MD, MPH

David L. Katz, MD, MPH

objectives (U.S. Department of Health and Human Services [DHHS], 2000a). Today’s Healthy People 2010 (HP 2010) goals and objectives build on the previous two decades’ accomplishments and set national targets for reducing disease and disability and promoting healthier, longer lives (DHHS, 2000b). Led by the U.S. DHHS, the overarching goals of the current initiative are to increase quality and years of life and to eliminate health disparities (Davis, 2000; DHHS, 2003). DHHS (2001) encourages working through communities and local organizations to influence individual behavior and the promotion and maintenance of environments conducive to healthier lifestyles.

>>BACKGROUND

Building on the health promotion premise that orga- nizations and communities are instruments of change (McLeroy, Bibeau, Steckler, & Glanz, 1988; Stokols, 1992), the DHHS Office of Disease Prevention and Health Promotion (ODPHP) initiated a pilot study in October 2001 to develop a national model for engaging community organizations in health promotion and dis- ease prevention activities that reflect the national HP 2010 goals and objectives. ODPHP awarded the Healthy People 2010 Microgrant Project, one of two pilot stud- ies, to Yale University’s Prevention Research Center (PRC) from a field of 80 applicants. A comparison of the two implementation models funded is described elsewhere (Hartwig et al., 2006). The primary purpose of this initiative was to promote the HP 2010 objectives among government and nongovernmental community- based organizations through the distribution of small grants or “microgrants” of up to U.S. $2,010. The idea of

The Department of Health and Human Services initi- ated a pilot “microgrant” or small grants program in 2001 to promote Healthy People 2010 (HP 2010) imple- mented by the Yale-Griffin Prevention Research Center. This article describes the 103 agencies funded under this initiative and 67 control group agencies. It evalu- ates the HP 2010 focus areas targeted and the effec- tiveness of promoting HP 2010 objectives through microgrants. Forty-four percent of the grant recipients and 79% of the control group agencies indicated low levels of familiarity with HP 2010 goals. Changes in knowledge of HP 2010 goals for the microgrant group increased significantly from 5.24 ± 3.67 to 7.83 ± 1.86 (p < .05). The results suggest that microgrants can be a useful mechanism to plant the seeds for developing community and organizational capacity to define local health priorities, practice and test new initiatives or expand existing programs and promote knowledge about HP 2010.

Keywords: Healthy People 2010; community capacity; small grants; microgrants; health promotion

S ince the 1979 U.S. surgeon general’s report on health promotion and disease prevention, the nation’s health agenda has been framed by a

“healthy people” platform that lays out decade-long

Health Promotion Practice January 2009 Vol. 10, No. 1, 24-33 DOI: 10.1177/1524839906289048 ©2009 Society for Public Health Education

Articles

24

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

Hartwig et al. / HEALTHY PEOPLE 2010 AND SMALL GRANTS 25

small grants arose from the practice of microfinancing or microcredit initially developed by the Grameen Bank in Bangladesh to provide small loans to poor women (Yunus, 2001). Since it was initiated in the 1970s, the loan mechanism has been used all over the globe, most commonly in low-income countries as a means to reduce poverty by increasing access to credit among the poor (Srinivas, 2005; Swider, 2003). Most often individuals receive the loans; however, in some variations organizations have been recipients as well. The most common form of evaluation measure for microcredit programs is the percentage of repayment. Bhatt, Painter, and Tang (1999) suggested that micro- credit attempts in the United States have worked less well than in the developing world where loans typi- cally have a 3% default repayment rate. In the United States, those who received microcredit loans generally increased their household assets and reduced their reliance on public assistance by more than 60%.

However, the number of loans made is relatively low, and the overhead costs for managing the projects are high. Other problems identified in the United States were the lack of aggressive advertising about the loans, challenges finding “creditworthy applicants,” higher salaries of U.S. residents, increasing overhead, and poor management by loan institutions in following up with loan defaulters.

Transferring the microfinancing model from a loan scheme to a grant scheme is an innovation, particularly in the United States. Only one prior example of this innovation being used within the U.S. public health context was found in the literature (Paine-Andrews, Francisco, & Fawcett, 1994). In this example, the local United Way in Kansas in partnership with the Work Group on Health Promotion and Community Develop- ment had $10,000 to distribute in small grants to formal and informal organizations following a recently com- pleted community-wide health planning process. Paine-Andrews et al. (1994) found the grants to be a useful tool in engaging community members in defin- ing their own health priorities and leveraging necessary resources. In the literature on HP 2010, we commonly see examples of a single research intervention targeting one or two HP 2010 objectives; there are no examples in the literature that we could find trying to influence hundreds of organizations simultaneously to rally around HP 2010.

Although not an explicit theoretical foundation for the initiative, we can look to the theory of diffusion of innovations (Rogers, 1995) to frame our understanding of the potential significance of the microgrants mecha- nism to increase organizations’ familiarity with HP 2010 and ability to achieve its objectives. Some of the key constructs in the diffusion of innovation theory include its relative advantage over what it will replace, complexity of the innovation (how difficult is it to do), adaptability (how easily it can be adapted by the user to existing skills and/or structures), observability (if one can observe others “using” the innovation), and tri- alability (can one try out the innovation and stop it; Oldenburg & Parcel, 2002). This article reports on the effectiveness of the model to promote HP 2010, the types of organizations participating, their objectives, and examples of the microgrant projects implemented.

>>IMPLEMENTATION MODEL

The PRC developed the request for applications (RFA) and application guidelines, report procedures, evalua- tion tools; organized advisory panels, and then placed a request for proposals (RFP) to agencies across the state of Connecticut. One hundred forty-four agencies

The Authors

Kari A. Hartwig, DrPH, is assistant clinical professor at Yale School of Public Health in New Haven, Connecticut and associate director of the Community Division for the Yale- Griffin Prevention Research Center in Derby, Connecticut.

Richard Louis Dunville, MPH, is an epidemiologist in the HIV/AIDS Section of the Georgia Division of Public Health in Atlanta, Georgia, and was a research assistant at the time of this study with the Yale-Griffin Prevention Research Center in Derby, Connecticut.

Michael H. Kim, MPH, is an analyst at HealthFirst in New York City, New York, and was a research assistant at the time of this study with the Yale-Griffin Prevention Research Center in Derby, Connecticut.

Becca R. Levy, PhD, is an associate professor of epidemi- ology and psychology at Yale School of Public Health in New Haven, Connecticut.

Margot M. Zaharek, MS, is a nutritionist at the Depart- ment of Health and Social Services in Bridgeport, Connecti- cut, and was the community action coordinator at the time of this study with the Yale-Griffin Prevention Research Center in Derby, Connecticut.

Valentine Y. Njike, MD, MPH, is the data manager at the Yale- Griffin Prevention Research Center in Derby, Connecticut.

David L. Katz, MD, MPH, is director of the Yale-Griffin Prevention Research Center, in Derby, Connecticut and associate professor at Yale School of Public Health in New Haven, Connecticut.

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

26 HEALTH PROMOTION PRACTICE / January 2009

responded to the RFP asking agencies to target an HP 2010 objective of their choosing; 103 agencies met the criteria for funding. To achieve an adequate control group size of 67, nonfunded agencies in Connecticut, as well as organizations in Rhode Island and Massachusetts, both small states with demographics similar to Connecticut, were encouraged to participate in the control group. All agencies completed baseline comparison surveys addressing organizational charac- teristics, organizational capacity and familiarity with HP 2010. Most of the implementation, management, and evaluation of the microgrants initiative were han- dled by two full-time staff with additional part-time assistance from faculty, data analysts, and masters of public health interns. During the course of the imple- mentation period, the PRC sponsored a series of work- shops for microgrant recipients on the topics of (a) grant writing, (b) project management, (c) evaluation, and (d) presenting findings and provided technical assis- tance by phone or in person as needed. At the end of the project, the PRC hosted a conference for all grantees where they presented their results through posters and oral presentations to local health department and state and foundation representatives.

>>METHOD

Design

A quasi-experimental pre- and postsurvey design was used to test the efficacy of providing microgrants to public health and non-public-health agencies to pro- mote HP 2010 objectives. The organizational capacity questions were taken from a United Way survey, and the questions related to HP 2010 were developed specifically for this project and subject to face and con- tent validation, but not criterion validation. The survey instrument was distributed by mail. The baseline sur- veys were collected from July to November 2002. A $100 incentive was offered to control group organiza- tions ($25 at the first survey and $75 for the end of proj- ect survey); to increase the response rate, the control group survey was shortened and agencies were first contacted by phone about their willingness to partici- pate in the survey, and upon agreement, the survey was sent by fax or mail. Follow-up surveys were distributed approximately 9 months later following completion of the microgrant projects in March to May 2003. During the period of implementation, 15% of agencies were randomly selected for onsite visits by the project coor- dinator, using an observation checklist for systematic review of project progress. At the end of the microgrant funding, staff entered all final reports into ATLAS.ti

(2003), a qualitative software package for qualitative analysis of project implementation themes. In addition, staff conducted three focus groups with differing groups of agencies to assess changes in organiza- tional capacity. These data are reported elsewhere (Dunville et al., n.d.).

Measures

Organizational characteristics. The baseline survey instrument recorded various organizational character- istics in the grantee and control group organizations. This section included multiple-choice responses for questions such as type of agency (e.g., civic, health and human service, government, etc.), and size of grants they had applied for in the past. A number of questions were open ended such as age of agency, total number of employees, size of population served, and percentage of population served by ethnicity, age, and gender. Following receipt of the surveys and initial data entry, the open-ended responses were recoded into categories such as 0% to 25%, 26% to 50%, 51% to 75%, and 76% to 100% of population was African American. Categories were used exclusively to display data; cal- culations were based on actual responses.

HP 2010 measures. To determine the level of organiza- tional knowledge and awareness of HP 2010 objectives, baseline and follow-up surveys included information on each organization’s familiarity with HP 2010 goals and objectives, previous work focusing on HP 2010 objectives, effectiveness in promoting HP 2010, and capacity to carry out the goals of the organization. These variables were measured on a scale of 1 to 10, with 10 indicating the highest value. For example, one question asked, “On a scale of 1-10 (1 = not at all effec- tive, 10 = extremely effective) how would you rate your agency’s effectiveness in promoting the goals of Healthy People 2010?” There were also a number of questions asking about each agency’s grant history, including number and size of past grants. Past success obtaining grants used a 1 to 5 scale, with 1 considered very successful and 5 as poor.

Sampling and selection. The selection process for microgrant recipients was based on their response to a RFP. The RFP was distributed through an Infoline data- base provided by the United Way, as well as radio, Internet, and newspaper announcements. Using set cri- teria, an External Review Committee reviewed and ranked the 144 proposals received and recommended 103 to the PRC for funding. Criteria for selection

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

included (a) a nonprofit agency in Connecticut, (b) project objectives targeted to one of the HP 2010 goals, (c) quality of implementation and evaluation plan, and (d) use of funds (e.g., explicit exclusion criteria for funding were items such as construction, endowments, commercial activity, etc.). Microgrant recipients com- pleted baseline surveys to receive project funds; 103 baseline surveys and 84 follow-up surveys were completed. The individuals directly responsible for man- aging each microgrant project and orga- nizational leaders (e.g., director, project manager) of the control agencies were asked to complete the surveys. It was encouraged, when possible, that the same person within each organization partici- pated in the pre- and postsurvey.

The sampling frame for the control group included a similar Infoline mailing to agencies in Rhode Island, Massachusetts, and Connecticut (not funded through the microgrant process). The comparison states were chosen given their similar geographic and population size, proxim- ity, and shared demographic characteristics. An initial 150 surveys were mailed to control group agencies; after 6 weeks, repeat mailings to the same agencies were delivered plus an additional 50 agencies. Following another 4-6 weeks, 50 of the agencies were contacted by phone and fax using an abbreviated sur- vey instrument. Surveys were mailed to a total of 200 potential control group agencies; 40 were mailed back, and an additional 27 were completed by phone or fax (after a phone contact) for a total of 67 baseline surveys. At the end of the project, 51 control group agencies completed the end-of-project surveys.

Analysis

All quantitative data were entered into Microsoft Excel spreadsheets, coded, and verified. SAS V8 (SAS, 2002) was employed for all calculations. For descriptive statistics, general frequency counts were generated as indicated in the tables. As the data are con- tinuous and not normally distributed, nonparametric methods were used. The Wilcoxon rank sum test was employed for between-group and within-group compar- isons. The Mann–Whitney U test was used to analyze correlations between specific variables. A p value of < .05 was used to determine statistical significance.

Narrative reports were entered into ATLAS.ti and coded initially according to type of agency, population

served and HP 2010 objectives. Additional codes were added for implementation characteristics such as unex- pected barriers and opportunities, lessons learned, leveraging of funds, and use of volunteers.

>>RESULTS

Descriptive Statistics

Characteristics of the organizations, including years of existence, total number of employees and volun- teers, size of population served, gender and ethnic dis- tributions, and type of agency were examined and are summarized in Table 1. In comparison to the control group, there was no significant difference in the distri- bution of agency age (p = .62), total number of employ- ees (p = .31), and size of population served (p = .07). However, grantees were more likely to target racial minority populations (p = .0017). The average target population served by the grantees was 22% Hispanic, 37% African American, 58% women, and 18% adults older than age 50 years. More than one half of the proj- ects attempted to address health-related disparities identified within their communities. For example, Connecticut Campus Compact provided mobile van medical and dental units to low-income populations; Connecticut Children’s Medical Center was able to include additional low-income overweight children in their childhood obesity reduction program. Two churches in Bridgeport, one largely African American and another Hispanic, conducted health fairs at their churches bringing in more than 100 participants from the

Hartwig et al. / HEALTHY PEOPLE 2010 AND SMALL GRANTS 27

FIGURE 1 Location of Microgrant Recipients in Connecticut

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

28 HEALTH PROMOTION PRACTICE / January 2009

church and neighborhoods. Figure 1 displays the geo- graphic distribution of organizations across the state.

There was a significant (p = .0019) difference in the types of agencies in each category. The greatest per- centages of grant recipients were health and human service (HHS) organizations (25.2%), followed by med- ical (22.3%), whereas HHS agencies made up more than one half of the control group. Examples of grant

recipient agencies included local health departments, the Visiting Nurses Association, an African American cancer support group, the Bridgeport Police Department, a local Girl Scouts chapter, neighborhood associations, and a homeless shelter.

The levels of organizational knowledge and aware- ness of HP 2010 objectives within the agencies are described in Table 2. This variable was assessed on a

TABLE 1 Baseline Characteristics of Organizations: Type, Age, No. of Employees, and Population Characteristics

Grant Recipients Control Group ( N = 103) ( N = 67)

% n % n

Type Educational 9.71 10 7.46 5** Faith-based 12.62 13 11.94 8** Health and human service 25.24 26 56.72 38** Community 13.59 14 14.93 10** Civic 4.85 5 5.97 4** Medical 22.33 23 2.99 2** Government 10.68 11 0.00 0** Other 0.97 1 0.00 0**

Age < 5 yrs 14.56 15 1.49 1** 5-20 yrs 24.27 25 44.78 30** 21-50 yrs 33.01 34 34.33 23** > 50 yrs 28.16 29 17.91 12** N/A 0.00 0 1.49 1**

Total employees < 5 people 20.39 21 32.84 22** 5-10 people 12.62 13 11.94 8** 11-20 people 10.68 11 14.93 10** 21-40 people 16.50 17 14.93 10** > 40 people 32.04 33 22.39 15** N/A 7.77 8 1.49 1**

Size of population served < 500 16.51 17 14.93 10** 501-5,000 21.36 22 16.42 11** 5,001-50,000 28.16 29 7.46 5** > 50,001 people 28.16 29 16.42 11** N/A 5.83 6 44.78 30**

% Ethnic minority < 30% 30.10 31 34.33 23** 30%-50% 13.59 14 8.96 6** 51%-75% 19.42 20 8.96 6** > 75% 35.92 37 11.94 8** N/A 0.97 1 35.82 24**

**p < .05.

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

Hartwig et al. / HEALTHY PEOPLE 2010 AND SMALL GRANTS 29

Likert-type scale with the question: “On a scale of 1-10 (1 = not at all familiar, 10 = very familiar) how famil- iar is your agency/organization today with Healthy People 2010 objectives?” Overall, most agencies showed little working knowledge of HP 2010 regardless of organizational type. However, grant recipients were significantly more likely than the controls to be famil- iar with HP 2010 at the baseline. At baseline, more than one fourth of the grant recipients (28, 27.45%) answered

1 (not at all familiar), while about one fourth (25, 24.51%) answered with a 10 (very familiar). In the con- trol group, more than one half of the organizations (37, 55.22%) answered with a familiarity rating of 1, with very few (2, 2.99%) answering with a 10. There was a significant difference (p < .0001) between the grant recipients and the control group for this variable. Organizations were then stratified according to type of agency. When HHS agencies were compared to nontra- ditional public health agencies such as schools, churches, and homeless shelters, there was no signifi- cant difference (p = .14) in their awareness of HP 2010 goals. In the follow-up survey, grantees and controls reported an increase in their familiarity with the HP 2010 objectives (see Figure 2); however, the increase was sig- nificantly more dramatic for grantees (p = .00012).

Statistically significant differences were found (p < .0001) between grantees and controls for agency effectiveness in promoting the HP 2010 goals and objectives. The reported ability to promote the goals of HP 2010 from baseline to follow-up increased slightly in the grantees but remained relatively stagnant in con- trols. There was no significant (p = .2087) difference between the groups. Respondents were also asked if they planned to implement new projects directly relat- ing to HP 2010 objectives, and grantees were more likely to respond affirmatively (p = .0016). Among the

TABLE 2 Baseline Agency Statistics: Familiarity With Healthy People 2010 (HP 2010), Previous Work Toward HP 2010,

and Effectiveness in Promoting HP 2010

Grant Recipients (N = 103) Control Group (N = 67)

Frequency % Frequency %

Familiarity with HP 2010** M = 5.235 σ = 3.673 M = 2.567 σ = 2.494 1 1-3 45 43.69 53 79.10 2 4-6 13 12.62 5 7.46 3 7-9 19 18.45 7 10.45 4 10 25 24.27 2 2.99

N/A 1 0.97 0 0.00 Wilcoxon mean score 99.10 63.53 Effectiveness in promoting HP 2010** M = 7.833 σ = 1.763 M = 4.129 σ = 2.884

1 1-3 4 3.88 14 20.90 2 4-6 13 12.62 9 13.43 3 7-9 62 60.19 7 10.45 4 10 16 15.53 1 1.49

N/A 8 7.77 36 53.73 Wilcoxon mean score 74.72 30.79

**p < .05.

0

10

20

30

40

50

60

70

1 (1-3) 2 (4-6) 3 (7-9) 4 (10)

Familiarity with HP 2010

F re

q u

e n

c y

Baseline Survey Post Survey

FIGURE 2 Microgrant Recipients Pre- and Postknowledge of Healthy People 2010 (HP 2010)

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

30 HEALTH PROMOTION PRACTICE / January 2009

microgrant recipients there were significant changes (p < .05) in level of self-reported organizational knowl- edge and awareness of the HP 2010 objectives from the start to the end of the study period, with a mean response of 5.2 at baseline versus 7.8 at follow-up. In the control group, the change was not significant, with a mean baseline of 2.5 compared to 3.5 at the end of project. On the same scale, grantees reported an increase in their organizations’ effectiveness in pro- moting HP 2010 objectives from a mean of 7.8 at base- line compared to a mean of 8.1 at follow-up; however, this difference was not significant. The control group

showed no change, with a mean of 4.1 at both points in time. Figure 1 displays the differences over time with the grantee organizations.

HP 2010 contains 467 objectives and 28 focus areas. In the current study, the HP 2010 focus areas selected by the microgrant recipients and the control group were generally comparable, with significant differences in only 4 of the 28 focus areas. As Table 3 indicates, the most common focus areas selected by microgrant recip- ients were nutrition and overweight (14.86%), physical activity and fitness (12.57%), access to quality health services (11.43%), substance abuse (8.57%), and tobacco

TABLE 3 Healthy People 2010 (HP 2010) Focus Areas Selected by Microgrant Recipients and Control Group

Grant Recipients Control Group

HP 2010 Focus Area % n % n

1. Access to quality health servicesa 11.43 20 2.30 2* 2. Arthritis, osteoporosis, and chronic back conditions — — — — 3. Cancer 1.14 2 1.15 1 4. Chronic kidney disease — — — — 5. Diabetes 4.00 7 1.15 1 6. Disability and secondary conditions 0.57 1 8.05 7* 7. Educational and community-based programsa 5.14 9 12.64 11* 8. Environmental health 1.14 2 2.30 2 9. Family planning 1.14 2 4.60 4

10. Food safety — — — — 11. Health communication 1.71 3 — — 12. Heart disease and stroke 5.14 9 1.15 1 13. HIV 1.71 3 3.45 3 14. Immunization and infectious diseases 1.14 2 0.00 0 15. Injury and violence preventiona 6.29 11 11.49 10 16. Maternal, infant, and child health 2.29 4 5.75 5 17. Medical product safety — — — — 18. Mental health and mental disordersa 6.86 12 10.34 9 19. Nutrition and overweighta 14.86 26 12.64 11 20. Occupational safety and health — — — — 21. Oral health 1.71 3 — — 22. Physical activity and fitnessa 12.57 22 3.45 3* 23. Public health infrastructure — — — — 24. Respiratory diseases 1.14 2 1.15 1 25. Sexually transmitted diseases 3.43 6 1.15 1 26. Substance abusea 8.57 15 14.94 13 27. Tobacco usea 7.43 13 2.30 2 28. Vision and hearing 0.57 1 — — Total 175b 87b

a. Top five focus areas selected by grant recipients and control. b. Some organizations selected more than one focus area; therefore, the total reflects the number of categories selected rather than the number of agencies. Total grant recipients = 103, and total control group organizations = 67. *p < .05.

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

use (7.43%). The most common focus areas targeted by the control group included substance abuse (14.94%), education and community-based programs (12.64%), nutrition and overweight (12.64%), injury and violence prevention (11.49%), and mental health and mental disorders (10.34%).

From the narrative reports submitted by the grantees, random site visits by staff and discussions with grantees at workshops and conferences, we were able to observe a number of patterns. More than one half the organizations developed new programs: piloting new initiatives, reaching a new target population, or focusing on a health promotion issue new to the agency. The Red Cross partnered with the Bridgeport Police Department to develop a cardiopulmonary resuscitation (CPR) and first-aid training program for seniors. Hispanic Health Council conducted an assessment of utilization of oral health services by low-income pregnant women and designed an oral health promotion program based on the findings. Nearly 40% of agencies expanded existing projects. For example, the Literacy Volunteers conducted a training for 50 volunteers to incorporate healthy eat- ing and exercise messages into their educational materials and addressing health literacy in reading prescription medicines.

Microgrant recipients also noted a number of chal- lenges in implementing the grant. The most commonly cited barrier was the limitation in the size of the grant. Many agencies reported that they had not calculated in the level of staff time required to implement the grant and either had to provide “in-kind” staff time to the initiative or find volunteers. Several projects did not have dedicated staff working on the project, making implementation inconsistent. Two projects returned funds because of staff turnover; six projects turned in only interim narrative reports, and another two turned in no narrative reports. Some organizations had prob- lems recruiting participants for their programs or needed more time to implement the project. Other agencies forgot to factor in costs such as transportation for participants.

Overall, grantees reported generally beneficial results. More than one third of agencies reported that they had leveraged their microgrant funds to obtain additional grants or resources with the consequence of heightening the importance of the activity in the eyes of other staff and administrators and in the community. For a hand- ful of agencies, particularly faith-based groups, this was their first grant, and they expressed the heightened sense of self-efficacy they had in writing and obtaining future grants. A number of agencies noted that the HP 2010 focus made their agency identify a health

component in their agency services for the first time (e.g., the Literacy Volunteers).

>>DISCUSSION

This evaluation of DHHS’ microgrant initiative demon- strates the utility of this approach in increasing awareness of the HP 2010 objectives among nonprofit organizations. These results correspond to baseline statistics, which showed that the grant recipients had a high level of HP 2010 awareness in comparison to the control group. In addition, grant recipients reported being much more effective in promoting HP 2010, with a mean score nearly twice that of the control group. The primary effect of the grants was to increase knowledge of HP 2010 among agen- cies, pilot new initiatives, and expand existing services.

Characteristics of the microgrant recipients and control group organizations were relatively similar with regard to years of existence, total number of employees, total number of volunteers, and characteristics of the popula- tion served. Among control group agencies, however, there was a disproportionately large number of HHS orga- nizations. This difference was statistically significant. Comparison between HHS agencies and nontraditional agencies (defined as civic, faith-based, or other) on famil- iarity with HP 2010 did not show a significant difference. One might expect HHS agencies to have greater awareness of HP 2010 objectives; however, for those completing this survey, their knowledge proved relatively limited.

The results indicate that the microgrant initiative raised awareness of HP 2010 among the grant recipients. The significant difference between the grantees and the controls at baseline is in part attributable to the fact that all grantee agencies were required to have a HP 2010 focus to participate in the microgrant project. As an anec- dote, several grant recipients reported that they had to look up the HP 2010 objectives on the Internet before they submitted their grant applications. Grant recipients completed the surveys after the award letters went out, and completing the baseline survey was a requirement to receive funding. Thus, the microgrant writing process probably increased the grantees’ awareness before the baseline measure was assessed. This is supported by the grantees’ significantly higher initial familiarity with HP 2010. Despite this requirement, 44% of the grantees indi- cated a low level of familiarity with HP 2010. Perhaps a truer reflection of where these organizations started was the control group, which had 79% of respondents stating a low level of familiarity with the nation’s health agenda.

In the RFPs, the microgrant recipients had the option to target their intervention plan toward any HP 2010 objective. Six focus areas were not selected by either the microgrant recipients or the control group, including

Hartwig et al. / HEALTHY PEOPLE 2010 AND SMALL GRANTS 31

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

arthritis, chronic kidney disease, food safety, medical products, occupational safety, and public health infra- structure. The lack of attention to these six areas poten- tially indicates a gap in services and programs. However, some of these focus areas are unique, specialty niches that require expertise uncommon among most community- based and HHS agencies targeted by this initiative. In addition, emphasis on the other 22 focus areas may be a reflection of the priorities set by local agencies based on community needs.

There are a number of limitations to the study design. The participating agencies were not randomly selected, limiting the generalizability of the results. Self-selection bias is a related factor; however, given the small size of the grant, one would have expected larger, long-standing organizations such as HHS agencies not to apply, and this was not the case. A similar solicitation or sampling strategy was used for grantees and controls thus reduc- ing potential differences between groups although some significant differences in types of agencies did arise. The smaller sample size (67 agencies) in the control group also limited statistical comparisons. For example, as the control agencies came from three different states, it would have been interesting to measure between-group differences; however, the representation from each state (17-28) was too small to calculate significant differences. Multiple mailings, phone calls, and a $100 incentive were used to encourage control group participation with mixed success. The financial incentive went directly to the agency rather than an individual, and it is not clear if individual incentives might have been more persua- sive. The analysis has also assumed that the persons completing the survey had accurate information and reported truthfully. All efforts were made to have a senior agency official complete the before and after sur- vey; however, the level of accuracy and respondent con- sistency is unknown.

This evaluation did not include a cost-effectiveness analysis. Such analysis would have provided more information on the cost-benefits of an agency distribut- ing microgrants and the related overhead. As noted in the U.S. microcredit example (Bhatt et al., 1999), high overhead costs in relation to number of grants provided was noted as a barrier. In the PRC model, with a general two-person staff to 103 project ratio the direct adminis- trative costs were relatively low. The heavier evalua- tion component necessary to assess a pilot, however, did drive up personnel and overhead costs but would not necessarily need to be as comprehensive in future designs. We were unable to assess overall health outcomes as a result of this initiative given the diversity of projects, nor would it be reasonable to expect that $2,010 would generate large changes.

The value of the microgrants, similar to microcredit programs, is that it promotes entrepreneurship and cre- ativity among a wide spectrum of people and agencies (Swider, 2003). Like the example in Kansas, the small grants were welcomed by community members who appreciated opportunities to define their own health objectives. Essentially, this HP 2010 microgrants initia- tive planted seeds across a wide spectrum of organiza- tions to practice new forms of health promotion, reach new populations, and to try out new services. As noted in the number of grants serving ethnic minority popu- lations, these grants also served to fill small gaps in health disparities.

The microgrant innovation for health promotion meets many of the criteria of the diffusion of innova- tions theory. The grant application process was simple with a high probability of funding. Given that there were no categorical funding requirements, agencies were able to adapt their health objectives closely to their own agency strengths or population beneficiary needs. A number of microgrant managers noted that the observability feature of the microgrant, demonstrating staff competency in a new area or beneficiary interests in the project, brought positive support from adminis- trators and board members. Trialability was also an important feature. Agencies were able to test out new ideas at relatively low cost; for projects that failed (e.g., low turnout of participants, etc.) little was lost, but important lessons were learned in skills necessary for areas such as recruitment, marketing, and project plan- ning. On the part of the funder, having a handful of projects “fail” is also low cost. A number of agencies reported a growth of their microgrant initiative through additional leveraged funds and by sharing the project idea with sister agencies; although the breadth of diffu- sion was not measured, the microgrants did initiate change. Furthermore, a better working knowledge of HP 2010 was widely disseminated.

>>CONCLUSIONS

The Healthy People 2010 Microgrant Project has served as a positive influence on the participating agencies by increasing their awareness of the nation’s health agenda and providing them small grants to encourage entrepreneurship and affect largely positive changes locally. The more organizations become famil- iar with, and work toward the objectives of HP 2010, the more likely those objectives will be met. The micro- grants also acted as an effective strategy for increasing the involvement of nontraditional agencies in the work of public health thus also increasing the public’s access to health messages and services.

32 HEALTH PROMOTION PRACTICE / January 2009

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from

Hartwig et al. / HEALTHY PEOPLE 2010 AND SMALL GRANTS 33

This is one of the first studies to examine organiza- tional knowledge and awareness of HP 2010 among a broad spectrum of organizations. The results suggest that further research is necessary to determine why awareness is so low and if it is a regional, northeastern phenomenon or one more widespread. In terms of policy, it suggests that funding agencies—including state and federal agen- cies and foundations—should emphasize HP 2010 focus areas in their calls for proposals. Social marketing of crit- ical focus areas through the media will also bring it to the general public’s attention and perhaps heighten the state and federal government’s accountability for reaching these targets. A secondary policy and practice recom- mendation is the use of small grants to promote HP 2010 or other health promotion initiatives and to develop local ownership of these national health objectives through public health and non-public-health agencies. Despite their small size, these microgrants have proven an effec- tive way for new organizations to enter into the public health arena at “low-risk” and practice community-based public health responsive to locally defined needs. If a funding agency wants to achieve a high-level impact in a community around a specific disease category, micro- grants are clearly not the answer when a larger sized grant would have greater effect. However, if funders want to encourage and document health promotion innova- tions that may direct larger future grants, microgrants are an effective tool.

REFERENCES

ATLAS.ti Scientific Software Development GmbH. (2003). Atlas.ti version 4.2. Berlin, Germany: Author.

Bhatt, N., Painter, G., & Tang, S.-Y. (1999). Can microcredit work in the United States? Harvard Business Review, 77(6), 26-28.

Davis, R. (2000). Healthy People 2010: Objectives for the United States: Impressive but unwieldy. British Medical Journal, 320, 818-819.

Dunville, R. L., Hartwig, K., Faridi, Z., Alonzo, H., Zaharek, M., & Katz, D. (n.d.). Microgrants and organizational capacity. Unpublished manuscript.

Hartwig, K., Bobbitt-Cooke, M., Wykoff, R., Nappi, S., Zaharek, M., & Katz, D. (2006). Microgrants to community organizations in support of Health People 2010: Description of two pilot programs. Journal of Public Health Management and Practice, 12(1), 83-89.

McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351-377.

Oldenburg, B., & Parcel, G. S. (2002). Diffusion of innovations. In K. Glanz, B. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed., pp. 270-286). San Francisco: Jossey-Bass.

Paine-Andrews, A., Francisco, V. T., & Fawcett, S. B. (1994). Assessing community health concerns and implementing a microgrant program for self-help initiatives. American Journal of Public Health, 84(2), 316-318.

Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: Free Press.

SAS, Inc. (2002). SAS version 8. Cary, NC: Author.

Srinivas, H. (n.d.). Microfinance bibliography. Retrieved March 2005, from http://www.gdrc.org/icm/icm-bibliography.html

Stokols, D. (1992). Establishing and maintaining healthy environ- ments: Toward a social ecology of health promotion. American Psychologist, 47(1), 6-22.

Swider, P. (2003). Microcredit: A Greenstar research brief. Retrieved February 26, 2005, from http://www.greenstar.org /microcredit/microcredit-brief.pdf

U.S. Department of Health and Human Services. (2000a). Healthy People 2010: Understanding and improving health (2nd ed.). Washington, DC: U.S. Department of Health and Human Services, U.S. Government Printing Office.

U.S. Department of Health and Human Services. (2000b). A report from the HHS Working Group on Sentinel Objectives. Section 1: Healthy People 2000 and leading health indicators. Washington, DC: Author.

U.S. Department of Health and Human Services. (2001). Healthy People in healthy communities. Washington, DC: U.S. Department of Health and Human Services, U.S. Government Printing Office.

U.S. Department of Health and Human Services. (2003). Healthy People 2010: fact sheet. Retrieved April 24, 2003, from http://www.health.gov/hpcomments/

Yunus, M. (2001). Banker to the poor: The autobiography of Muhammad Yunus, founder of the Grameen Bank. Karachi, Pakistan, New York: Oxford University Press.

at WALDEN UNIVERSITY on December 8, 2014hpp.sagepub.comDownloaded from