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A Conceptual Sustainability Strategy for a Rurally-Based Community Health Promotion Initiative

Anthony U. Emekalam*

Elizabeth City State University/University of North Carolina Doctor of Pharmacy Partnership Program, Elizabeth City, North Carolina, USA

*Corresponding Author:
Anthony U. Emekalam, PharmD, RPh
Elizabeth City State University/University of North Carolina Doctor of Pharmacy Partnership Program
Elizabeth City, North Carolina, USA
E-mail: [email protected]

Received date: April 05, 2012; Accepted date: April 08, 2012; Published date: April 14, 2012

Citation: Emekalam AU (2012) A Conceptual Sustainability Strategy for a Rurally-Based Community Health Promotion Initiative. J Health Med Informat 3:e101. doi: 10.4172/2157-7420.1000e101

Copyright: © 2012 Emekalam AU. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Sustaining grant-funded rural community health promotion initiatives following expiration of active funding cycles is usually challenging. Rural communities are described as periphery to cities and somewhat isolated with all larger communities located more than 30 miles away and are perceived as lacking in essential resources that create and nurture businesses [1,2]. Statistics show that rural residents are comparatively poorer than urban and metropolitan residents. For instance in 2005, 17% of rural residents lived below poverty line whereas in metropolitan areas it was 13% [3]. Furthermore, as funding sources and grant making agencies limit, restrict, prioritize, and restructure funding because of current national economic downturn, it is imperative that rurally-based community healthcare promotion projects become familiar with a locally-dependent strategy that fosters sustenance of life-saving community health initiatives.


Community-based health promotion and preventive health care services are significant in addressing health disparities and expanding access to health care services in rural communities [4]. Over the years, such projects have been implemented in different community settings to address many health issues in rural communities because experts believe that they are very effective in delivering meaningful grass root health care services to rural populations [5]. Their benefits are highlighted by abundance of grant-funding opportunities available from many government agencies and programs and numerous private organizations and foundations for different kinds of health and wellness programs that utilize community-based strategies [6,7]. Designed and implemented at various levels and in different community settings, they address many health issues and concerns including risk factor screenings, prevention and wellness programs for diabetes and cardiovascular diseases, prostate and breast cancer awareness programs, childhood, adolescent, and adult obesity control and prevention programs, and HIV/AIDs programs among so many others [8-12].

However, in spite of their notable benefits, sustainability continues to be a major challenge forgrantees and grantors [13]. Reported sustainability concern in 6 out of 9 foundation-funded programs in Western United States irrespective of their settings, target groups or health goals. Their study revealed that deficient funding and need for diverse pool of dependable long term funding sources were named as major obstacles to achieving current program goals and objectives by program staff and collaborators. Additionally, 8 of these 9 community programs listed guarantee of resources to ensure that programs become self sufficient and 6 named program integration into the community to ensure continuation of health programs after funding cycle expires as future program goals. Sustainability is also an issue of concern to funders of health oriented projects and innovations. Typically these projects are funded as demonstration or pilot projects by government agencies and private foundations for 3-5 years during or after which other sources of funding or support must be identified [14].

Whereas, it may not always be necessary to promote sustenance of some programs beyond their initial funding cycles for reasons such as changes in circumstances, people, situations, and problems or identification of more efficient and effective methods of addressing targeted health issues discontinuation of some programs may have adverse outcomes [15]. At the very least, termination of some programs particularly health initiatives that focus on screening for prevention of chronic and infectious diseases has been reported to be counterproductive with conditions reverting to pre-intervention status when the health promotion initiative ends[16,17]. Also, there may be complete loss or significant decrease in community support and trust where such practices are rampant or common place [18].

Additionally, sustained programs translate into sustained effects over time thereby making proper evaluation of long term effects and assessments of programs possible [19,20]. Moreover, there is usually a period of dormancy between start of program implementations and observable/measurable impacts on target communities [21,22].As outcomes may not be observable for about 3-10 years following initial implementations [23]. Furthermore, discontinuation of beneficial programs is an investment loss for funding organizations and loss of meaningful services to communities [24-26]. Consequently several ideas and strategies on program sustainability have been described including important features or characteristics that increase chances of sustaining any given program beyond initial funding cycles.

Generally, it is argued that continued existence of funded programs either in their native states or other forms is driven by initiation of coalitions that continue to promote goals and objectives using current or other resources [27]. This approach extends lives of programs through continued impacts from networks of processes and activities within the community created during active cycles of programs [28]. Identified elements of this process to include creation of partnerships, collaborations and linkages; mobilization and communication within the community; development of vision, mission and political will of the community and use of systems, organization, knowledge/skills, connectedness, and resources of the community sector. Another approach to program sustainability is identification and implementation of strategies that integrate or adopt programs into ongoing organizational systems (institutionalization or routinization). This strategy involves embedding program activities, goals and objectives totally or in part into organizational processes of traditional community establishments to the extent that external funding for such programs become unnecessary and identification of native states becomes impossible as they become part of core services of other organizations [14,29]. Irrespective of sustainability strategy pursued, it is clearly evident that processes and procedures of full implementation involve careful planning and properly defined goals. This implies that sustainability goals, objectives, specific actionable items and definite strategy(s) plus a plan for measuring implementation process and outcomes are clearly defined and pursued. Sometimes, the whole process is started during initial implementation stages of the native health promotion initiative. It has also been suggested and often required by most grant makers that seekers of funding for health promotion initiatives include sustainability strategies in application narratives suggesting that sustainability is not a latent goal but a planned approach [16].

But even with careful planning and superb implementation strategies, still believe that nature or type of any given program is key to sustainability [30,31]. They argued that since programs that promote cure are more readily funded than those promoting prevention, such programs are more likely to be sustained through continued government funding than those providing preventive care and services. Therefore, health service projects such as health worker training, clinic construction or provision of similar infrastructure are more likely to be sustained through federal funding than projects on family planning and proper nutrition[31]. Listed ability or willingness to consider nontraditional funding sources among other characteristics of programs with increased likelihood of being sustained and described access to diversity of funding including use of local funding together with ongoing planning as essential program sustainability elements [32,33]. Furthermore, National Expert Panel on Community Health Promotion recommendations to the National Centers for Disease Prevention and Health Promotion (NCCDPHP) in 2006 included promotion of training on sustainability strategies that includes capacity building as very important elements for sustaining community health promotion programs.

Since sustainability of preventive programs are relatively more challenging with regards to access to continued funding, it is imperative that providers of such programs are conversant with nontraditional/ alternative strategies that secure resources for program continuation. Therefore, special skills in process development and articulation of scarce rural resources that are currently deficient in most sustainability literature become prominent and essential. Strategies discussed in this article are practical ideas developed from discussion points and recommendations from sustainability strategies interfaced with human behavioral elements developed while planning a sustainability strategy for a diabetes and cardiovascular diseases prevention community health promotion initiative in rural northeastern North Carolina.

Key Elements

The underlying concepts of this strategy is articulation and integration of published sustainability concepts of capacity building and institutionalization interfaced with economic dynamics of typical rural communities woven into a practical, stepwise, and easy to follow protocol [34,27]. It is designed under the key proposition that communities are usually supported by local economies consisting of networks of businesses and social organizations that guarantee their continued existence. These businesses and organizations may be classified into four major categories:

i. Fundamental businesses or organizations (FBoOs)

ii. Community drumbeat organizations (CDOs)

iii. Education and Care Services (EaCSs) and

iv. Health Advocates and Provider organizations (HAaPOs).

Except in extremely rare cases, at least 1 business or organization from each of these categories exists in every rural community [35] .

FBoOs provide services that support basic human necessities (food, clothing and shelter). Services provided by CDOs define communities by promoting ideologies, creeds and beliefs. They include churches, political parties, special interest groups, social clubs and recreational organizations. EaCSs provide child support and infrastructures that cater to children and seniors. Schools, Day Care Centers, Old People’s Homes, Nursing Homes and Assisted Living Facilities are all in this category. HAaPOs support community health needs and include all community or regional hospitals, clinics, doctors’ offices of various specialties; safety net organizations and health advocate organizations.

Number of businesses organizations within each genre and scope of operations affect recruitment and engagement efforts. Local grocery stores, hardware stores, food supply chains, restaurants, doctors’ offices and local clinics are potential rural health promotion support resources.

This strategy begins with an exhaustive compilation of businesses and other organizations within the local community. For most rural communities, this is not difficult to accomplish because they are relatively smaller in number than in urban communities. However, a local office of commerce could assist with this need.

Its operative framework summarized in Figure 1 consists of a distinctive 4-step process that is driven by the overarching goal (summary of anticipated major outcome or accomplishment) of the program. The next steps are identifying, listing, and defining all potential activities needed to accomplish this goal and all resources required to facilitate implementation of recommended activities. Finally, identified resources are broken down to finer details through a delineation process that disintegrates them into sub-units (subresources) commensurate with traditionally smaller business capacities of most rural businesses and organizations [36]. This last step also called resource assortment allots resources progressively into three sub headings in terms of relevance in meeting program goals and relative magnitudes of financial burdens either as; primary, secondary or tertiary resources (Figure 2).


Figure 1: Basic framework.


Figure 2: Resource Assortment.

Potential local collaborators are required to provide sustainability supports at sub-resources level (substenance) thereby making recruitment and engagement of many collaborators to share and contribute to accomplishment of mission and goals possible. Moreover, assortment of resources makes provision of supports less burdensome on potential collaborators since demands are easier to bear and less stressful [37,38].

Substenance is a sustainability strategy that distributes burden of support for key operational resources of a rural health promotion program among diverse local businesses and organizations where each one provides sustainability support for fragment/s (sub-resource/s) of major operational resources. It requires collaborating supporters to only make convenient contributions thereby increasing likelihood of obtaining needed sustainability supports [36]. The primary goal of substenance like every other sustainability plan is to ensure that a program continues to meet its original goals either through integration of applicable sub-resources into routine operational procedures of other local businesses and organizations (institutionalization) or creation of suitable alliances with stable local establishments (capacity building) [39].However, deciding on a sustainability plan for any given sub-resource (institutionalization or capacity building) is based on the functional category to which it (the sub-resource) has been previously assorted (primary, secondary or tertiary). Substenance generally recommends institutionalization of all tertiary and most secondary resources and using principles of capacity building to secure primary resources. Whereas it is impossible to guarantee this outcome at all times, this approach appears to hold the best potential for sustaining a rurally-based community health promotion project for the longest possible length of time by ensuring that those resources that are fundamentally necessary for continued promotion of its goals and objectives are reasonably guaranteed.

Since substenance depends entirely on successful recruitment and engagement of sub-resources-providing locally-based rural businesses and organizations, the strategy requires that businesses and organizations be further arranged into 4 functional sub headings to reflect categories of sub-resources that they are most likely to support and help track sustainability efforts. Accordingly, local businesses and organization irrespective of classification (FBoOs, CDOs, EaCSs or HAaPOs) are listed as Adjuncts, Facilitators, Partners or Contributors.

Adjuncts support programs by making primary, secondary, or tertiary contributions occasionally in indeterminate patterns or schedules. They provide varied services of different magnitudes at different times and are very important in this sustainability protocol. The most important attribute of adjuncts is their ability to function as gap-fillers; providing whatever sub-resource that is needed to complete full implementation of specific goal-supporting activities.Collaborators that provide or facilitate core services or activities are called facilitators. Core services/activities are central and invariably essential to reaching major goals and principal objectives of a program. Facilitators make payments of stipends, wages and salaries of essential personnel, rents and utility bills and procurements of critical supplies possible. Services provided may be in cash or kind. Partners are services-providing collaborators whose services either complement or amplify overall outcomes or program goals. Collaborations are based on shared goals, visions or strategies and mutual interests. Finally, collaborators that provide non-specified services that are marked for use according to discretions of program organizers and administrators are called Contributors. Services provided by contributors are beneficial in meeting emerging needs and unforeseen expenditures. They provide leverage.

A good sustainability plan should have engaged collaborators from all four support categories. The more diverse the pool of collaborators, the better the likelihood of securing a lasting sustainability plan. Figure 3 is a schematic representation of a sustainability plan that is based on this protocol created for a community health diabetes and cardiovascular diseases prevention and management initiative. It highlights program goals, goals-tending activities (strategies), needed activities-supporting resources and targeted support-providing local collaborators.


Figure 3: Sustainability plan for a community health diabetes and cardiovascular diseases prevention and management initiative.

Identifying and Engaging Local Collaborators

Fundamentally, there are no clear indicators or elaborate characteristics by which potential collaborators can be identified. However, some attributes are good predictors and proper understanding of these can impact recruitment and engagement processes and outcomes.

Usually, businesses and organizations that readily become program supporters are often indigenous and depend greatly on local economies to operate successfully. They are usually owned and operated by local entrepreneurs with special ties to the communities and have good reputations and great public relations. However businesses outside of this description may sometime provide some support as signs of appreciations and goodwill for their home communities.

Furthermore, businesses/organizations that advertise themselves in words or engage in business practices that indicate attachments and commitments to their local communities evidenced by inclusion of possessive pronouns such as “your” in advertisement lines and issuance of special rebates and discounted pricings for local or vulnerable community residents are also more likely to show interests in supporting efforts that promote health and wellness in their communities than those that do not.

Evidences of prior or current supports or sponsorships of charitable initiatives in resident communities are also good indicators.

To streamline this process, it is very helpful to create a template that lists all local businesses and organization and using these identifiers to highlight those with better collaborative potentials (Table 1). This is a time-saving practice that ensures that recruitment efforts and resources are most effectively invested on businesses and organizations with best recruiting chances.

S.No A & B Grocery Johnson’s
Andrew’s Day Care
& Senior Center
(A) (F, A, C) (C) (P, C)
Public relationship X X X
Identification with Community X X X
Potential as collaborator Likely Likely Likely Unlikely

Table 1: Guide to potential collaborators.

Typically, the more the number of attributes associated with a business or organization, the better its collaborative potential and recruiting chance. Therefore beginning recruitment efforts with businesses and organizations with most attributes and working downwards to those with lesser or no attributes at all are good practices.

Engagement Protocol

Making the connection

Once potential collaborators/supporters are identified, the next step is to follow a carefully described plan to secure predetermined supports starting with preparations for initial contacts and meetings and continuing with several strategic encounters designed to persuade potential collaborators to ultimately commit to providing desired supports.

Initial contacts should be face to face business-type meetings. As much as possible, discussion of intents and purposes must not be conducted over telephones, by emails or other electronic media. Relentless efforts must be made to secure meeting appointments with appropriate stakeholders who should also choose dates, places and times of meetings. This helps to ascertain that these individuals will have enough time to listen and discuss ideas productively. Initial meetings are the most important meetings of this protocol and are the rate and progress limiting steps of overall process as poor/unsuccessful meeting outcomes will very likely hinder further encounters and abruptly end engagement process. Adequate preparations must be made for these meetings with discussion topics chosen carefully, worded appropriately, and delivered excellently.

The major goal of initial meetings and contacts is to stimulate enough interests in potential supporters/collaborators to guarantee ongoing conversations, discussions, and meetings which are invaluable for growing interests to levels that secure relationships and collaborative supports. Therefore, requests that impose severe financial obligations or activities that may cause disruption of normal business operational routines must be avoided as these could hinder considerations for potential supports. Goals and objectives of community health promotion endeavors for which supports are sought and potential impacts of proposed collaborations must be clearly stated and where applicable presented in texts highlighting possible alignments with known or perceived mission/s of potential supporters in ways that does not portray overzealousness or display of ambitious salesmanship. Also discussions or emphasis on any potential benefits to these businesses or organizations must be strategically avoided during these initial meetings as they tend to heighten suspicion and cast unnecessary doubts on intentions.

Initial Requests/Entry Level Requests

Generally, low hanging fruits which are simple and unimposing are main targets of initial requests for supports. Requests such as permission to leave education/services-advertisement flyers, hang posters or use sidewalks/spaces to conduct health risk screenings are examples of appropriate types of requests during initial contacts and meetings. These ice breaker support-requests must be so affordable and extremely easy to implement that it will make no sense for potential supporters to decline them.

If initial requests are granted, implementations must be expedited. Delayed implementation can diminish perceived value and importance of requested supports which may further lead to loss of sustained interests that are crucial to securing intended supports. Continuation of permitted initial projects or activities for reasonable lengths of time is recommended before requesting additional commitments.

To keep businesses/organizations engaged, it is necessary to provide regular feedbacks on outcomes such as numbers of individuals attending events and other significant results or benefits accomplished through these initial supports. These help to strengthen relationships, validate collaborations or partnerships, build trusts, foster willingness for continued engagements and establish foundations for advancing full support-securing processes.

Generally, types of initial requests to any prospective supporter must be appropriate for their intended terminal roles (adjunct, facilitator, partner or contributor) in the overall sustainability plan. Since securing each of these roles are planned efforts and ultimate supports are designed to be realized in small increments in the form of initial and subsequent requests, having consistent requests at all times help avoid unintended surprises that can hinder securing full supports and is especially true for businesses and organizations intended for supportive roles of facilitators and partners. For facilitators, an example of a good initial(entry level) support request is asking a potential supporter to cover costs of or donate small quantities of the cheapest testing supplies and for partners to leave business cards or servicesflyers in a doctor’s office or business location. Subsequent requests must be similar to initial ones but may require higher levels of supports or involvements however, format must continue to be consistent until targeted support levels are reached and secured.

Securing collaboration, partnership and support

The operational paradigm for advancing participation and support of local businesses and organizations from initial engagement protocols to predetermined positions in overall sustainability plan is to proceed slowly with keen observation and focus. Securing meaningful and enduring supports usually take time and since collaborators are likely to perceive supports as community investments and potential sources of goodwill to their businesses and organizations willingness to grow participation and commitment depend largely on measures of return on investments [40]. When value added from initial commitments are not yet apparent or clearly determined, potential supporters may be reluctant to broaden commitments therefore inappropriate timing of requests for additional supports may lead to loss of earlier commitments. Moreover, since returns on investments are usually slow to materialize, it is necessary to patiently wait for right times and opportunities to advance processes.

One way to ascertain appropriateness of timing to begin conversations about growing commitments and supports is evidence of heightened enthusiasm or satisfaction of potential collaborators. These signs are wide, varied and usually not confusing but will require careful observation and little understanding of personalities of these stakeholders. The most outstanding sign and by all measures the best is where potential collaborators create these opportunities themselves by suggesting ideas to improve on current activities or routines during casual discussions and encounters. Once the right times are determined, it is most productive to schedule meetings solely for these discussions. Use of facts and data generated from current levels of collaborations to justify additional supports is highly encouraged. Meetings must afford stakeholders opportunities to contribute ideas and make critical suggestions. Requests made at these times must still not be overly burdensome but must reflect growths, improvements on current activities and aligned with anticipated support levels of each potential collaborator. This entire process is repeated over and over again until levels of supports are reached and firmly secured.


Rural communities typically face and deal with health issues that are fundamentally different from those of larger cities, towns and urban areas. Ideally, receiving adequate and meaningful heath care services can be a major challenge for rural residents due to several reasons including fewer doctors, nurses, dentists and other health care providers and facilities resulting in late diagnosis of serious chronic diseases and poorer health outcomes. Additionally, economic, cultural, social, educational and legislative factors have been named among contributors of rural health disparities. Rural residents therefore have higher chronic disease rates compared to urban residents. Since it is often difficult to get quality health care in rural communities due to some of these reasons, preventive health promotion initiatives that include screening for risk factors and health education programs are very important in meeting health needs of residents of rural communities. However, many of these life-saving programs do not last past their funding cycles for lack of alternative support resources or new funding opportunities which make identification of sustainability protocols for such rurally-based grant-funded health promotion programs very important to rural health care.

From a public health perspective, program sustainability is the capacity to continue the provision of a program’s services in ways that will continue its health promotion efforts after the termination of external support [41,42]. The strategies described in this article do just that and can guarantee meaningful level of sustainability for such rurally-based grant-funded health promotion initiatives.

Development of this plan requires careful planning and substantial investments in time and as with other meaningful sustainability plans or protocols, it is imperative to begin planning and integrating these efforts at initial implementation stages of a project during the active cycle of the grant and perhaps even before the grant is awarded [43]. This is particularly relevant and important to this protocol because its success is largely dependent on principles of trust, partnership and unity of purpose which are typically developed over time.


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