The Community Action Model (CAM) is a five-step framework for building the capacity of community-based organizations to address health inequities through policy, systems, and environmental change. The CAM brings together community residents, community-based organizations, and the City and County of San Francisco’s Tobacco-Free Project to design and implement community-driven campaigns. The health disparities that exist between, on the one hand, low-income communities and communities of color, and, on the other, more affluent communities, are well documented. There are higher smoking rates, higher concentrations of outlets that sell tobacco, and more advertising and promotions of smoking in low-income communities and communities of color. Recognizing the need to bring community members into the conversation to solve these health inequities, the SFDPH Tobacco-Free Project has utilized the CAM framework to fund organizations working on tobacco-control issues since 1996. This case study provides a brief description of San Francisco’s use of the CAM and documents lessons learned and best practices for other public-health agencies implementing community-capacity-building efforts.

Youth Leadership Institute TURF CAM Advocates 2008

The SFDPH Tobacco-Free Project has used the CAM framework to provide funding and technical assistance to community-based organizations since 1996. Rooted in Paulo Freire’s popular education theory, the CAM was developed by San Francisco’s health educators in the early 1990s.[1] Instead of focusing on changing the individual behaviors of community members, the CAM builds the capacity of community-based organizations to upend the systemic forces that create health inequities. The underlying theory of the CAM is that community members become effective agents of change when they are engaged in the development of solutions that improve the conditions that oppress their communities. The CAM’s five-step framework allows community-based organizations to intentionally engage, lead, and train community members in these systems-change objectives.

Partnering with Community-Based Organizations and Residents

To implement this model, the Tobacco-Free Project uses a competitive request-for-applications (RFA) process to solicit applications from local community-based organizations that are interested in working on tobacco-control campaigns that eliminate health inequities in low-income communities and communities of color. The Tobacco-Free Project selects a cohort of organizations to receive a two-year grant of approximately $175,000. The amount of funding available to organizations has varied over the years on the basis of the availability of resources and the budget of the Tobacco-Free Project. With the funding received, organizations appoint a project coordinator and recruit up to eight community residents to participate in the project.

The Role of the Tobacco-Free Project

The Tobacco-Free Project plays the role of funder, convener, and trainer. During the two-year cycle, the Tobacco-Free Project staff work closely with the project coordinators from the funded organizations to implement the five-step model. Funded organizations and advocates identify the issue that resonates most with their community. While organizations work with their own teams on the selected community issue, San Francisco’s program structure allows the organizations to move through the five steps as a cohort in a learning community setting. The Tobacco-Free Project provides ongoing training and technical assistance to the project coordinator and advocates throughout the two-year cycle to ensure that they are able to conduct data collection, analyze data, and identify and implement a realistic action or activity that has the potential for social change.

The Five Steps in the Community Action Model

Each of the five steps builds the capacity of the organizations and advocates to understand a critical step in systems-change work. A curriculum and tool kit in three languages accompanies each of the steps.[2] Capacity building through training is ongoing and tailored to the skills needed to complete each step of the CAM process.

Step1: Train. First, the project coordinator and advocates are provided with education and training about the history of the transnational tobacco industry; tobacco control, public health and health inequities; and policy, systems, and environment change. During this phase, each CAM group must select a specific community issue that they want to address, such as smoke-free housing or tobacco advertising. Advocates are encouraged to think creatively about tobacco control and to integrate related issues that have deep meaning in their community, such as housing rights, food security, or other equity issues.

Step 2: Diagnose. During the second step, advocates conduct a community diagnosis to assess the strengths and needs of their community. The diagnosis phase may include qualitative and quantitative research methods like focus groups with neighbors, interviews with key policymakers or stakeholders, public-opinion surveys, community-mapping projects, counting/observations, and other methodologies.

Step 3: Analyze. The third step includes analyzing the results of the diagnosis to identify key findings that help narrow the focus of their selected issue and to identify a menu of possible actions or activities that could address the issue. Learning to message the issue and share these key findings is a pivotal next step toward creating change.

Step 4: Implement. The fourth step is implementing the selected action, such as advocating for a city ordinance, revising regulations, working with a private business to change its practices, etc. Advocates are encouraged to define an action that meets three criteria—it is achievable; it is long term / sustainable; and it compels another entity to do something to change the environment for the well-being of all. These criteria are critical differentiators for the CAM because it requires advocates to go beyond an educational intervention in identifying an outcome that changes the policies, systems, and environments in which their community lives.

Step 5: Enforce. The final step is to enforce the action to ensure that the intended systems change takes hold.

Through each step, community advocates are the foot soldiers; project coordinators are the organizers; and the public-agency staff (i.e., the Tobacco-Free Project staff) are the coaches. The steps allow each of these partners to play unique but complementary roles in supporting community health initiatives. For example, in 2009, the Youth Leadership Institute’s community diagnosis revealed that there was a higher concentration of retail stores that sold tobacco in low-income neighborhoods compared to high-income neighborhoods—meaning higher levels of access to tobacco and increased exposure to harmful advertising in lower income communities. Instead of working with individual retail stores to stop selling tobacco, the CAM group developed an innovative ordinance that would cap the number of tobacco-retailer licenses in each jurisdiction in San Francisco, thereby attempting to create a more equitable retail environment in all neighborhoods. The San Francisco Tobacco Retail Density Policy was eventually adopted because of the support and strategy of the CAM project, and the CAM team has partnered with the local enforcement agency to ensure that stores that lost their tobacco retail license are no longer selling tobacco.

For more details on the San Francisco Tobacco Retail Density Policy and other specific projects that have utilized the CAM in San Francisco, visit the San Francisco Tobacco-Free Project website.

[1]. For more information about the CAM, please see the list of articles and resources at the end of this case study.

[2]. CAM tool kits for community agencies can be found here: http://sftobaccofree.org/actions/.

Public health departments achieve greater success and enjoy more legitimacy when they partner with impacted communities and support upstream efforts to impact the social determinants of community health. As a result, public health departments are moving away from the role of funding only direct-service providers toward building community capacity to advance policy, systems, and environmental change to address health equity and to be responsive to communities. Public health departments in city or county governments can benefit from frameworks that support community-driven solutions to public-health goals.

While community partners often have deep expertise about the needs and strengths of their communities, they may not have the skill set or capacity to move beyond the community asset and needs assessment phase to develop actions or solutions that can create systems change. As public health agencies decentralize their work by funding community partners, they often struggle with finding a good framework for supporting community-driven systems-change campaigns that are realistic, actionable, and aligned with the goals and funding streams of the public health agency.

The CAM bridges this gap by providing a strategy that draws on the strengths of both the community partners and the public health agency. The result is a public-agency-supported, community-driven effort to define community strengths and needs, and promote solutions that are actionable and grounded in best practices. By seeding community participation, the goal of the CAM is for the community to acquire the skills to go beyond simply being engaged to driving the process in partnership with the public health agency. Informed by over 20 years of experience implementing this model in San Francisco, the CAM is a best-practice framework for partnership between public-agency and community partners. This section details the lessons learned and considerations for other public agencies interested in implementing a community-capacity-building model.

In a community-capacity-building framework, public agencies must develop greater comfort with allowing the community partner to define the action agenda and implement the campaign.

This model upends the traditional role of the public agency as an external funder and judge of the value of a funded community project. The CAM expands the role of the public agency beyond that of a traditional funder toward that of a partner and capacity builder. Similarly, instead of simply being the receiver of funds, community partners share their community expertise while engaging in technical assistance and insight that builds their skills and insider knowledge related to systems change.

In its role as “expert” on policy and systems, the public agency can support community partners in selecting CAM actions that are realistic, achievable, within the purview of local control, and likely to yield the desired outcome. However, the public agency must create space for the community partner’s expertise in understanding the lived experiences and behaviors, concerns, and preferences of residents to drive the community campaign. This means stepping back and being comfortable with the CAM actions being defined by the community’s interests and diagnosis as opposed to the public-health-agency’s interests. The CAM requires a mutually respectful relationship between the public agency and community partner, with a structured and consistent partnership throughout the two-year cycle.

Community capacity-building requires a focused investment over multiple years.

Policy change takes time and requires multiyear investments and strong community-based partners that are able to dedicate the resources to focus on a single issue or action for several years. A CAM grant is awarded for two years because it is expected that the training, diagnosis, analysis, action, and implementation related to a single issue takes that long, and sometimes even longer. This is different from traditional grants, which often provide general operating support for the nonprofit, which might mean that a nonprofit is able to work on several different projects or actions at the same time. A public agency plays an important role in building community-partner tolerance for the slow pace of policy work.

In addition, turnover may occur among advocates and project coordinators over the two-year period—a common challenge in nonprofit environments that must be considered when making these types of investments. Public-agency staff should plan to provide support and leadership in staff transitions so that the work done is not wholly dependent on one person holding it together. The consistent training and regular communication between the public agency and the community-based organizations and advocates ensure that these transitions are as seamless as possible. As a result, even if participants do not work on the CAM over the entire two years, the project coordinators and advocates should still be able to walk away with knowledge and skills that they did not have before participating in the project.

Community capacity-building should provide a cohort experience among the funded organizations, coupled with individual support.

The CAM’s intended outcomes are twofold: to create social change through community participation and to deepen the skills and knowledge of the community so that they may continue to apply the lessons learned from the CAM in affecting social change after the grant ends. As opposed to traditional grants, a CAM grant requires regular and consistent communication between the public-agency funder and the organizations participating in the cohort. The public-agency funder needs to make clear the requirements for staff participation and other organizational resources that might be needed in order to receive this grant.

Under the CAM model, the funder takes on a greater role in supporting the organization’s success through individualized support that is tailored to the strengths and needs of the organization and its project. When the support needed is not within the expertise of the public agency, the funder should be prepared to broker access to external trainers and technical-assistance providers that support each organization as needs arise. In addition, creating a cohort experience allows the organizations to learn from each other and share resources that might be limited at each of their organizations. The CAM-cohort experience, coupled with individual support, ensures that organizations move through each phase required to complete a CAM action while at the same time providing organizations the flexibility to dig deeper into each phase if they want to or need to.

The success of a community capacity-building project should be defined by the increased capacity of the community partners.

The success of the project should not be whether the intended action was achieved. While affecting policy, systems, and environmental change is one of the goals of each project, as a funder the public agency should evaluate success on the basis of the extent to which the funded group acquired skills and stayed on track to meet project benchmarks. To achieve this, the public agency needs to set up a structured set of benchmarks, timelines, tools, training, and other technical assistance to shepherd the funded group through the process so they meet the project deliverables. The funded group needs to define the content of the CAM project so that the issue they have chosen has deep meaning to them and therefore is an issue that they are fully invested in achieving. The action is dependent on many outside forces and political pressures that may make the action unsuitable for that point of time. In San Francisco, many CAM projects that did not successfully achieve their action during the first cycle were able to continue to collect data, ideate, and garner support to ultimately achieve success in a subsequent cycle of CAM grant funding. The focus on community capacity building as the ultimate success marker of a grant engenders support and deepens participation from the community-based organizations and advocates.

Check out the website for the CAM timeline, curriculum, and other tools that can be utilized by other funders interested in implementing the CAM.

Compared to a traditional contracting relationship, the CAM requires a greater investment of resources from the public-agency funder, community partners, and other external resources.  The public agency, such as a local health department, needs to align resources that respond to the needs, strengths, and preferences of community partners in the CAM cohort. The CAM requires a predetermined structure that includes regular individual and cohort meetings, dedicated staff time, and project timelines and benchmarks. This table describes the conditions and resources that must be in place to successfully support organizations funded by the CAM.

The CAM uses a tiered approach to capacity building that touches the public agency, community partner, and community advocates. There are four conditions that determine whether a CAM project is successful in building community capacity for systems change: 1) the reputation of the CAM partner organization; 2) the qualifications of the project coordinator; 3) the organization’s relationship with a coach from the public-agency funder; and 4) the effective participation and engagement of resident-advocates.

The community partner—represented by the project coordinator—is a critical bridge between the coaching role of the public agency and the implementing role of the community advocates. Community partners need to bring trusted relationships with diverse community members and deep experience with community organizing. The leadership within the partnership must be committed to the CAM project and understand the staff time and resources needed to implement this project.

A successful project coordinator has knowledge and expertise of the community, the ability to work with a team of advocates in a training/coach role, and the ability to receive training on policy work. A project coordinator must be an organized person who can shepherd advocates through a predefined process. The staff person who serves as the project coordinator must dedicate approximately 75% of their time to the project. They must also be able to communicate with multiple audiences, including communicating with public-agency staff regarding work plans and budgets; policymakers and stakeholders regarding their CAM project; and community members regarding the CAM process and the purpose of systems-change projects.

Finally, the staff coach from the public agency must develop a positive, cooperative relationship with the community partner. The coach plays an integral role in supporting the project coordinator and brokering resources that can ensure that the organization and its advocates gain and share skills related to systems change. Coaches should be matched to the organization depending on their knowledge of the topic that the organization wants to work on and their experience with the organization’s mission, values, and guiding frameworks (for example, youth development, community organizing, or other values).

Tonya has served as the chair of the San Francisco Tobacco-Free Coalition since 2010. When she began using the CAM, she was the executive director of the Girls After School Academy, where she served for over 11 years. She currently works as an associate at Crawbren & Associates LLC.

What was the impact of the CAM?

“Working with the CAM model opens the hearts and minds of everyone who is involved with it, from the youth to the project coordinators to everyone they interact with. It allows people living in impoverished areas to look at their community through a new lens. People often think, ‘How does tobacco matter to my life? I’m hungry. I need a new pair of shoes.’ But CAM taught them to think about the impact of tobacco on their communities, to better understand how tobacco companies intentionally target their communities, and to use their power to protect their neighbors, loved ones, and themselves.”“The highlight of working on CAM is always the impact you see on the health advocates. In my first project working on smoke-free public housing, I worked with girls who were from the most impoverished area in San Francisco—and no one ever expected them to care about or investigate these issues. Everyone’s expectations—including their own—were low for these girls. Where so many of their peers were not finishing high school, so many of the girls who participated in the CAM project were so inspired that they excelled in school and completed college. CAM instilled in them the ability to care about themselves and their ability to influence the community. The steps for CAM are not just about a public-health model; CAM instills lifelong skills like life mapping or planning, communication skills, teamwork, and camaraderie. CAM taught these girls to ask the right questions and to go one step at a time until they find a solution that works.”

CAM Projects (2002–2012)

Smoke-free public housing
The San Francisco Housing Authority adopted a 100%-smoke-free-building policy for all 6,543 public-housing units in the city.

Rejecting tobacco funding

Four local African American cultural organizations adopted policies that rejected funding from tobacco companies or their subsidiaries.

Storefront advertising

A city policy that reduced the percentage of store windows dedicated to alcohol advertisement

Mele began working for the Tobacco-Free Project in 1991. She collaborated on the development of the CAM and worked with the model for 15 years. She continues to use the CAM in her current position as the Executive Director of the Office of Community Schools and Family Partnerships at San Francisco Unified School District.

What was the process of developing the CAM?

“When we began our work, people thought about tobacco control in terms of individual-behavior change, and all of the interventions were focused on getting people to quit smoking. We came together to look at community organizing and policy change as a way to change the environment to prevent young people from starting to smoke in the first place… The CAM focuses on recognizing and valuing the knowledge and skills of those most impacted by the predatory nature of tobacco companies and provides them with a framework to identify tobacco-control policies that can transform health and lives…Every time we implemented the model, we learned something new. It took about 10 years of iteration for the model to develop into what it is now.”

Why do we need the CAM?

“The CAM supports the whole idea of public health from a social-justice perspective, of trying to change the power structures that create the haves and the have-nots. If you really get down to it, the practice of public health done well is about creating equity. When you start with a model that has this at its basis, those most impacted by the political, cultural, and socioeconomic

Angel served as a youth advocate in the Bay Area Community Resources (BACR) CAM project in 2015. In 2016, Angel was hired by BACR as the project coordinator for the same CAM project.

What is it like working with the CAM model?

“CAM is like our car—it helps us get places. Without it, we wouldn’t know where we were going. Each step is followed by a different action to complete the ultimate goal. As an advocate, when I first learned about the work we would be doing, it was overwhelming. ‘We’re supposed to do what? In how long?’ It’s a lot, but if you take the time to digest each step and how it leads to the next step, you see that it can be done. It’s the perfect model. It’s so organized. You can’t really fail.”

What is the best part of working with CAM?

“Coming into this, I thought about people smoking as an independent decision. If it’s hurting them, they’re just hurting themselves. I didn’t think about how it was affecting others or about the unwanted consequences of smoking inside. When we started talking to other organizations and people, we saw that this is a bigger community problem that a lot of people care about.”

What have you learned while working with the CAM?

“Creating a policy is a really long process. It’s not just one meeting with your Supervisor. It’s a process that you have to prepare for and think about the outcome. The CAM model helps you look at the bigger picture. It helps you meet people and organizations that you wouldn’t have connected to. It shows you how important building relationships is.”

CAM projects
(2015–present)

Smoke-free multi-unit housing

Currently advocating for landlords to voluntarily adopt smoke-free policies for multi-unit housing complexes in San Francisco.

Tobacco price increase
Currently developing a policy to increase the minimum price of tobacco products in San Francisco.

Rosalyn was a CAM project coordinator in 2012 when she worked for Breathe California, a member of the San Francisco Tobacco-Free Coalition. She currently works as a project director at Bay Area Community Resources.

What was the impact of the CAM?

“When we gathered data, we got out into the community, talked to the community, and understood people’s arguments. This process gave us data and prepared us to talk to other people in the community about the work we were doing.”

“The CAM model was a good and comfortable introduction to the advocates on how to get a policy passed. The advocates already had a background in public health but had never worked in policy. The CAM model helped them understand and be comfortable with policy, the steps to get data, and how to get a policy passed.”

What did you learn from working with the CAM?

“I learned a lot about policy. I worked in tobacco for a long time, but that was my first time working in policy. While I was learning policy in the CAM model, I was also teaching it. But I had a lot of guidance from my supervisor, DPH, and the structure of the model.”

“The CAM model was clear in terms of the steps that you need to take and the order to do it in. It didn’t feel overwhelming to have to do a bunch of  things at the same time. It made the process of getting a policy passed very easy to understand.”

CAM Project (2012)

Smoke-free street events in San Francisco

A San Francisco policy that made all street events in San Francisco smoke-free.

For 20 years, the CAM has been used by the San Francisco Department of Public Health to build community capacity to participate in policy, systems, and environmental changes. The CAM is a framework that can be used by public-agency funders who are pivoting away from funding individual-behavior-change efforts and moving toward systems-change efforts that improve community health. This case study documents lessons learned and best practices for other public-health agencies considering implementing community-capacity-building efforts.

Resources

CAM Project Case Studies

http://sftobaccofree.org/case-studies

CAM Tool Kits for Community Partners (available online in English, Spanish and Chinese) http://sftobaccofree.org/actions/

CAM Curriculum for Public-Agency Funders (available online in English, Spanish and Chinese)

https://www.sfdph.org/dph/comupg/oprograms/CHPP/CAM/default.asp

“Community Action Model: A Community-Driven Model Designed to Address Disparities in Health” in the American Journal of Public Health, April 2005

http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2004.047704

Evaluation of CAM Projects in San Francisco, 2013

https://sanfranciscotobaccofreeproject.org/case-studies/increasing-cultural-competence/

For additional questions, please contact Derek Smith, Director of the San Francisco Tobacco-Free Project, at [email protected].

The table below lists all the CAM projects and associated actions funded by the San Francisco Tobacco-Free Project from 1996 to 2016.

This report was prepared by Bright Research Group. An Oakland-based and women- and minority-owned firm, Bright Research Group specializes in evaluation, community engagement, and strategic planning for the public sector, nonprofits, collaboratives, and private entities working to achieve greater social impact.

www.BrightResearchGroup.com

Community Action in Public Health Policy