The Health Services Utilization and Improvement Model (HUIM) as a horizontal participatory implementation program.
Abstract: This paper illuminates the participatory character of the Health Services Utilization Improvement Model (HUIM) and draws distinctions between classical implementation models such as the Top Down and Bottom Up models, and the horizontal participatory approach actualized in the HUIM. Classical models are compared to the Horizontal Participatory approach utilized in the HUIM using the following criteria developed from the literature: Goal Clarity and ambiguity; Structural and Cultural relationships between the implementation and formulation settings; Number of participants or actors involved in the policy or program continuum; Attitudes of implementation setting towards the policy; Flexibility of implementation actors in adjusting policy/program goals or means; Degree of conflict among stake holders; Role of implementation players/actors in policy/program formulation; Fluidity of boundaries between implementation and formulation settings; and the role of evaluation. The author concludes that classical models do not capture the reality of health education and health promotion programs serving Head Start populations and similar at risk groups. A horizontal participatory implementation approach is recommended for health education and health promotion programs serving Head Start programs or other vulnerable populations.
Subject: Medical care (Utilization)
Health care industry
Actors
Actresses
Author: Tataw, David Besong
Pub Date: 01/01/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2010 Source Volume: 25 Source Issue: 1
Topic: Event Code: 200 Management dynamics Computer Subject: Health care industry; Company business management
Product: SIC Code: 8000 HEALTH SERVICES
Organization: Government Agency: United States. Head Start Bureau
Geographic: Geographic Scope: California Geographic Code: 1U9CA California
Accession Number: 308741532
Full Text: INTRODUCTION

In the past two decades, scholars and advocates have intensified their calls for an increase in the consumer's voice during a medical encounter, in the health care system, or in health promotion initiatives (Denton et al., 1999; Ginsberg & Menapace, 1997; Leea & Garvin, 2003); and for public health policy development and practice to be evidence-based, to involve citizens' participation, to be advanced through partnerships, and to be based on cooperative relationships with grassroots organizations (IOM, 1988). The ability of the consumer to be heard during a health services encounter and his/her ability to participate in health services decision making is only possible when communication during consumer-expert encounters, moves from an expert dominated monologue to a dialogue where there is an exchange of information between expert and consumer rather than a transfer of information from expert to consumer (Leea & Garvin, 2003). A dialogue creates space for a consumer-expert relationship that nurture's the consumer's acceptability of the provider's services through active participation and trusting relationships among stake holders. Trust and participation in decision making has been shown to increase consumer self efficacy and satisfaction with health services in at risk low income populations (Doescher et al., 2000; Bond et al., 2004; Tataw, Bazargan, Patel, 2009). A cultural and structural horizontal relationship facilitates greater participation from at risk populations in health promotion programs in which decision making is consensual through a give and take process rather than unidirectional from expert to low income consumer. A horizontal culture means that there is no attitude or feeling of superiority or inferiority among stake holders. A horizontal structure implies that decision making is not top down as in a hierarchical framework. Decision makers are at the same level in the decision making process with equal input and regard for all stake holders.

The aim of this paper is to describe the horizontal participatory implementation approach actualized in the Health Services Utilization Improvement Model (HUIM) and to compare HUIM's participatory implementation approach to Top Down and Bottom Up classical models. The participatory character of the HUIM from planning, formulation, to implementation as well as implementation evaluation is described. The implementation model in the HUIM is then compared to classical models in order to assess the extent to which classical models capture the reality of horizontal participatory programs serving Head Start and other at risk populations.

In the HUIM, the stakeholders work together from planning through formulation, and to implementation. The participatory character of the HUIM aligns planning, development, and implementation with the participatory governance in Head Start programs. Head Start programs are overseen by citizen policy councils made up of the parents of enrollees who act as the Board of Directors for the programs. In this way, a participatory implementation approach conforms to a participatory governance environment which was created to empower the Head Start parents and the community to meet the needs of children and families. Empowerment has been advanced as both a means and an end in enhancing and promoting health (Wallerstein 1988, 1992; Braithwaite et al., 1994; Labonte 1994; Perkins & Zimmerman, 1995; Tataw et al., 2007; Tataw, Bazargan, James, 2009). The HUIM is an example of emergent participatory community health education and health promotion programs which adopt implementation strategies that are different from strategies prescribed in classical models.

THE HEALTH SERVIVES UTILIZATION AND IMPROVEMENT MODEL (HUIM)

The Health Services Utilization and Improvement Model (HUIM) was designed to reduce low levels of health services utilization and improve preventive health techniques and disease self-management for head start families with the ultimate goal of attaching each child to a medical home. HUIM is a 2-year program encompassing non-clinical case management involving 600 children and families, community provider orientation reaching 80 providers, and educational services reaching 600 members of Head Start families. There were 250 participating parents representing 600 children. The average participating Head Start family had 2-3 children. The intervention took place at eight sites of the Charles R. Drew University Head Start Program, four intervention sites in the first and second years. The second year also had four control sites (Tataw et al., 2007).

After completion of baseline assessments in the intervention sites and when applicable in control sites, enrollees in both intervention and control sites received five health educational/training workshops covering areas related to prevention, identification, and treatment of diabetes, asthma, obesity, tuberculosis, and child injury. In addition to educational workshops, enrollees in the intervention sites received structured case management delivered by bilingual English and Spanish Community Health Workers who were trained for this purpose. Also, thirty minute, on site, in-service, information sessions was scheduled with all consented providers to share and exchange information about the unique needs of Head start families. Information sessions were delivered by program trained staff and included information regarding how to complete Head Start forms, billing practices, class and cultural issues that handicap self-expression by Head Start families.

The full program and its outcomes evaluation results have been described elsewhere (Tataw et al., 2007; Tataw & Bazargan-Hejazi, 2009). This paper focuses on HUIM's participatory implementation character. The HUIM was planned, developed, structured, and implemented in a participatory framework.

CITIZENSHIP AND PARTICIPATORY GOVERNANCE

The nature of citizenship and participatory governance are important factors that shape the social context that affects community health outcomes. Democratic participation has recently gained prominence in urban politics (Marshall, 1964), but the notion can be traced to the Greek city-states, where it was believed that every citizen should be allowed to participate in decision-making. The political rights of citizens entail the entitlement of individuals to participate in their governance, through rights, which are associated with systems of democracy (Prior et al., 1995; Republic of South Africa, 2000; Abram & Cowell, 2004). Citizen participation is not only an integral part of community development (Abbott, 1996); but it democratizes planning, and promotes social justice by allowing all citizens, especially disadvantaged groups to influence policy making at the city level (Imparato & Ruster, 2003; Souza, 2003); and is considered a crucial component in the provision of basic needs, efficiency, and self-reliance (Cox & Sinclair, 1996).

PARTICIPATORY COMMUNITY HEALTH PLANNING

Participatory governance leads to citizenship participation in community health and creates opportunities for citizens to be part of conceptualization, planning, implementation and evaluation of community health programs (Aston et. al., 2009; World Health Organization (WHO), 2003). Participation leads to empowerment (Kretzman & McKnight, 1993) and stimulates critical consciousness and trusting relationships (Freire, 1970). Participatory governance can also trigger policy development and systems change (Rose, Gomez, & Valencia-Garcia, 2003); and ensure that local ownership and consensus are obtained, interagency coordination is established, and all stakeholders, not just proprietary interests, are involved in policy development and planning (Penner, 1994).

PARTICIPATORY GOVERNANCE AND PARTNERSHIPS IN THE HEAD START PROGRAM

Head Start is a national program that promotes school readiness by enhancing the social and cognitive development of children through the provision of educational, health, nutritional, social and other services to enrolled children and families. Head Start programs promote school readiness by enhancing the social and cognitive development of children through the provision of educational, health, nutritional, social and other services to enrolled children and families. They engage parents in their children's learning and help them in making progress toward their educational, literacy and employment goals.

Citizen governance and partnerships are emphasized in Head Start Programs. Significant emphasis is placed on the involvement of parents in the administration of local Head Start programs. Head Start programs are overseen by parents through the Policy Council which acts as the local Board of Head Start Programs. The policy Council has many committees with oversight over different aspects of the Local Head Start. The HUIM came under the supervision of the Program Development committee of the Head Start Program.

Head Start serves families within the context of the community, and recognizes that many other agencies and groups work with the same families. Collaboration with community entities ensures that the highest level of services is provided to children and families, and fosters the development of a continuum of family centered services, and advocates for a community that shares responsibility for the healthy development of children and families of all cultures.

Head Start's shared governance and the community that shares responsibility approach lend themselves to interventions that are driven by shared partnerships and collaborations. The HUIM was an example of such an intervention which is planned, developed and implemented within a participatory framework.

HUIM PARTICIPATORY PLANNING AND PROGRAM DEVELOPMENT

HUIM PARTNERS AND COLLABORATORS

The HUIM was planned, developed and implemented by a partnership between the Head Start community (parents and Head Start employees) and university researchers. The partnership relied on a network of collaborators encompassing hospitals, payers, health providers, public health organizations, institutions of higher learning, and other community-based organizations and volunteers. These collaborations were a critical ecological factor as HUIM created an environment that supports self-efficacy, self-advocacy, and self-management for participating families through education and structured non-clinical case management.

Parents and community involvement improved the acceptability of the program among Head Start staff and community health providers.

HUIM PROGRAM DEVELOPMENT

The needs assessment for the HUIM program was developed from systematically collected evidence including public health data on South Los Angeles and Head Start enrollment and compliance tracking data. This data was analyzed in conjunction with data collected from pre-program brainstorming sessions with Head Start parents and families. The planning and program development committee of Drew Head Start Policy Council and Faculty from the Department of Pediatrics at Drew University jointly evaluated the data and then developed the program to fit the needs of Head Start children and their families. The Policy council is made up of parents of Head Start enrollees' and members of the community. The program that emerged was jointly submitted by the Head Start policy council and the Department of Pediatrics for funding to The California Endowment. The California Endowment funded the program for two years.

HUIM PARTICIPATORY IMPLEMENTATION.

ORGANIZATIONAL STRUCTURE

Figure one below illustrates the organizational structure of HUIM. The implementation structure of the HUIM was a critical part of the participatory character of the HUIM. HUIM was implemented in an embedded structure. In the embedded structural variation of the Preventive Health Education and Medical Home Project (PHEMHP), the educational and service linkage organization is embedded in a payer, provider, or community-based organization (Tataw, Bazargan, James, 2009). In the case of the HUIM, the program staff operationally became a part of the target or host organization which is the Drew University Head Start Program. The Drew University Head Start program is an autonomous program affiliated to Drew University and funded by the US federal government. The HUIM program staff were Charles R. Drew University Department of Pediatrics employees, but were physically located at the Head Start program location in the community, and operationally integrated into the Head Start organizational structure with reporting relationships to Head Start senior managers. By reporting to Head Start senior management, HUIM staff were brought under the control of the Head Start Citizens Board which is known as the policy council. HUIM educational and case management staff was led by a Program Manager. Through this structural arrangement, the program manager of HUIM operationally became one of the Head Start managers and reported to one of the Deputy Directors of the Head Start Program. The HUIM program manager simultaneously reported to the HUIM external Program Director/Principal Investigator, who was a faculty member in the Department of Pediatrics at Charles Drew University (Tataw et al., 2007). By structurally aligning the HUIM program staff with the Head Start organizational structure, the full participation of Head Start employees and parents in the implementation of the HUIM was facilitated. This also created both structural and cultural horizontal relationships between Head Start parents and HUIM staff rather than hierarchical relationships found in top down expert-low income consumer relationships.

IMPLEMENTATION COMMITTEES

The HUIM was implemented through a committee system. There was a planning committee, a technical committee, and an advisory committee. Head start staff and parents were part of the post-award planning, technical, and advisory committees which oversaw the implementation of the program. The planning committee was made up of Head Start staff, Department of Pediatrics faculty and staff, and the Head Start Policy Council. The implementation planning committee developed the implementation plan and hired initial staff to start the program's implementation.

After the implementation planning phase, the planning committee evolved into the technical committee of 6 members and an advisory committee of 20 members. The technical committee developed and monitored technical issues including, but not limited to refining the program design, implementation and evaluation protocols and instruments. This committee was made up of the Department of Pediatrics faculty, HUIM program manager and the Head Start Health Manager.

[FIGURE 1 OMITTED]

The advisory committee ensured program integrity and assisted HUIM staff in meeting the objectives of the program and grant contract. The advisory committee also ensured compliance with Head Start's policies and procedures. The advisory committee oversaw the technical committee and all other HUIM activities. In addition, the HUIM Advisory committee became one of the standing committees of the Policy Council and was chaired by the Head Start Director and the Chair of the Policy Program and Development Committee. The Advisory committee met once a month to receive progress reports from HUIM staff and the technical committee. The monthly advisory committee meeting, was an opportunity for the program staff to provide and receive feedback from Head Start supervisors, parents, and policy council officials. This feedback was immediately integrated into the program either through program redesign or implementation strategy changes.

COMMUNITY HEALTH PROVIDER ROUND TABLES

Providers were a critical part of the HUIM triangle made up of Head Start parents, community health providers and HUIM staff. Provider round tables were organized in the post award phase of HUIM so that community health providers serving Head Start families can provide input into the development of provider training modules. Parents also attended the provider round tables and shared their experiences and expectations with community health providers serving their children. The content and delivery strategies of provider health orientation workshops came out of the dialogue which took place during the health provider round tables.

VOLUNTEERS

A volunteer program is critical to the effective implementation of the HUIM. Volunteers drawn from the Drew University residency training and medical education programs, Head Start parents and extended family members, allied health programs, and graduate health professional programs in neighboring universities helped in the development of training content, data collection and case management tools. Student volunteers participated in program implementation as part of their service learning. The volunteer program was also an opportunity for the larger community to participate in the HUIM program.

IMPLEMENTATION EVALUATION

HUIM evaluation research was approved by the Charles R. Drew University Institutional Review Board. There was an outcomes evaluation of the HUIM (Tataw et al., 2007; Tataw & Bazargan, 2009); but the implementation process of the HUIM was evaluated through a process evaluation. As a feedback loop into the implementation process, process evaluation is an important tool for quality assurance and for making sure the program is doing what it planned to do.

There HUIM process evaluation was made up of six components. An event specific pre- and post-survey containing questions on knowledge and workshop delivery effectiveness was used to measure the effectiveness of each parent and health provider educational workshop immediately before and after the workshop. Another survey instrument was also used to assess the effectiveness of the non-clinical case management support process from the perspective of the parents who participated in the case management support process. A third process evaluation survey was used to measure awareness and knowledge of the HUIM program by Head Start employees in the intervention sites. A fourth mechanism of assessing if the program was implemented as expected and reaching the participants anticipated was the use of sign-in sheets at every event. This allowed the program to track the type of participants as well as the number of people participating in HUIM events. A fifth component of process evaluation was the stake holder feedback from standing committees including the technical committee, advisory committees, and the health provider round tables. The final process evaluation instrument was the task and deadline check list. The check list helped HUIM staff and Head Start policy council and grantor to determine if HUIM was completing program activities on time.

Pre and post survey results, a Head Start employee survey, and attendance records of educational activities revealed that educational workshops were effectively transferring information to participants and participation in educational workshops was increasing. It was also clear that many Head Start employees in the intervention were either not aware of HUIM or did not have any knowledge of the program. Parents, employees, and health providers' process evaluation results are summarized below:

* Pre and post test results of specific parent workshops showed an average increase in systems and preventive health knowledge of 40% per a session.

* Compared to the first year, parent attendance at health education sessions increased by 400% within the first six months of the second year.

* Preliminary data from pre and post test results of provider onsite workshops showed an average increase of 50% in health provider awareness of the needs of the Head Start population.

* 60% of employees in the intervention centers were not aware of the existence of HUIM in the first year of the program

* 80% of the employees in the intervention centers did not have a good knowledge of the program in its first year

Nonclinical Case Management process evaluation results revealed that HUIM staff followed prescribed program implementation protocols in being respectful to participants, giving them relevant information, providing social support and attaching them to a payer source and regular source of care. It also revealed that the staff was not very effective in attaching participants to a local provider when children were assigned to a health provider outside their area of residence by a public managed care health plan.. A short coming of the non-clinical evaluation is the absence of questions assessing parents' participation in developing the management plans. Three hundred and seventy participants were surveyed in the four intervention sites. More people consented to participate in this survey than were formally enrolled in the HUIM project. Nonclinical case management results are summarized below:

* 33 % of parents surveyed reported receiving structured case management support

* 77% of parents who received non-clinical case management considered HUIM staff to be very helpful

* 63% said they received a reminder about their appointment with HUIM staff for non-clinical case management 1 week or more in advance

* 75% of participants in non-clinical case management showed up for their non-clinical case management appointment

* 75% were notified of what documents to bring to a case management appointment

* 75% showed for their case management appointment

* 56% said case management helped them to get health insurance

* 23% said case management helped them to switch to a local provider

* 78% said case management helped to identify a regular source of care

Feed back Issues from the Advisory committee and the Health Providers Round Table included the following recommendations which were adopted by the HUIM program:

* Recommendations for onsite training of health providers

* Recommendation for multiple strategies for follow up evaluations including phone and face to face interviews

* Recommendations to cut down educational training modules to 30 minute delivery sessions.

* Recommendation to align parent educational sessions with required Head Start parent educational programs.

* Recommendations to get all HUIM staff certified as authorized public insurance plans enrollees

In response to the poor program awareness and knowledge in the intervention sites as revealed in the process evaluation results, HUIM program staff provided HUIM orientation to all Head Start staff at the beginning of the Head Start program year. HUIM updates were also provided at each quarterly parent and employee all day conferences.

HORIZONTAL PARTICIPATORY IMPLEMENTATION APPROACH IN THE HUIM COMPARED TO CLASSICAL IMPLEMENTATION MODELS.

This section reviews dominant implementation models in the literature and compares these models to the HUIM 's horizontal implementation approach. Top-down and Bottom-Up models have dominated academic discourse on program and policy implementation in recent history. Top Down models advocate for the supremacy of formulation settings and decisions made at formulation settings, while bottom up models generally advocate for the dominance of the implementation settings and actors. Both models present a vertical construction of the implementation process in an intergovernmental hierarchical framework and fail to capture the reality of horizontal participatory implementation approaches such as the one actualized in the HUIM. While many scholars have attempted to modify or reconcile the two classical models above, Matland (1995), contributed to our understanding of implementation theory by focusing on the theoretical significance of ambiguity and conflict in policy implementation. Hanks (2006), brought implementation literature closer to the reality of participatory public health promotion programs with her partnership model of implementation which created space for program targets in the implementation process and even foresaw the community and family as part of the program. HUIM's horizontal participatory implementation approach is different from the classical and partnership models because it presents a horizontal construction of the program/policy process and is more representative of the emergent participatory character of health promotion programs which serve at risk low income populations such as head start parents. In addition, HUIM's horizontal participatory implementation approach also includes all stakeholders in the entire program continuum, from planning, formulation, to implementation.

Matland (1995), in his ambiguity/conflict matrix uses ambiguity and conflict as analytic constructs. The matrix describes three implementation conditions, assesses the conditions by examining their levels of ambiguity or conflict and then identifies policy types in the classical tradition that would match each of the three conditions. The conditions identified include administration implementation, political implementation and experimental implementation. Administrative Implementation involves low policy ambiguity and low policy conflict. This process fits a typical Top Down model. Political Implementation involves low policy ambiguity and high policy conflict. This variety fits the more sophisticated Top Down power models that recognize political factors in the implementation process. Experimental Implementation involves high policy ambiguity and low policy conflict. Policies in which both means and goals are unclear fall into the experimental category. In addition, policies with clear goals but unclear means also fall in the experimental category. The HUIM's horizontal participatory implementation approach falls in the experimental implementation component of Matland's matrix but it is neither a top-down nor bottom-up model. While the HUIM has clear goals, the means to achieve the goals were not usually clear but rather emerged as the program's implementation unfolded.

Table One below, provides a comparison of the classical models to HUIM's horizontal participatory implementation approach. The horizontal participatory approach used in the HUIM is compared to the classical models using the following criteria developed from implementation literature: Goal Clarity and Ambiguity; Structural and Cultural relationships between the implementation and formulation settings; Number of participants or actors involved in the policy or program continuum; Attitudes of the implementation setting towards the policy; Flexibility of implementation actors in adjusting policy/program goals or means; Degree of conflict among stake holders; Role of implementation players/actors in policy/program formulation; Fluidity of boundaries between implementation and formulation settings; and the role of evaluation. This comparison helps to illuminate the degree to which classical models capture the reality of cultural and structural horizontal participatory approaches emerging from health education and health promotion models serving at risk low income populations such as Head Start parents.

GOAL CLARITY AND AMBIGUITY:

Goal clarity and ambiguity represents the degree to which policy or program goals at the formulation setting are clear or ambiguous. Top down theorist call for consistent and clear policy goals (Van Meter & Van Horn, 1975). The purpose of clear goals in top down models is to limit the opportunities for policy adjustments in the implementation settings, Bottom up approaches do not advocate goal clarity at the policy formulation setting. Ambiguity is preferred because it gives more room for implementers to shape policy through the use of what has been referred to as "street bureaucrats. The HUIM policy goals are clear, evidence based, and designed through tested methods using rational processes and organizational structures, yet the means of getting to the goals is not necessarily clear at all stages of formulation or implementation. The goals are clarified and the means of achieving the goals emerge through the participatory implementation process.

STRUCTURAL AND CULTURAL RELATIONSHIPS BETWEEN THE IMPLEMENTATION AND FORMULATION SETTINGS:

Structural relationships refer to the degree to which stake holders within or between settings are organized. Are they organized into hierarchical systems or are they interacting at the same level? Cultural relationships refer to the extent to which there is dialogue rather than monologue among stake holders. It also refers to the opportunities for all stake holders to be heard and equally regarded without a sense of superiority or inferiority.

Top downers concentrate on the authoritative power of statutes to the exclusion of pre or post statutory factors in their conception and prescription of the implementation process. Bottom-top models give a central role to the implementation setting or service providers (Berman, 1978; Hjern and Porter, 1981; Hjern, 1982; Hjern & Hull, 1982; Hull & Hjern, 1987; & Lipsky, 1978). Bottom Top models identify macro and micro implementation levels. At the macro level, central organizations devise a program while at the micro level local organizations implement the program.

Classical models, frame program formulation as something that occurs exclusively in a federal-state-local intergovernmental hierarchy. They do not capture horizontal relationships at the community level involving governmental agencies, program beneficiaries, researchers, and community organizations. Classical models separate formulation and implementation settings in their conceptualization of the policy/program continuum, actors do not move from one setting to another as full participants. While the bottom top models recognize policy setting influences on the implementation environment, they basically see the two settings as separate and distinct, and they elevate the role of the implementation settings above the formulation settings.

Hank's partnership implementation model operates in a vertical structure but injects a horizontal culture to advance consumer empowerment in a one to one relationship with the expert.

The model focuses on the micro level and proposes a relationship improvement approach which operates within a provider-patient framework. It foresees community and family involvement in the implementation of policy at a micro level but does not clearly demonstrate or explain how the community and family would get involved. Hank's (2006) model creates space for a partnership between the providers and policy targets in the Special Supplemental Nutrition Program for Women, Infants, and Children program which is locally implemented. In the partnership model, program targets collaborate with public health experts in cycles of learning and doing.

In the horizontal participatory implementation approach followed in the HUIM, the formulation and implementation settings are tightly coupled through an embedded structure. Actors move in and out of the different phases of the policy/program making process. There is also a horizontal cultural relationship in the HUIM participatory approach which allows for full participation of all stake holders. The participatory approach does not separate policy from the implementation settings. The HUIM implementation process is structured so that the main partners are operationally united in one organization and one setting. Structural relationships between the two settings are horizontal and involve shared partnerships and collaboration among community actors based on equality of participation and common interest. Actors move from one setting to another, the settings and actors enter into formulation/ implementation phases or moods as required to advance the goals or interests of participants. All stake holders including the policy/program targets participate in the formulation and/or implementation phases of the program.

NUMBER OF PARTICIPANTS OR ACTORS INVOLVED IN THE POLICY OR PROGRAM CONTINUUM:

The number of participants or actors involved in the policy or program gauges the degree to which a program or policy is inclusive of stake holders. Top down models call for a limited number of actors (Pressman and Wildavsky, 1983). This is because Top downers believe that the fewer the participants in the process, the less likely it is to have conflict and the higher the chances of the formulated policy staying intact when implemented. Equal participation of all stakeholders is critical in the horizontal participatory approach actualized in the HUIM. In a low income and multiracial minority community such as South Central Los Angeles California, where the HUIM was implemented, equal participation by all groups (parents, researchers, community organizations) is critical to the acceptability of the implementation process and the continuous support of the program. The HUIM ensures equal participation of stake holders through a participatory planning, formulation and implementation approach that is structured for collective reliance on evidence, open communication, and shared responsibilities.

ATTITUDES OF THE IMPLEMENTATION SETTING TOWARDS THE POLICY:

This criterion refers to the goals of the policy as framed in the formulation setting. Top downers place implementation responsibility in an agency sympathetic with the policy's goals (Van Meter & Van Horn, 1975; Sabier, 1986). Bottom up models would rather leave the policy goals to be clarified by the "street bureaucrat" at the local level implementing the program. In the horizontal participatory approach actualized in the HUIM, the formulation and implementation settings are merged and actors have a common interest and inclination to constantly review policy/program goals, as well as the means to achieve stated goals.

FLEXIBILITY OF IMPLEMENTATION ACTORS IN ADJUSTING POLICY GOALS OR MEANS:

This area sheds light on the level of creativity permitted at the implementation setting. Top down models seek to limit the extent of change necessary in any initiative (Van Meter & Van Horn, 1975; Mazmanian & Sabatier, 1983), Top downers also see implementation as a purely administrative process with weberian purity and not tainted by political factors. Environmental factors in the implementation settings should play a very limited role. Bottom up models call for implementation flexibility at the local level so that local service providers should determine policy/program outcomes (Palumbo, Maynard Moody, & Wright, 1984). In HUIM's horizontal participatory approach, while there is goal clarity, the form of each individual project by micro partners is ambiguous, flexible, and contextual. The means are collectively clarified and refined as the program advances from one phase to another. For instance, each health provider implements HUIM requirements in his/her own way, each Head Start center adapts the program to its own reality except that the effectiveness standards of the HUIM stayed constant. Because the means of achieving the goal were ambiguous, the stake holders met regularly to review and remap the particulars of every stage of the implementation process.

DEGREE OF CONFLICT AMONG STAKE HOLDERS IN THE POLICY OR PROGRAM:

This refers to the extent to which a model allows for conflict or anticipates conflict in the policy/ program continuum. Top down models are not very supportive of conflict so they call for limits to the number of actors in the formulation and implementation process. Absence of conflict also advances the goal of top downers to limit alterations to policies/ programs at the implementation settings. Bottom up models recognize intensity of conflict and the difficulty in forging agreements, so they do not seek to have goal clarity at the formulation level. They believe the implementers should clarify policy/program goals and means as well as determine outcomes based on local realities. The horizontal culture in HUIM's participatory implementation approach anticipates conflict because of the wide range of stake holders; and it is designed to hear everyone out and for the resolution of differences by consensus in a collegial atmosphere.

ROLE OF IMPLEMENTATION PLAYERS/ACTORS IN POLICY/PROGRAM FORMULATION:

The classical implementation models do not provide a clear decision making role for implementation participants in the policy formulation setting because the two settings are conceptually distinct in these models. In a horizontal participatory approach, actors move from the formulation to the implementation setting and vice versa. Since both settings are united in the HUIM embedded structure, the setting converts from one phase to another depending on the needs of the program. Implementation actors definitely have a say in the policy/program formulation because all stake holders are involved from planning, formulation, to implementation.

FLUIDITY OF BOUNDARIES BETWEEN IMPLEMENTATION AND FORMULATION SETTINGS:

This refers to the extent to which boundaries between the formulation and implementation settings are tightly defined or the degree to which actors in the formulation and implementation phases are kept separate. Clearly, top down models conceptually put a wall between the formulation and implementation phases. Movement is predominantly unidirectional from the political decision maker to the administrative implementer. The Bottom Up models also see the two settings as separate and do not anticipate a lot of movement across implementing and formulation boundaries. The horizontal participatory approach practically eliminates the boundary between formulation and implementation. Actors move from one setting to another and the two settings are not spatially separate. The HUIM renders the boundary between the formulation and implementation settings practically irrelevant and shifts that boundary to a purely conceptual level.

THE ROLE OF EVALUATION::

Evaluation is a critical component of horizontal participatory implementation in a community health education or health promotion program. To discuss the role of evaluation in the horizontal participatory implementation of the HUIM, we must understand what implementation success means. Scholars view implementation success differently; Ingram and Schneider (1990), cite several definitions including compliance with directives of statutes, achieving specific indicators, achieving goals of statutes or improving the political climate around a program. The partnership model (Hanks, 2006), and conflict/ambiguity model (Matland, 2006), consider goal achievement and outcomes measures as part of the implementation evaluation process. In a horizontal participatory implementation approach, implementation success is tied to the achievement of the processes and structures necessary for goal achievement. Implementation measures need to be distinguished from outcomes measures. Process evaluation is therefore the evaluation strategy best suited for implementation evaluation. Process evaluation investigates whether or not the program is carrying out the activities articulated in the design: whether the required relationships and structures are in place and the desired beneficiaries are been reached. Process evaluation then becomes a feedback loop as the results are used to redesign the implementation process if needed.

CONCLUSION AND IMPLICATIONS FOR COMMUNITY HEALTH PROMOTION PRACTICE AND RESEARCH

This paper has described the participatory character of the Health Services Utilization Improvement Model (HUIM) including program planning, program development, organizational structure, and implementation. The HUIM as an example of emergent participatory implementation approaches in Community Health Education and Health Promotion practice is compared to classical implementation models using criteria developed from implementation literature. The analysis demonstrates that the classical models do not capture the reality of horizontal participatory implementation programs such as the HUIM. The author proposes the conceptualization of a horizontal participatory implementation model that captures the reality of participatory programs serving at risk populations such as the Head Start population served by the HUIM. Such a model will be a descriptive and prescriptive model based on trends in the field. The next step will be the development of research designs to collect empirical data that will support the effectiveness and generalizability of the conceptual model beyond at risk populations such as Head Start, and including diverse and less diverse populations.

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David Besong Tataw, PhD, is affiliated with the Department of Policy and Administration, School of Public Service, Jackson State University, Jackson, MS 39211. Please send all correspondence to: Dr. David Besong Tataw, 14547 Reservoir Place, Chino Hills, CA 91709. Phone/fax: 909-597-4342. Cell: 951-255-8377. E-mail: dbtataw@yahoo.com
Table 1. HUIM Horizontal Participatory Implementation
Approach Compared To Three Major Implementation Models

Criteria         Top Down         Bottom Up
                 Models           Models

Goals and        Clear goals,     Ambiguous
Means Clarity    clear means      goals and
and ambiguity                     means

Number of        Limited          Many actors
Actors

Degree of        Limited Change   Extensive
Change                            change

Attitudes if     Sympathetic      Implementers
implementation   Implementation   adopt policy
setting towards  Agency           to local
Policy                            context

Structural       Structurally     Structurally
relationships    and culturally   and culturally
                 vertical         vertical.

Flexibility      Limited          High
in Adjusting     implementers     implementers
policy           autonomy         autonomy and
                                  flexibility

Conflict         High Conflict    Low Conflict

Boundary         Tight            Tight
Fluidity         boundaries       boundaries
                 between          between
                 settings         settings

Role of          Limited Role     Limited Role
implementers
in Formulation

Evaluation       Outcomes         Outcomes
                 measures         measures

Criteria         Partnership         HUIM as a
                 Model               Horizontal
                                     Participatory
                                     Model

Goals and        Clear goals,        Clear goals
Means Clarity    ambiguous           and ambiguous
and ambiguity    means               means

Number of        Limited Actors      (Many actors(all
Actors           (provider-target)   stakeholders
                                     involved)

Degree of        Extensive change    Extensive Change
Change

Attitudes if     Implementers        Sympathetic
implementation   adapt policy to     implementers
setting towards  beneficiary         who are also
Policy           needs               formulators

Structural       Structurally        Structurally
relationships    vertical,           and culturally
                 culturally          horizontal
                 horizontal

Flexibility      High                High
in Adjusting     implementers        implementers
policy           autonomy and        autonomy and
                 flexibility         flexibility

Conflict         Low Conflict        Low Conflict

Boundary         Tight               High boundary
Fluidity         boundaries          fluidity
                 between
                 settings

Role of          Limited Role        Implementer has
implementers                         central role in
in Formulation                       formulation

Evaluation       Outcome             Process
                 measures            evaluation
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