Thursday, December 15, 2016

What’s in a word? The challenge of “infrastructure” funding

By Lise E. Fried

Status of nonprofits
Donors and funders often want to know how much of a nonprofit’s revenue was spent on “infrastructure” or “overhead.” Donors and foundations want to fund “programs” not “infrastructure.”  But, how can programs exist without infrastructure?  At home you pay for heat, light, furniture, etc, and we have to do so at nonprofits too.  Restaurants have to pay for staff to order supplies as well as produce pizza.   It is the same for nonprofits.
I participated in a recent webinar by Guidestar 1 that showed some fascinating data on nonprofit status collected by Bridgespan.2  Some of the data are based in an important article, “The Nonprofit Starvation Cycle,” published in 2009 in the Stanford Social Innovation Review .3  It did not surprise me that in 2014, 24% of nonprofits were “in the red.”  What was more compelling was that the twenty nonprofits that Bridgespan studied spent between 21% and 89% of direct costs on “infrastructure.”  Back in the 1950s, the federal government believed that 15% of direct costs should be the overhead (infrastructure) goal for nonprofits. It was a myth and the federal government no longer believes 15% is appropriate.  It is a rare organization that can survive on that percent.  And, more importantly, as shown in the article mentioned above “infrastructure drives impact.”  So, spending little likely means accomplishing less than the organization could if it were better funded for core dollars.

Measuring impact

The Institute for Community Health (ICH) is a sixteen-year old participatory evaluation and innovative research nonprofit creating sustainable community health. ICH is moving from a primarily donor-funded infrastructure to infrastructure funded as part of the cost of doing business on grants and contracts.  For ICH, funding for infrastructure has always been an issue.  We struggled for years to show our donors the impact of their dollars. Their dollars paid for the organization to exist, lead, manage, pay rent, and more, all of which drives impact.  Moving to explaining this same issue to foundations and other funders, we have a similar challenge.  Again, it is not that different from a restaurant that needs staff to make food and management to run the restaurant.  We need staff to run our programs and staff to manage the organization.

Language of impact

I agree with other participants on that recent webinar that part of the problem is the word “infrastructure.”  We all agreed that some other terms might be better – “core funding” got the most votes.  Federal (and other) grants call it “indirect”, some call it infrastructure, but it all means the same thing.  Terms that highlight the fact that these costs are part of the work and not a separate set of costs make more sense.


Ultimately, what matters is impact.  Has a nonprofit organization helped anyone?  If so, how many people and in what ways?  Have we met our goals? If yes, then organizations funding the work that led to that impact should help pay the core funding dollars that made it happen.

1.       Tips, Tricks & Secrets to a Successful GuideStar Profile  (

2.       Eckhart-Queenan J, Etzel, M, Prasad S.   Pay-What-It-Takes Philanthropy, Bridgespan

3.        The Nonprofit Starvation Cycle, Stanford Social Innovation Review, Fall 2009


Thursday, October 27, 2016

Using photovoice to engage participants in qualitative data collection

By Ranjani Paradise

My Camera. Paul Reynolds, 2006, (Flickr).
Used under Creative Commons Attribution 2.0
Here at ICH, we do a lot of qualitative data collection as part of our research projects, program evaluations, and needs assessments. While we often use traditional methods such as interviews and focus groups, we also use photovoice as a creative and fun alternative to traditional qualitative data collection approaches.

What is photovoice?
Photovoice is a method that originally came from the world of participatory action research. It was first used by Caroline Wang and Mary Ann Burris in 1992 to empower women in a rural Chinese village[1] and is now used to explore myriad topics in a variety of fields. With photovoice, participants take photos to represent their perspectives about a particular issue, and the photos are used to stimulate discussion, reflection, and action.
What are some of the unique advantages of photovoice?

Photovoice is a great method for engaging participants and creating a safe space for open discussion. In our experience, photovoice can help you:

  Empower participants and give them a unique mode of expression

  Catalyze dialogue and reflection about personal and community issues

  Understand issues from others’ points of view

  Share participants’ stories in a compelling, visual way with leaders, policymakers, or others

How have we used photovoice at ICH?

At ICH, we have used photovoice as part of our evaluations of several programs, including:
  • GRO: A gardening program for immigrant and refugee families in the Boston area
  • Pathways to Family Success: A program for immigrant parents in Cambridge, MA to help them better understand the U.S. school system and support their children’s education
  • Young Men Matter Too!: A sexual health program for young men of color in Springfield and Holyoke, MA

As you can see, photovoice can be used to explore many different topics with many different populations!
Photo from the GRO photovoice project
“I took this picture because this man was walking in the street and smelled the basil. He said that every time he pass by he smells the nice smell of the basil and he needs this green. He likes this green.”
Photo credit: Amina Osman, Refugee and Immigrant Assistance Center
Want to learn more?
For a great introduction to the photovoice method, check out Caroline Wang’s paper entitled “Photovoice: A Participatory Action Research Strategy Applied to Women’s Health” (Journal of Women’s Health 8(2), p. 185-192, 1999).  
ICH will be presenting our second photovoice webinar in the spring of 2017, which will include a practical, step-by-step guide to conducting photovoice projects. Here’s what participants had to say about our first photovoice webinar, which we presented last spring:
“It was a very informative and well conducted webinar.  Thank you so much!”
“The webinar was well organized and informative.”
“It was useful and well presented.”
We hope you’ll join us for the 2017 webinar - keep an eye on our website for more information in the coming months!!
[1] Wang, C., & Burris, M.A.. Chinese Village Women as Visual Anthropologists: A Participatory Approach to Reaching Policymakers. Social Science & Medicine, 42, p. 1391-1400, 1996.

Thursday, September 29, 2016

Behavioral Health Integration and the Workforce: the Cambridge Health Alliance Experience

By Leah Zallman, MD, MPH

Behavioral health integration has caught the national eye for its potential to improve patient outcomes and patient satisfaction, in addition to reducing costs.  Behavioral health integration is a healthcare delivery approach that is geared towards addressing mental and behavioral health concerns in primary care.   Early success of these programs has led to increased attention to the immense need for developing a sufficiently and adequately trained workforce to deliver integrated care. Indeed, these programs require large investments in the workforce, and the work of integration requires a cultural shift in how healthcare institutions care for their patients.  And yet, relatively little attention has focused on how the workforce is responding to the work of integration – to what degree the workforce feels more supported in caring for patients with mental health conditions, is more satisfied with their work, or alternatively, is more burned out by the high levels of effort this entails.

 Informed by 25 years of care integration, one of our partners, Cambridge Health Alliance, has embarked on an innovative and extensive behavioral health integration program.  We have been working with Cambridge Health Alliance to better understand how this program is affecting their workforce through annual surveys of their primary care and behavioral health staff. Together, we have learned that primary care providers feel more knowledgeable about how to care for these patients, across a variety of measures. We have also learned that staff report higher degrees of systems integration –for example, more primary care providers report talking with their mental health colleagues on a regular basis, which is mirrored by an increase in behavioral health providers’ report that they speak with their primary care colleagues on a regular basis. 

First and foremost, this experience has highlighted the power of a well conceived and enacted program, like Cambridge Health Alliance’s behavioral health integration team, to change the workforce experience.  And it has also highlighted how thoughtful, prospective evaluation of the workforce experience can provide programs like Cambridge Health Alliance with meaningful data that helps shed light on the workforce experience.

Monday, September 8, 2014

Meeting people where they are: How the radio is being used to eradicate health disparities among the Haitian population in Somerville, MA

As an ICH intern I have had the privilege of working on a number of projects, one of which was the Kwen Sante (Health Corner) radio show survey. This project, led by Marie-Louise (Malou) Jean-Baptiste, MD, an internist at Cambridge Health Alliance, sought to engage the Haitian population living in Somerville through radio segments about health-related topics such as hypertension, cancer, and HIV/AIDS. Traditionally, the radio has been a vehicle for providing important social and political information in Haiti. Therefore, by disseminating health information to this community via the radio in Haitian Creole, Dr. Jean-Baptiste is able to provide heath information to those with low literacy and limited English skills in a way that is relevant to this unique population. 

To help assess the effectiveness of Kwen Sante among Haitian individuals living in Somerville, Dr. Jean-Baptiste partnered with the Institute for Community Health (ICH) to conduct a one-time survey at a local church health fair event to evaluate whether residents were familiar with the radio show, what they had learned, and whether the show was improving their health. Out of the 43 respondents, 26 (60.5%) reported listening to Kwen Sante. Although the sample size was small, the results were positive overall, with most respondents citing that they had either learned something new about their health and/or applied their new knowledge to their lives. See the chart below for results from one question of the survey.

Working on this project through ICH taught me that even when the sample size is relatively small, you can still find something interesting to take away from the experience. For instance, even though the project was aimed at Haitians living in Somerville, 16 out of the 26 listeners lived elsewhere in the Boston area, telling us that Kwen Sante has attracted more listeners than those originally intended. Fantastic! Overall, ICH helped demonstrate that the Kwen Sante radio show is making a positive impact amongst Haitian residents, and from what I can tell, it has the potential to reach many more.

Janelle Mellor is a student at Boston University School of Public Health concentrating in Global Health. For more information on the ICH internship program and to apply for current intern positions, please contact Reann Gibson at


The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Tuesday, June 10, 2014

Using Creative Methods to Evaluate Youth Programs

By Kelly Washburn & Julie Carpineto 

We are the evaluators of an urban high school-based teen pregnancy prevention program in Everett, MA called “Empowering Youth in our Community”. Our partner, whom ICH has worked with for 9 years, is the Family Planning and Adolescent Community Services Division at the Cambridge Health Alliance.  

Each year, the program is required to conduct a site-specific evaluation. In previous years, we conducted focus groups with the high school students involved in the program to meet this requirement. However, two years ago - while reviewing the qualitative data from those groups - we realized the data was not that different than previous years. This realization led to discussions on how to conduct an evaluation to find new information, while continuing to ensure that the students could play an active, participatory role.  Together with the program partners, we developed a three-series collage project, drawing from the principles of Photovoice and other arts-based evaluation techniques. We aimed to engage participants in a discussion of a major theme addressed in the program: healthy relationships.

Developing the Evaluation Question
The first step in our process was to determine our evaluation question. We collaborated with the program coordinator to come up with “What does a healthy relationship look like to you?”  This question was chosen for a couple of reasons, the first being the timing of the evaluation with the program sessions. Students had recently completed a series of classroom sessions focused on healthy and unhealthy relationships, and we were interested in understanding how those sessions shaped their vision of healthy relationships. Furthermore, data from focus groups conducted in previous years revealed that the relationship sessions stuck out to students and had the most impact on them personally.  By asking this question, we were able to gain a more in-depth understanding of students’ opinions about this topic.

Collage Implementation
Over 90 high school students, in five separate classes, were asked to individually pull images from popular magazines that, from their perspective, represented healthy relationships. We left the type of relationship up to the individual students to think about, and many discussed a combination of romantic, friend, and family relationships. They were then led in large group discussions about why they chose their images.  Looking at their chosen images, students were asked to reflect on their thoughts, feelings, perceptions and experiences related to the different types of relationships. 

Afterwards, students were asked to work in small groups to combine their images to form a larger, collective collage poster. These posters served as visual representations of the students’ perceptions of healthy relationships.

Next Steps
The final phase of this project will include individual interviews with participating students to gather additional information about the collage process and their overall experience as program participants.

Lessons Learned:  
  • Magazine selection should be a part of initial planning. Examples of the magazines we used included: Glamour, People Magazine, Sports Illustrated, and Marie Claire.
  • Chose a diverse range of magazines. Make sure your selection of images is representative of your population!

Hot tip:
  • This project can be done with a small budget, limited time and with almost any participant population.
  • This project is a fun and creative way to engage young people in evaluation.

Cool Trick:
  •  If available, take notes from the large discussion on a white board. This serves as another visual representation and can help students develop their collages.  

ICH staff have expertise in a variety of program evaluation methods and strive to tailor each evaluation to meet the needs of individual clients and programs. Learn more about ICH's Program Evaluation services.

The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Tuesday, May 27, 2014

The Many Faces of Data: Qualitative and Quantitative Perspectives during My Internship at ICH

By Sami Hamdan

As an intern at the Institute for Community Health (ICH), I had the opportunity to study several different aspects of public health that fascinate me. However, my work at ICH also gave me the opportunity to explore health care and health reform through a lens that I had not previously considered: qualitative and quantitative data for evaluation.

As a Health Policy and Management concentrator at Boston University School of Public Health, I have been particularly interested in health reform and improving the delivery of care. I had taken many public health classes during my time as an undergraduate, and so I began my first full MPH year with a basic understanding of public health. As my classes continued to delve more deeply into health policy and management, I became very interested in gaining more practical experience with the health care system. Because the health care system is so complex, I wanted to gain deeper insight into the daily work of researching and supporting healthcare interventions. Because of this, I became interested in ICH’s work.

During my time at ICH, I worked as an intern for the Accountable Care Organization (ACO) and Patient-Centered Medical Home Transformation (PCMH) projects with the Cambridge Health Alliance, primarily with the results from a two year Workforce Survey. I assisted with quantitative and qualitative data analysis, report development, and several other small tasks that make a large project work. I became very familiar with Excel, especially the little short cuts that make long and complex data entry more efficient and accurate. I also learned how to use Excel for qualitative work and how to do basic qualitative coding. I realized that qualitative data offers a fascinating insight into people’s ideas and can give life and perspective to quantitative data and survey answers. I also learned that developing reports is not just about the information, but also about making a clean and engaging presentation (especially for graphs and charts) and using concise language. I was also able to attend several meetings with site leadership at the various Cambridge Health Alliance sites; learning how to present data back to clients was a very useful and important skill.

During my time at ICH, I had a wonderful experience working with very dedicated and supportive team members. I learned the value of working with a strong team, especially when reporting an immense amount of data concisely but accurately. I also learned the value of different perspectives in data: the quantitative and the qualitative. Because I spent so much time with the qualitative data on this project, I learned how powerful it can be, particularly when it is combined with quantitative data. Qualitative data provides nuanced feedback and gives a voice to the numbers, which are useful and incredibly important, but sometimes unclear. As is the case with so much else in health care, it takes multiple perspectives to form a clear picture.

Learn about the ICH Internship Program

The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Wednesday, April 23, 2014

Adapting Race & Ethnicity Categories to Fit your Community

By Jeff Desmarais & Ranjani Paradise

In honor of National Minority Health Month, ICH is exploring the complexities of race and ethnicity data collection. Any program, organization, or institution seeking to identify and address racial and ethnic health disparities must collect race/ethnicity data on the individuals they serve. However, in practice this proves challenging, as individuals often do not identify with the racial and ethnic categories provided.

ICH partners with the Cambridge Health Alliance (CHA) Zero Disparities Committee to ensure that race and ethnicity patient data are both accurate and meaningful for patients and the hospital. We assist CHA with patient demographic data collection and analysis, which helps CHA address disparities in service utilization and ensure that all patients receive linguistically and culturally appropriate care. We collect race data by asking patients to choose one or more of the categories defined by the federal Office of Management and Budget (OMB):
·        American Indian or Alaska Native
·         Asian
·         Black or African American
·         Native Hawaiian or Other Pacific Islander
·         White
·         Other

These OMB categories are required for state and national reporting and allow us to easily compare the race distribution of our patient population with other healthcare systems’ or communities’. However, CHA’s patient population is extraordinarily diverse, and the concept of race varies widely across cultures. Many of our patients simply do not relate to the OMB race definitions and categorizations. For example, Latino patients and Middle Eastern patients often express confusion when asked to select a race, as many do not see themselves fitting any of the given categories. And while it may seem clear that patients from India should fall under the Asian category, some Indians disagree - to them, Asian indicates East Asian and is distinct from South Asian. Overall, more than 25% of CHA’s patients do not identify with any of the OMB categories and choose “Other” as their race, which calls into question the usefulness of the OMB categories in our increasingly diverse community.

Because of these issues, we also collect detailed ethnicity data to better characterize our patients’ cultural backgrounds. Patients are asked to self-identify their ethnicity (or ethnicities) from a list of more than 150 options (e.g., Algerian, Bangladeshi, Egyptian, Greek, Nepalese, Syrian, etc.). We strive to make these ethnicity options specific enough that patients can select one or more with which they truly identify. Overall, we find that ethnicity data can be far more useful than race data for ensuring we provide culturally appropriate care to everyone we serve.

ICH also works as the evaluator of the Youth First Initiative in Holyoke and Springfield, MA. Youth First is a community-wide teen pregnancy prevention initiative, which was developed with grant funding from the Centers for Disease Control and Prevention. The Initiative is a collaboration between the Massachusetts Alliance on Teen Pregnancy (MATP), the YEAH! Network, and many stakeholders within the two communities, including schools, community organizations, and health clinics. Youth First began in 2010 and its goal is to reduce teen births by 10% by 2015 in Holyoke and Springfield, MA. While the overall teen birth rates in these communities are significantly higher than the state’s, there are also large racial/ethnic disparities within the communities.

Source: Births (Vital Records). Massachusetts Community Health Information Profile (MassCHIP). Version 3.0r328. Massachusetts Department of Public Health. Data downloaded May 6, 2013

Thus, collecting meaningful race/ethnicity data is critical to both improving and documenting improvement in teen pregnancy prevention efforts.

One of the key components of the Youth First initiative is implementing evidence-based sexual health education programs for adolescents. As a part of reporting requirements for funders, we collect race/ethnicity data from program participants via surveys. Collecting this data allows us to understand the populations we are reaching. In addition to the OMB race categories, the CDC requires data for the following ethnicity categories:

·         Hispanic or Latino
·         Not Hispanic or Latino

Cultural practices, beliefs, values and behaviors, all of which can reflect a person’s identity, can have an impact on a community’s health. Collecting data that taps these identities, if done meaningfully, can serve as an indicator to better understand, explain and ultimately address health inequities. With large Spanish-speaking communities in Springfield and Holyoke, it is critical to use measures that capture their unique and specific identities. Using the race/ethnicity categories often required by funding organizations can prohibit a comprehensive understanding of how communities might view themselves. For example, a Dominican or Puerto Rican teen might not identify with any of the OMB racial categories. Additionally, using the ethnicity category “Hispanic or Latino” can mask differences within Spanish-speaking communities. A teen that grew up in rural Mexico might have very different experiences, behaviors and values than a Puerto Rican teen that grew up in Holyoke. In this project, in order to ensure identity is accurately captured, we added an additional question that includes a much more comprehensive list of 29 different ethnicity categories (for example: Puerto Rican, Caribbean Islander, Dominican, Korean), thus expanding our understanding of identity among youth enrolled in evidence-based programs.

Capturing race and ethnicity data is essential not just for program improvement purposes, but also for ensuring that public health interventions are actively addressing health inequities. In developing alternative ways of measuring this data, it is critical to engage the community during the instrument development phase. It’s often necessary to go beyond the basic race/ethnicity reporting requirements, and delve deeper into communities’ understanding of race, ethnicity, and identity, in order for the data to be meaningful and actionable. 

The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.