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Fam Community Health
Vol. 33, No. 3, pp. 1–10
Copyright c
2010 Wolters Kluwer Health |Lippincott Williams & Wilkins
Community Readiness
An Effective Model for Tribal
Engagement in Prevention of
Cardiovascular Disease
Mickey Peercy, LCSW; Janeen Gray;
Pamela Jumper Thurman, PhD; Barbara Plested, PhD
Significant health disparities exist among culturally diverse minority populations in the United
States. The ways in which healthcare providers recognize and respond to this issue is critical.
Methods must be effective, culturally appropriate, and engage the community if they are to be
utilized, and they also need to be sustainable to make a significant impact. American Indians and
Alaska Natives face many unique health disparities and challenges and they confront many barriers
when seeking care and treatment. These obstacles make it essential for healthcare professionals
to engage the community in the development of culturally appropriate strategies with which
to address health issues. This article describes a community-based participatory approach that
was executed successfully by the Choctaw Nation of Oklahoma. By utilizing the Community
Readiness Model, it effectively built on the culture and resiliency that exists in each of 10 com-
munities to more successfully implement community-responsive health prevention and treatment.
This article discusses the experience of the Choctaw Nation in its assessment and engagement of
the community in addressing cardiovascular disease. Data are presented that reflect the successful
use of the Community Readiness Model and discussion is provided. This article emphasizes the
use of an effective community-based participatory method, Community Readiness, that enabled
the Choctaw Nation to make strong “inroads” into its respective service area through successful
community engagement. Key words: American Indian,cardiovascular disease,community
interventions,Community Readiness,heart disease
The provision of culturally competent ser-
vices is dependent upon understanding
the different cultural meanings of health and
health seeking behaviors. Cultural compe-
tence is a set of congruent behaviors, atti-
tudes, and policies that come together in a
[AQ2]
system, agency, or amongst professionals and
Author Affiliations: Choctaw Nation of Oklahoma,
Durant (Mr Peercy and Ms Gray); and Council Oak
Training and Evaluation Inc, Fort Collins, Colorado
(Drs Thurman and Plested).
The authors thank the participating communities of the
Choctaw Nation of Oklahoma for their involvement in
this project. This research was funded by the Centers
for Disease Control and Prevention, REACH US 2010,
Cooperative Agreement # 1U58DP001030.
Corresponding Author: Mickey Peercy, LCSW,
Choctaw Nation of Oklahoma, PO Box 1210, Durant,
OK 74702 (mpeercy@choctawnation.com).
enables that system, agency, or those profes-
sionals to work effectively in cross-cultural
situations.1[AQ3]
Statistics provide information indicating that
there are significant health disparities that ex-
ist among culturally diverse minority popula-
tions in the United States. The ways in which
healthcare providers recognize and respond
to this diversity is critical to the development
of culturally appropriate healthcare as well
as effective engagement of the community
in utilizing and accessing those health ser-
vices. American Indians and Alaska Natives
(AIs/ANs) face numerous health disparities
and challenges, and they confront many bar-
riers when seeking care and treatment. These
obstacles make it essential for healthcare pro-
fessionals to engage the community in the
development of culturally appropriate strate-
gies with which to address health issues. This
1
2FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2010
article describes an effective community-
based participatory research (CBPR) ap-
proach that was implemented by the Choctaw
Nation of Oklahoma (CNO) using the Com-
munity Readiness Model,2–7 a model used
both nationally and internationally for com-
munity and organizational mobilization and
policy change as well as community engage-
mentandsupport.Itisastrength-basedmodel
that builds on the culture and resiliency exist-
ing in each community to more successfully
implement health prevention and treatment.
If a community demonstrates a lower readi-
ness level to address an issue, in this case, car-
diovascular health, then the assessment will
guide the user in addressing a related issue
that the community may be more willing to
address. In doing this, community engage-
ment and investment is realized and healthy
changes can occur. The article presents the
experience of the CNO in its engagement of
the community members by using a related
issue, methamphetamine use in the CNO ser-
vice area, to gain a foothold in the community
for the larger issue of the prevention and treat-
ment of cardiovascular disease (CVD). Data
will be presented that reflect the success-
ful use of the Community Readiness Model
to address CVD and its consequences among
Native people residing in the 101
2counties
served by the CNO.
Education about maintaining health and
knowing when to seek help is essential and
in this case, the Choctaw Nation Core Capac-
ity Building Program and the Lifetime Legacy
Program were proactive in the establishment
and the support of health-focused coalitions
in each of 11 communities to focus on suc-
cessful intervention to raise awareness of CVD
and its consequences. Through this unique in-
tervention, the provision of community-based
services such as health screening, home visit-
ing, tracking, and follow-up were developed
and initiated.
Statistics from Indian Health Services Trend
Report8and the Centers for Disease Control
and Prevention (CDC)9lists CVD as the lead-
ing disease cause of death for AIs/ANs. In
fact, more AIs/ANs older than 45 years die of
heart disease than any other disease.9Tribal
Health reports that studies among numerous
individual tribes have shown that rates of
heart disease have dramatically increased over
the past 2–3 decades and that incidence data
indicate that coronary heart disease (CHD)
rates in American Indians now exceed rates
in other US populations and further that CHD
may more often be fatal in American Indians
than in other groups. Not only are CVD death
rates substantially higher than in the general
population but they continue to increase.10
These numbers likely underestimate the level
of CVD and CHD when one considers how of-
ten racial misclassification of AIs/ANs occurs.
These statistics are of concern and call
for more effective prevention and treatment
strategies to be initiated by Native com-
munities. Health disparities related to race,
ethnicity, and socioeconomic status exist
throughout our healthcare systems,11 and im-
provements are needed if we are going to have
healthier Native people.
AIs/ANs are a diverse population with ap-
proximately 560 federally recognized tribes.
Of all racial/ethnic populations, AIs/ANs have
the highest poverty rates (26%), twice the na-
tional rate.12 When poverty rates are high,
there are concomitant socioeconomic bur-
dens that are present and often persistent,
resulting in increased rates of health dis-
parities. In addition, the rates of injuries
and the incidence of diabetes were 2–3
times higher among AIs/ANs than among all
racial/ethnic populations combined.12 The 5
most common chronic diseases are the same
for AIs/ANs as for the general US population
(CVD, hypertension, arthritis, diabetes, and
gallbladder disease); however, the prevalence
rates for these diseases in AIs/ANs are signifi-
cantly higher than in the general population.12
In the disease category, CVD is now the lead-
ing cause of mortality among Indian people,
with a rising rate that is significantly higher
than that for the US general population.13 Fur-
thermore, AIs/ANs have the highest preva-
lence of type 2 diabetes in the world,
with the incidence of type 2 diabetes rising
faster among AIs/ANs children/young adults
Community Readiness 3
than among any other ethnic population—2.6
times the national average.13
The rates of substance dependence and
abuse among persons aged 12 years and older
are highest among AIs/ANs (14.1%), and rates
of illicit drug use (10.1%), alcohol use (44.7%),
and binge alcohol use (27.9%) are among the
highest in the nation.13 AIs/ANs die at higher
rates than do other Americans from alco-
holism (770%), tuberculosis (750%), diabetes
(420%), accidents (280%), homicide (210%),
and suicide (190%) and sadly, AIs/ANs born
today have a life expectancy that is almost
6 years less than that of the US population
(70.6–76.5 years).13
OKLAHOMA HEALTH DISPARITIES
According to the CDC, in 2005, CVD, pri-
marily heart disease and stroke, were the na-
tion’s leading causes of death among all racial
and ethnic groups. In 2003, the Henry Kaiser
Foundation indicated that Oklahoma had the
third highest heart disease death rate and the
10th highest stroke death rate in the nation.
From 1996 to 2000, Oklahoma had heart dis-
ease death rates higher than the national aver-
age (629 per 100 000 vs 536 per 100000) and
higher stroke death rates (131 per 100 000 vs
121 per 100 000).12 The percentage of smok-
ers in Oklahoma was also higher than the
national rate (25.1% vs 22.0%).8Women in
Oklahoma also have higher than average CVD
death rates, with heart disease death rates of
513 per 100,000 (vs 438 per 100 000 nation-
ally) and stroke death rates of 128 per 100 000
(vs 117 per 100 000 nationally).8
Health disparity in the Choctaw Nation
In Oklahoma, the American Indian popu-
lation is as follows: 273 230 AIs/ANs popu-
lation or 7.9% of the total population. The
Choctaw tribe is the fourth largest tribe in
the country. Of the population by selected
tribal groupings, the Choctaw tribe listed a
self-report number of 158 774, although cur-
rently, the tribal membership population for
the tribe is 149 570. The estimated number
of members residing within the CNO ser-
vice area is 69 350. The jurisdiction bound-
aries of the tribe is a 10 1
2county service
area which encompasses Atoka, Bryan, Coal,
Choctaw, Haskell, Latimer, Leflore, McCur-
tain, Pittsburg, Pushmataha, and southern
Hughes counties (21% of the state). It is im-
portant to note that the 15 000 square mile
service area is approximately the size of Ver-
mont and located in the southeast corner of
Oklahoma. It is extremely remote and hilly
with a somewhat rugged terrain. The area in-
cludes some of the highest-risk rural counties
of the state with high rates of unemployment
and poverty, low education levels, and lack
of insurance or employed without insurance.
Nine of the counties are cited in Oklahoma re-
ports as being “medically underserved” and 7
of these counties are classified as “health pro-
fessional shortage areas,”15 the highest level of
medically underserved or needy. As noted pre-
viously, in Oklahoma, heart disease is listed as
the leading cause of death for American Indi-
ans. Substance abuse, especially the rising use
of methamphetamines in rural Choctaw area,
is now starting to affect more communities
on a daily basis and it can have a devastating
effect on heart health. This is becoming more
and more evident in our Choctaw healthcare
systems.
Through a review of the medical database
within the Choctaw tribe, hypertension was
found to be 1 of the top 3 reasons that ambu-
latory visits are made to the clinics in the 10 1
2
county service area. In some Choctaw coun-
ties, it was listed as number 1 and in others
number 2 or 3 but always in the top 3. Table 1
is specific to the CNO and lists percentages of
the population affected by the various CVD
risk factors in 2008.
Overall, Oklahoma’s AI/AN population
health status remains poorer than that of
the general population and AIs/ANs have
higher rates of CHD and myocardial infarc-
tions than do Whites. They have higher preva-
lence rates of heart disease and diabetes
risk factors of obesity, higher blood pres-
sure, and higher blood cholesterol than do
Whites, and a review of literature reflects that
4FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2010
Table 1. Disease of risk factors of CNO members presenting at CNO clinics/hospital in 2008
Disease of risk factor CNO Disease of risk factor CNO
Diabetes 28.3% Overweight (25+) 80.4%
High blood pressure 26.4% Sedentary lifestyle 32.3%
Obese body mass index (30+) 64.5% Smoking 50.0%
Abbreviation: CNO, Choctaw Nation of Oklahoma.
limited studies have been conducted on CVD
among AIs/ANs. The Oklahoma Indian Dia-
betes Study16 found that 41% of diabetes pa-
tients developed CHD within 9 years of on-
set. Finally, each tribe and community may
have a different culture and a different method
of accessing healthcare. Providing culturally
competent services while attempting to en-
gage the community and tribal members is
a challenge, one that is dependent upon un-
derstanding the different cultural meanings of
health and health-seeking behaviors. It is ev-
ident that differences in the cultural makeup
of the target population demand special at-
tention in project design and delivery. What
is key is the fact that in addition to the unique
cultural makeup of the various tribes living
within the Choctaw service area, many are
geographically remote and utilizing/accessing
services is a challenge due to reliable trans-
[AQ4]
portation, fuel prices, and sometimes even
knowing when they may need assistance with
health issues. Therefore, it is essential to en-
gage the community at all levels of the assess-
ment, the development of strategies, and the
execution of those strategies to effect success-
ful change.
THE COMMUNITY READINESS MODEL
The project implemented by the CNO used
the fundamental principles of CBPR. It was de-
veloped using input from the coalitions, com-
munity member surveys, community needs
assessment data, Community Readiness inter-
views, and the overarching guidance and sup-
port of the tribe and Tribal Council. Utiliz-
ing social ecological theory and integrating
the traditions and culture of the tribe were
of utmost importance in this application. The
cohort decision was based on the Commu-
nity Readiness scores that were completed in
2007.
The Community Readiness Model measures
the reality and perception of the community,
which is a unique assessment. This may or
may not be the “real truth,” but knowing the
“truth of the community” is what is important
when seeking community involvement and
gaining acceptance and support of the strate-
gies developed. The model was conceived
16 years ago by 2 of the authors, Pamela
Jumper Thurman, PhD, and Barbara Plested,
PhD, along with Eugene Oetting, PhD, and
Ruth Edwards, PhD. It quickly gained accep-
tance in many venues. It has been used in
all 50 states and 14 foreign countries for at
least 40 various social issues in communities.
There are more than 40 published articles on
the model. It provides an easy-to-use struc-
ture that assists communities, organizations,
and groups in assessing how ready an orga-
nization or community is to address an is-
sue. The assessment begins by conducting an
assessment with key respondents. The num-
ber of interviewees may vary from community
to community. The structured assessment in-
cludes questions that relate to the following 6
dimensions of a community/organization:
The dimensions of readiness are key fac-
tors that influence a community’s prepared-
ness to take action on the issue. The 6 di-
mensions identified and measured in the Com-
munity Readiness Model are comprehensive
in nature. They are an excellent tool for
diagnosing the community’s needs and for
Community Readiness 5
developing strategies that meet the identified
needs.
a. Community efforts:Towhatextentare
there efforts, programs, and policies that
address this issue?
b. Community knowledge of the efforts:
To what extent do community members
know about local efforts and their effec-
tiveness and are the efforts accessible to
all segments of the community?
c. Leadership:Towhatextentareappointed
leaders and influential community mem-
bers supportive of prevention or action
on the issue?
d. Community climate:Whatistheprevail-
ing attitude of the community toward the
issue? Is it one of helplessness or one of
responsibility and empowerment?
e. Community knowledge about the issue:
To what extent do community members
know about or have access to information
on the issue and understand how the issue
impacts their community?
f. Resources related to the issue:Towhat
extent are local resources—people, time,
money, space, etc—available to support
efforts?
The Community Readiness Model has 9
stages of readiness (Table 2). Each of the 6
[AQ5]
dimensions was scored and given a level of
readiness. These 6 dimension scores provided
the tribe with a clear understanding of the
tribe’s level of readiness and which type of
interventions it should implement. Each level
of readiness has suggested types of strategies
that a community or tribe should use to move
to a higher level of readiness.
METHODS
A total of 33 community members within
the CNO were interviewed using the Commu-
nity Readiness Model. Thirty-three interviews
occurred in 2007 (pre) and 33 interviews
(post) in 2009. There were 24 months be-
tween the pre– and post–Community Readi-
ness assessments. Those interviewed during
the pre- and postassessment represented in-
dividuals from the medical/health field, so-
cial services, mental health and substance
abuse treatment programs, tribal leaders, el-
ders, spiritual/religious leaders, and commu-
nity members at large. A total of 18 women
and 15 men were interviewed for the pre-
assessment, and 17 women and 14 men were
interviewed for the postassessment. The in-
terview questions focused on participants’
readiness to address the effect of metham-
phetamine use on CVD within the Choctaw
Nation.
Each Community Readiness interview was
scored independently by 2 scorers who used
established anchored rating scales for each
dimension. These anchored rating scales are
based on the 9 stages of readiness. The scorers
then determined a stage score for each of the 6
dimensions on each of the interviews. Follow-
ing the first level of scoring, scorers met to ob-
tain an agreed upon or “consensus” score for
all dimensions. The interrater reliability prior
to the consensus meeting was .92. With the
consensus scores established, the dimension
scores were then added and divided to ob-
tain the average for each dimension. These
scores became the final 6 dimension scores.
From these scores, the CNO developed the ap-
propriate strategies needed to address the is-
sue. There are strategies that have been tested
in communities for every level of readiness,
and the tribe modified these strategies for its
culture and resources. Using the appropriate
strategies allows a community to move to the
next levels of readiness.
RESULTS
The prestage scores for each dimension of
the Community Readiness Model were as fol-
lows: (a) community efforts—6 (initiation),
(b) knowledge of efforts—3.7 (vague aware-
ness), (c) leadership—4.5 (preplanning),
(d) community climate—3.7 (vague aware-
ness), (e) knowledge of the issue—4.9 (pre-
planning), (f) resources—4.8 (preplanning).
During the 2 years between the pre- and
postassessment, the Choctaw Nation Core Ca-
pacity Program and Lifetime Legacy Program
6FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2010
Table 2. xxxx
Stage Description
1. No awareness This issue is not generally recognized by the community
or leaders as a problem (or it may not be truly an issue).
2. Denial/resistance At least some community members recognize that this
issue is a concern, but there is little recognition that it
might be occurring locally.
3. Vague awareness Most feel that there is local concern, but there is no
immediate motivation to do anything about it.
4. Preplanning There is clear recognition that something must be done,
and there may even be a group addressing it. However,
efforts are not focused or detailed.
5. Preparation Active leaders begin planning in earnest. Community
offers modest support of efforts.
6. Initiation Enough information is available to justify efforts.
Activities are underway.
7. Stabilization Activities are supported by administrators or community
decision makers. Staff are trained and experienced.
8. Confirmation/expansion Efforts are in place. Community members feel
comfortable using services, and they support
expansions. Local data are regularly obtained.
9. High level of community ownership Detailed and sophisticated knowledge exists about this
issue, prevalence, causes, and consequences. Effective
evaluation guides new directions.
implemented various CVD prevention strate-
[AQ10]
gies that were developed using the Commu-
nityReadinessscoresasthebasisfortheir
community and tribal action plans. The Com-
munity Readiness assessment in 2007 indi-
cated that the majority of respondents were
much more concerned with the metham-
phetamine problem in their communities than
with CVD. As a result, the program staff fo-
cused their intervention efforts on metham-
phetamine use and how it affects the body,
especially the heart.
The community was ready to learn about
prevention and health issues related to
methamphetamine use and opened the door
to a great opportunity that met the pro-
gram aims to incorporate the issue of heart
health into the community and tribe. The ac-
tion plan, implemented by the Core Capac-
ity Building Program and the Lifetime Legacy
Program, included strategies to implement ed-
ucational presentations to youth, adults, and
elders on methamphetamine and its effect on
CVD. Methamphetamine use was identified as
a major concern in the community and by
focusing the presentation on that, commu-
nity groups and schools began contacting the
program to schedule presentations. Provid-
ing the community with what it wanted was
one of the best forms of marketing. The staff
made the presentations in schools, churches,
senior centers, health clinics, and organiza-
tions throughout the CNO. The presentation
concluded with the participants identifying
someone with whom they could exercise and
furthermore, they were willing to make a
commitment to walk, swim, and so forth for
at least 1 month. The staff, in collaboration
with other health projects within the tribe,
held annual youth and adult wellness camps.
During these camps, participants were ed-
ucated about healthy eating styles, physical
Community Readiness 7
Figure 1. Community Readiness pre (2007) and post (2009) scores related to cardiovascular disease.
Leadership (C), P<0.01, and knowledge of issue (E), P<0.05, were found to be significantly different
from pre to post. However, all of these indicators are in the correct direction (improvement over time)
and these results may be impacted by power (sample size). That is, believe this figure, not the Pvalue.
activity, and cultural history as it related to
health issues. Participants made commitments
to share the information with family and
friends and to identify a partner who would
serve as an exercise partner.
The project staff was also involved in the
policy development of “no smoking” on all
tribal property. The tribal council passed this
policy and it has been strongly enforced by
the tribe. Finally, the project developed nu-
merous eye catching and informative educa-
tional flyers on types of exercise that could
be done anywhere, workstation or home.
As a result, the attendance at public pre-
sentations, school presentations, community
events, health fair booths, prevention activi-
ties, and health camps exceeded all expecta-
tions. More than 20 000 people were directly
affected by this project.
The post–Community Readiness assess-
ment was conducted in 2009. The poststage
scores for each dimension were as follows:
(a) community efforts-–7.5 (stabilization),
(b) knowledge of efforts-–5.5 (prepara-
tion), (c) leadership-–5.2 (preparation), (d)
community climate-–4.2 (preplanning), (e)
knowledge of the issue-–5.9 (preparation),
(f) resources-–6.2 (initiation). From pre to
post, the dimensions of leadership and knowl-
edge of the issue were found to be sig-
nificantly different. However, all dimensions
were in the correct direction showing in-
crease/improvement over time (Figure 1). [AQ6]
In addition to the improvement in readiness
scores from pre to post, the project collected
data at the annual CNO Labor Day Festival
in 2007 and 2008 from 480 tribal/community
members. The following are the results of that
survey:
Figure 2 reflects an increase in physical ac-
tivity from 2007 to 2008 for female respon-
dents from 73.9% to 85.6%. The physical ac-
tivity rates for male respondents remained the
same, 80.9% to 79.5%.
The data collected in both 2007 and 2008,
as shown in Figure 3, reflect a decrease in
smoking for both male and female respon-
dents. During this time, the tribal “no smok-
ing” policy was implemented and the tribe
also experienced an increase in the number
of people enrolling in the smoking cessation
classes.
8FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2010
Figure 2. Have you exercised in the past month?
Both Figures 4 and 5 reflect an improve-
ment from 2007 to 2008 in the number of
male and female participants who indicated
that they were following medical advice re-
lated to heart disease, diabetes, high blood
pressure, and high cholesterol level. At the
same time, the project, along with other
health providers in the tribe, initiated efforts
that emphasized increasing patient compli-
ance with medication and medical advice. Not
only did the Community Readiness scores re-
flect improvement but the change was also
evident in increased rates in exercise, a de-
Figure 3. Participants who smoke.
crease in smoking, and an increase in medical
advice compliance.
[AQ11]
DISCUSSION
The article emphasized that by using
an effective community-based participatory
method, the Community Readiness Model,
the CNO now has CVD prevention/treatment-
focused coalitions well established and all
have made strong “in-roads” into their re-
spective communities through successful
Community Readiness 9
Figure 4. Follows medical advice—female.
community engagement. Likewise, all of the
coalitions have been involved in determining
the most appropriate intervention and in the
development of the community action plan as
well as the dissemination plan for this project,
proving that when community is involved in
the development of a plan, it is more likely
Figure 5. Follows medical advice—male.
to utilize and support that plan. The CNO im-
plemented interventions that were appropri-
ate to the tribes’ levels of readiness and has
improved all 6 levels of readiness. On the ba-
sis of the postreadiness scores, updated inter-
ventions will be implemented throughout the
tribe.
10 FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2010
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Title: Community Readiness: An Effective Model for Tribal Engagement in Prevention of
Cardiovascular Disease
Author: Mickey Peercy, Janeen Gray, Pamela Jumper Thurman, and Barbara Plested
Author Queries
AQ1: Please provide the highest academic degree for Janeen Gray.
AQ2: Please check whether the author affiliations are OK as typeset?
AQ3: Please provide page number for the quoted matter.
AQ4: Should the word “reliable” be changed to “unreliable” in the sentence “What is key ...
issues”?
AQ5: Please check the citation of Table 2.
AQ6: Please check the citation of Figure 1.
AQ7: Please provide page range for reference no. 7.
AQ8: Please provide necessary information for reference no. 8.
AQ9: Please note that reference no. 14 has not been cited in the text. Either cite it in the text
or delete it from the list, renumbering the subsequent references both in the text and
in the list.
AQ10: Please provide caption for Table 2.
AQ11: The legends for Figures 2-5 do not seem to be OK. Please check.
11
