The PSE change approach is a way of modifying the environment to make healthy choices practical and available to all community members. This page shows the four phases of the PSE change model in comprehensive cancer control, which are explained in detail in the following sections of the ACS CCC PSE Change Guide . Click the plus icon on the right side of each section below to learn more about each topic and link to additional resources.
1: The Development Phase
In this phase, multisectoral leaders sign on to support the PSE change approach. The coalition is engaged and then collects evidence-based data, assesses readiness, creates a PSE change agenda, and frames the issues. It also expands partnerships and develops a communication plan.
While many CCC coalitions have been implementing PSE change interventions for years, others may be less familiar with the benefits of the approach or find themselves implementing one-time events and programming. In either scenario, it is important to garner leadership support early in the development process.
Consider convening a meeting of your leadership (CCC Principal Investigator, CCC Program Director, Coalition Chairs, and Workgroup Chairs) to discuss plans for implementing a strategy—including its benefits—and ask for leadership feedback and support. This could be as simple as sharing two or three examples of successful PSE change approaches (p.10) that you feel may be replicable in your coalition, as well as asking leaders to be present and vocal at your planning meetings.
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After gaining leadership support, the next step is to ensure you have a committed core of coalition partners who are interested and invested in the PSE change approach. You’ll want to include members and organizational partners based on their knowledge, skills, goals, and work styles. A mix of experienced and inexperienced members will provide balance, which is important to a high-functioning team. You may find it both helpful and necessary to form a workgroup or policy group to develop and implement your strategies. Based on lessons learned over the past 10 years, a dedicated policy analyst can be critical to successful implementation of PSE change work.
Including partners from different industries, such as education, planning, health care, transportation, agriculture, business, government, groups focused on health equity, faith-based groups, and housing can bring an important outside perspective to your work. We will discuss expanding partnerships later in the guide, but to begin, consider the following roles when looking for committed coalition partners:
See PSE Change Guide on "Coalition Roles" pp. 13-14
If your comprehensive cancer control (CCC) plan is up to date, you have likely done a great deal of the groundwork already for this section of the model. Your CCC plan is specific to your region and based on data collected about people living there. Collecting and using these relevant data are critical to the successful implementation of PSE change approaches. Data help to define the problem, describe the starting point, and monitor progress toward achieving your goals.
Review the State Cancer Disease Burden
If your CCC plan needs revising or you are considering work in a PSE change area that is new to your coalition, data gathering and analysis will be the foundation upon which your efforts are built. By assessing the state cancer disease burden, you can establish a baseline for monitoring change. Assessments can also identify knowledge gaps that may need to be considered. Talk to your coalition partners to see if their organizations can provide recent cancer disease burden data.
Conducting an Environmental Scan
The University of Kentucky Markey Cancer Center conducted an environmental scan in 2014 to increase pediatric HPV immunizations in the state. The university identified two project leaders and adhered to the one-year timeline provided by the National Cancer Institute. Researchers analyzed data from surveys, interviews, and television program transcripts. Findings were consolidated into a paper and a poster presentation for the funding organization, partners, and others with an interest in the project. More details of the environmental scan can be found in the article Environmental Scanning as a Public Health Tool: Kentucky’s Human Papillomavirus Vaccination Project
Conduct a Statewide Public Policy Scan
As you consider what PSE change interventions to pursue, it is helpful to first get the lay of the land. Policy scans compare policy options to identify the most effective policies for addressing the PSE change project issues. For more information about conducting a public policy scan, see CDC’s interactive and informative POLARIS website
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Next, your coalition needs to assess its capacity to implement PSE change interventions. Take a step back and consider your readiness to proceed with developing and implementing a PSE change agenda.
- To prepare for collaborative PSE change efforts, consider:
- The overall context for collaboration: What is the current social, political, and economic climate? Is it a good time to implement your PSE change approach?
- The coalition’s capacity to collaborate: Do you have a track record of teamwork?
- The coalition’s capacity to lead PSE change implementation: Does your CCC coalition readily take the lead? Will PSE change work be a “new” endeavor?
- What factors could be barriers or facilitators to collaboration?
- Are members of the community demographic you are trying to reach a part of your coalition? Does the coalition have access to community leaders?
- What are some historical community considerations related to the PSE change strategy?
This assessment can be a relatively simple process conducted during a coalition meeting. The purpose is to gain an understanding of whether members are ready to move forward.
At this point, you have buy-in for the PSE change approach from leadership, engaged coalition partners, and data to define the problem. The next step is to develop a PSE change agenda. The PSE change agenda, much like a state CCC plan, is a consensus document that serves as a road map for a coalition’s PSE change approach. The work you did compiling surveillance data and conducting an environmental scan will provide insight into your PSE change agenda. Look at the data and determine where to focus.
Identify Priorities
Prioritizing your issues helps you to create a PSE change strategy that can be implemented within a given timeline. A coalition may choose to work on all priority areas; however, certain areas may only be ready for education and outreach, while other areas may be primed for education, outreach, and implementation. Either way, the coalition needs to agree on a path forward.
Consider what the data told you, what issues are the right choice based on your policy scans, community assessments, and the interests of your coalition partners. The synthesis of this information will point you to priority issues that have the greatest potential.
See PSE Change Guide Worksheet about Identifying Priorities" – pp. 17-20
Framing is the way a problem is presented to partners, community members, and decision makers. By using words, numbers, and images, you can encourage people to understand the health benefits of a particular issue you are trying to address. For example, framing can educate policymakers as to how or why they may want to prioritize an issue which data shows can benefit their constituents, and which policy initiatives might be most effective to address the issue.
Effective framing considers the perspectives of the primary audiences. The work you’ve done to recruit diverse coalition members will help you with framing. Ask key partners to write an informal list of talking points about why their networks, colleagues, and constituents should support a PSE change priority.
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Now that your coalition has a focused PSE change agenda, the next step in the Development Phase is to build partnerships with organizations outside of the current coalition that will help you accomplish your priorities. The following section describes organizations that can be helpful—or even critical—for sustaining a PSE change approach.
Conduct Partnership Assessments
As we know, comprehensive cancer control is based on collaboration—implementing as a coalition what you could not achieve as an individual organization working on your own. Partnerships remain the cornerstone of your PSE change work. Take this opportunity to widen the net by expanding your partnerships based upon your chosen priority issues.
See the PSE Change Guide Worksheet about Partnership Assessments- p. 21
The last step in the Development Phase is to create a communication plan to ensure that your coalition is literally “sending the right message” about your PSE change efforts. The right messages give your coalition the power to reach broad audiences, affect public perceptions, and influence practices around the coalition issue. What opportunities exist for you to communicate both internally and externally about your strategies?
Internal Communications
Effective internal communication creates a shared vision, establishes roles and expectations for the coalition members, promotes collaboration and coordination among coalition members, and helps inform members of coalition successes. Frequent and positive internal communication also increases member motivation and satisfaction, enhances implementation of coalition activities, and is an important aspect of enhancing sustainability.
External Communications
A coalition or workgroup should strive to keep community members and leaders informed about the actions and achievements of the group and to obtain input on objectives, activities, and goals. This helps enhance sustainability by promoting buy-in from the community, improving awareness of the coalition and its activities, increasing support for the coalition, and creating enhanced opportunities for collaboration and financing.
See the PSE Change Guide Worksheet about External Communications pp. 22-23
2: The Implement Phase
In this phase, the coalition educates decision makers, conducts community outreach, and implements the PSE change and communication strategies planned in the initial development phase.
Coalitions can be comprised of diverse sets of partners who may have different rules for how and when they can communicate with decision makers. Communicating with decision makers can take the form of educating, advocating, or lobbying. Educating helps to inform about the health benefits of a strategy or policy; advocating attempts to bring about social change on behalf of an organization; and lobbying attempts to influence the decisions of legislators. No CCCP staff or activities funded with federal dollars can be used to lobby lawmakers or advocate for funding or for the initiation or passage of any type of legislation. CCC program and coalition members must follow the rules of their state and organization when getting involved with policy actions. Protocols differ by professional industry.
See the PSE Change Guide Worksheet about Educating Decision Makers - p. 26
Community partnerships are an effective way to bring about environmental and behavioral changes that improve community health. Continuing involvement of community members is essential for your coalition’s PSE change efforts to have a broad reach and create lasting change. In the Development Phase, we encouraged you to identify a community organizer or advocate to be involved in your core coalition team when addressing PSE change. This person or people can continue to be your bridge to the community, helping the coalition build a groundswell of support.
CCC coalitions are well acquainted with the concept of community outreach. It is a foundational aspect of developing and implementing comprehensive cancer control plans. Apply these same community outreach principles to PSE change strategy implementation. Continue to check in with community members about the process and be clear about how it will change to help the community.
See the PSE Change Guide Worksheet about Educating Decision Makers - p. 26
In the previous phase, you created a communication and media plan. Now it’s time to put it into action! Effective communication strategies amplify your efforts by promoting your key messages to primary audiences and by engaging and involving many more people to bring about desired PSE changes.
Manage Your Communication Messages
People who can share your messages are not likely to be experts on your PSE change activities. Nor will they have enough time to sift through long white papers or piles of policy documents to pick out the main issues and objectives of your work. You must help others quickly understand the importance of the coalition’s mission and goals and how they can best convey your health messages to their readers, viewers, and listeners.
Manage Your Communication Opportunities
Last-minute communication and media opportunities can arise because of unforeseen current events or changes in legislative policies. Often quick decisions will be needed. In the Development Phase, you identified coalition partners with communication skills. As your PSE change strategies take shape, these team members should be prepared to respond to various media opportunities. Identify specific people to write content for press releases, blog posts, social media messages, and radio public service announcements. Additionally, identify and train speakers to speak on behalf of the coalition.
See the PSE Change Guide Sections:
3: The Sustain Phase
In this phase, coalitions monitor and provide ongoing evidence that support PSE changes to create lasting impacts. They continue their education and communication efforts to the public and decision makers, as well as address challenges to PSE change strategies.
The process of educating decision makers is not finished after implementation. They need to be proactively updated about changes as they are happening. Consistent communication sustains their buy-in and enables them to respond appropriately. Keep everyone informed. Conduct regular face-to-face or video meetings, emails, and conference calls to keep your coalition up to date.
Keep in mind that coalition members must follow the rules of their state and organization when working with policy decision makers. Acceptable education and interaction protocols were stated above for nonprofit, government, and academic employees, as well as for individuals.
Continuing and adjusting the PSE change and communication strategies is also an important part of the Sustain Phase. PSE changes are usually long-term efforts and are continuously revised based on feedback from ongoing implementation. For example, an initiative to eliminate sugar-sweetened beverages in health care organizations statewide is likely to be a long-term, multi-phased effort.
How do you know if your CCC coalition’s communication strategies are hitting the mark? Consider the following questions, adapted from the American Cancer Society National Colorectal Cancer Roundtable Evaluation Toolkit.
- Are we consistently communicating accurate and timely information about our intervention?
- Are our communication strategies increasing community members’ and decision makers’ discussions on the intervention topic?
- Are our communication strategies reaching the number of people we thought they would? Are we reaching our intended audience?
- Have we solicited feedback from the community about our communication strategies? What are they saying? Are changes needed?
Flexibility is vital. If you need to change an aspect of the initial implementation plan, remember to make corresponding changes to the communication plan.
Work with Partners to Monitor Implementation of PSE Change
Monitoring the implementation of your new PSE change strategies is not always straightforward. For example, if your strategy involved restrictions on the marketing of e-cigarettes to youth, thorough monitoring would entail detecting infringements of that policy and identifying the intent and responsibility for the infringements and penalties. Part of your coalition’s role in this process could be to provide information as to how this was done successfully in other states by linking coalition partners with the latest public health policy research. Effective monitoring of policies often includes coordination among different enforcement agencies and consistent procedures throughout a community. Coalition partners could provide linkages among agencies as appropriate and help partners find consensus on unified messaging.
See the PSE Change Guide Worksheet about Monitoring Implementation – p. 31
Expect and be prepared to encounter challenges to new PSE changes. Try to understand why people might resist the changes—their reasoning and their strategies—so that you can identify the best ways to respond to them.
See PSE Change Guide Worksheet on the topic about Addressing Challenges- p. 32
4: The Evaluation Phase
In this phase, the coalition evaluates its efforts to maximize their effectiveness and determine their outcomes. The coalition uses this information to guide the evolution of its strategies and to promote the public health benefit of the strategies implemented.
Evaluating your PSE change efforts may seem intimidating, but it is critical to the success of future PSE change efforts. Evaluating your efforts gives you vital information about how things are progressing, what strengths can be maximized to propel the effort further, and what midcourse corrections are required so that your efforts make the desired impact. It is also beneficial to your public health colleagues who have been contributing to these efforts.
Partners provide insight that ensures that evaluation results and recommendations can be used. Partners can play a valuable role in the evaluation and can inform the evaluation goals, questions, design choices, and data collection methods of your project. Choose partners that are interested in the coalition’s priority PSE issues and engage them early in the evaluation process. Define clear roles and responsibilities for their involvement. When working on PSE change evaluation, the following partners can provide valuable perspectives:
- Policy analysts
- Public health evaluators
- Subject matter experts
- Decision makers
- Policymakers
- Healthcare quality improvement staff
- Public health epidemiologists
- City planners
- Those who are affected by your policy change
After you have your evaluation partners on board, consider what factors have affected your policy implementation work. Brainstorming a list of these factors will help you see where the opportunity for evaluation focus may lie, as well as help frame the results of the evaluation. Achieving PSE change often requires flexibility to adapt to changing conditions and emerging opportunities.
Perhaps a story about radon made the news in your state, causing lots of public interest and potential for momentum.
- Did a policy opportunity steer your work in a particular direction? Another factor that might have affected your policy work are key partnerships.
- Was there a new partner whose enthusiasm and connections opened doors? Coalition capacity might also affect your policy work.
- Did you receive a grant or gain a staff member with expertise that expanded your coalition’s capacity?
Look back on the steps you took in the Development and Implementation Phases and identify factors that were critical—both positive and negative. These factors should be mentioned in your evaluation, as they’ll give context to what helped or hindered your policy work.
You have assessed which factors have affected your policy work and brainstormed a list of lessons learned. Now you can prioritize the aspects of your PSE change efforts that you’d like to evaluate. The entirety of your work does not need to be evaluated. Focus your efforts!
Consider the following:
- Do you see themes emerging?
- Was there a pivotal event or partner that had a huge influence on your PSE change efforts?
- Where did you face the greatest resistance or barriers?
- What strategies or processes felt most replicable or scalable?
- Are there specific elements you want to understand better to inform future work?
Consider focusing in on one or more of these in your evaluation, such as policy successes, changes, and failures, stakeholder engagement, or the process you went through to identify and implement your PSE change strategies.
Prioritizing your evaluation areas by what is of interest to your partners or funders can also help sustain your efforts long-term. Funding, resources, and staff time must also be considered when prioritizing your evaluation areas. In other words, “Do what you can, with what you have, where you are,” – Theodore Roosevelt.
Now that you have chosen one or more areas to focus on in your evaluation, you can walk through an evaluation model to help you complete an evaluation that results in a report or brief to share with partners. By following the steps in the model to the right, you’ll collect information that can be used to inform your next PSE change steps or future projects. CDC’s six-step evaluation model provides a framework for your evaluation efforts. It ensures that evaluations are built with program improvement in mind.
The evaluation model is iterative, like the policy framework. A helpful step-by-step evaluation guide with leading questions, templates, and worksheets can be found in the Comprehensive Cancer Control Branch Program Evaluation Toolkit.
