Teresa Cutts: Community Asset Mapping

Community Asset Mapping can play a key role in transforming health. And one person who’s been in the field leading the way is Dr. Teresa Cutts. Since 2007, Cutts (standing, left) has led mapping processes in a variety of places, including South Africa, Memphis, Chicago, New York, and North Carolina. For a history of the evolution of the mapping process, click here. This summer the mapping program “CHAMP Access to Care” was used in five under-served neighborhoods in Forsyth County. Three of the workshops were held in Spanish to “hear” the voices of Hispanic/Latino seekers of health services.

Interview by Tom Peterson

What is Community Asset Mapping?

Community asset mapping has been around a long time, since the sixties, and even before that in the U.K., working with farmers and agriculture, called Participatory Rural Appraisal. Another key part, Assets Based Community Development, or ABCD, emerged in the Chicago area, from the work of Kretzman and McKnight. It’s built on the concept that you can’t build or grow a community based on what you don’t have. Appreciative inquiry is a huge component of what we do. It focuses on asking more questions and listening carefully instead of following or inserting a pre-formed agenda. The last component, from the South America, is liberation theology. That celebrates the people on the ground and encourages them to speak truth to power. This means that they see and own and engage their own capacity and power.

As mentioned above, the type we engage in is a hybrid developed from the African-based PIRHANA model called CHAMP (Community Health Assets Partnership). Over time we worked with the DNA of the foundational ARHAP process to transform it into the CHAMP Access to Care model that is better suited to the United States context. The goal is to improve peoples’ access to healthcare. The other aim of the mapping is to hear the voice of the healthcare providers and, more important, the voice of the healthcare seekers, the so-called consumers of healthcare.

What is it designed to do?

The mapping process allows us to make visible the not only tangible assets but the intangible assets. For example, the clinic on the corner is tangible. The manner in which care is delivered is intangible. In Africa, people would walk many, many kilometers to a mission hospital to receive care instead of go to a government hospital that’s more convenient and better resourced but treated them shabbily. The asset was the way the care is delivered.

This form of mapping also allows us to make visible and better connect the relationships and social capital of not only providers but also those who seek care. We create spider grams that show how people are connected in terms of resources. They show whether they share funds or have, or want to, develop trusted relationships.

What happens in the mapping process?

The process involves two days of workshops. One day is devoted to those who seek healthcare, the other to those who provide healthcare. Within a month we create a report and hold a follow-up meeting in which we transparently report back the findings of both workshops. Then we post all the reports, comments and qualitative data on our websites so everyone can see it and continually nurture what we call “virtual community teams”.

A typical mapping is held at a community center or a neighborhood church that’s easy to get to and park. We usually hold workshops on Thursdays, Fridays or Saturdays. For the providers we have a half-day, ending around one. For the seekers it’s usually a six-hour event with a long lunch break. The exercises are a bit different, but there is usually an icebreaker followed by different mapping exercises. For example, the seeker participants draw a map of their community and what’s important to them. The providers start with a timeline with culturally, economic, historic events or place their organizations on a map, to show the organizational “footprint.” These processes help people place themselves in a given neighborhood and learn about each other—where they worship, play, go to school.

Typically, those who engage in workshops are surprised at the depth of information they gain from these processes as well as the ability to make new connections with others who can help them. For example, in the provider workshop, we have an exercise called the “collaborative contributions grid.” The participants name not only what they would like to receive from partners, but also what they can offer or give. This often forces under-resourced groups to think outside the box in terms of what they can offer to their fellow organizations.

The process animates the assets on a map based on the perceptions of how people work, worship and play in a given neighborhood. For example, in Memphis we created a map of local parks. In one of those parks, as it turns out, only the front part was mowed. The rest was overgrown and the drug dealers did their business in the back part. So what looked like an asset turned out to be a liability, and it wasn’t a safe place at all. We would also learn that while some clinics are open, the care they offer or the lab turnaround time and reports were of such poor quality that people don’t go there.

So people in a neighborhood give you really important information in terms of true access.

What other kinds of conversations emerge?

The historical context of an area often becomes visible in a mapping process. For example, in North Carolina there was a eugenics program in which “feeble minded” poor people, mostly women, were often sterilized involuntarily. This led to very negative perceptions and feelings toward one of the local health systems that still persist more than four decades after the program stopped. This intergenerational distrust is a huge barrier to access in a relatively small town, but it’s another example of those intangible factors. That’s not an asset, but it’s important in terms of context.

Mapping helps the parties to understand the historical trauma that shapes and form how people live and relate to one another. So the process also offers a forum for truth telling and transparency, which, hopefully, can begin a remediation process of sorts. Also, it is critically important for new providers in training in a given health system to know of historical trauma issues from the seekers’ perspective, such that they can offer seekers the very best care, being knowledgeable about and sensitive to those events. This could really improve health disparity outcomes in the long run.

You spoke of trust and relationships. How do they emerge from mapping activities?

The process is the starting point for building a trusting relationship between a health system and the community and other partners. The dialogue allows participants to springboard a relationship. It’s also a forum for the grassroots voices to be heard. And ultimately the results can help shape policy with the unique input of people on the ground.

This signals to people in community that a health system cares enough to ask questions and hear the voices of people who need care. It’s important to change perceptions, about health systems in a given area and understand those cultural issues what are important to figuring out the barriers to access. For instance, in our East Winston seekers’ mapping, racism and the eugenics program, arose as barriers to trust that impacted care pathways.

In more concrete terms, a health system can build a clinic but health seekers may not come. This often happens when health systems do a GIS-only mapping of areas lacking in say, primary care access. People say they want a clinic. You build it and nobody shows up because local seekers don’t trust the providers or organization.

Instead, in Memphis, we created what we called “Wellness without Walls” based on what health seekers said they wanted in terms of those intangible aspects of “how care was delivered.” Our seekers in the under-served zip code 38109 wanted clinical care that was delivered respectfully and built on relationships and trust.

So even though the community members said they wanted a brick and mortar clinic, we started by bringing healthcare to people at a local community center every two months to begin to first take the time to build relationships. We then followed up with each person through our place-based navigator, Joy Crawford, to create continuity of care. And we partnered with our largest insurance plan, Cigna, which also had high, inappropriate use of the Emergency Department from the 38109 zip code area. As a result, we brought charity care increases down almost 9 percent in one year, when the year before it had risen 31 percent. That signals what mapping and “hearing the voices” of health seekers on the ground and developing better care based on that input can do that is highly valuable to many stakeholders. It’s a “win-win-win-win” for health seekers, providers, health systems and payers, all-around.

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