Client and network: Granite United Way and New Hampshire Public Health Network regions
Regions: Carroll County, Capital Area and South Central
DMC focus: Community needs assessment, rural and underserved populations, healthcare and social service access, and Substance Use Disorder prevention, treatment and recovery
Deo Mwano Consultancy assessed how COVID 19 affected service access across three New Hampshire Public Health Network regions. Resident and provider surveys, interviews, listening sessions and local engagement informed recommendations for stronger coordination and more accessible services.
The challenge
The assessment examined the experiences of underrepresented and underserved populations seeking healthcare support, social services and Substance Use Disorder (SUD) prevention, treatment and recovery resources. Rural communities were a significant focus because geography, transportation, limited provider capacity, technology access and local resource availability could influence whether residents received help.
COVID 19 intensified existing barriers. Residents could face housing, food, employment, childcare, mental health and SUD needs simultaneously. DMC examined these circumstances together while accounting for regional differences.
DMC responsibility
DMC designed and executed the community engagement and research strategy, gathered quantitative and qualitative information, engaged providers and residents affected by SUD, analyzed barriers and developed recommendations. The team identified organizations with existing relationships in the target communities and worked through those partners to support participation and understand the context behind the data.
Regional partners and perspectives
Carroll County Coalition for Public Health
Frontline providers offered a rural perspective on limited local resources and interconnected transportation, housing, food, childcare, employment and SUD service needs. Providers described coordinating across organizations to address needs beyond their individual missions.
Capital Area and South Central Public Health Networks
DMC engaged organizations serving immigrant and underserved populations in the Capital Area. Overcomers Refugee Services contributed insight into trust, stigma, awareness of SUD resources and community engagement. In South Central, outreach focused on organizations supporting residents facing barriers to SUD services and other essential support.
DMC community engagement and assessment approach
Identify → Engage → Listen → Validate → Co Design → Recommend
Map the regional service ecosystem
DMC identified organizations and providers operating within each region, with particular attention to those working directly with underserved populations. Two DMC Program Managers conducted outreach through telephone calls, emails, Zoom meetings and relationship building conversations, reaching more than 100 potential community partners and service providers.
Engage trusted local partners
DMC worked through Public Health Networks and organizations already serving the communities being assessed. Partners were encouraged to distribute surveys, participate in interviews and listening sessions, and explain how residents navigated services. These relationships provided pathways to participation and helped the team understand local service conditions.
Offer multiple ways to participate
The research included two quantitative surveys: one for people affected by SUD personally or through a loved one, and another for service providers. Group interviews, listening sessions and direct conversations added qualitative detail. Regional outreach materials, videos, email, telephone and virtual engagement supported the participation strategy.
This combination allowed DMC to examine measurable patterns alongside the experiences and circumstances behind them. Participation did not depend exclusively on residents finding and completing a survey on their own.
Examine resident and provider perspectives
DMC compared the experiences of people seeking services with those of caseworkers and providers helping residents obtain support. The surveys highlighted access concerns from both perspectives.
| Survey perspective | Reported finding |
|---|---|
| Individual respondents | 51% reported that COVID moderately or substantially affected their ability to access SUD services. |
| Service providers | Providers reported that 53% of clients who could benefit from services were not receiving what they needed. |
These two distinct measures point to access concerns from both resident and provider perspectives.
Understand the rural context behind the findings
In Carroll County, providers described residents managing housing, food, employment, childcare, transportation, isolation, mental health, technology and SUD related needs simultaneously. DMC examined what happened when residents tried to obtain help, including the coordination providers needed to connect them with appropriate support.
Major findings
Local availability influences whether residents receive care
When appropriate services were unavailable locally, residents did not necessarily travel elsewhere for help. Some accepted lower levels of care, while others stopped pursuing services. Service availability therefore needed to be considered alongside residents’ ability to reach and use it.
Rural providers support needs beyond their formal missions
Organizations frequently responded to housing, food, transportation, childcare and employment needs as well as their primary service responsibilities. Relationships between organizations were central to connecting residents with help.
COVID 19 amplified existing barriers
Transportation challenges, resource scarcity, housing and food insecurity, and service capacity constraints predated the pandemic in many communities. COVID intensified these pressures and complicated the work of providers already responding to them.
Trusted relationships support meaningful engagement
Working with organizations that already had credibility in local communities helped DMC reach underserved populations and interpret the findings within their regional context. The assessment emphasized the importance of these relationships in both research and service access.
From research to action
DMC translated the findings into recommendations for stronger collaboration across agencies, streamlined referrals, integrated services, sustainable resources and clearer regional coordination. The recommendations emphasized solutions within existing community service networks, informed by the organizations and residents closest to the challenges.
Delivered value and strategic impact
The completed assessment brought resident and provider perspectives together across three regions, identified interconnected access barriers and provided community informed recommendations. Outreach to more than 100 potential partners supported the regional engagement strategy.
DMC’s contribution was evidence and practical direction for service improvement. The work connected SUD access with broader social needs, rural geography, local capacity and referral relationships, giving partners a basis for considering coordinated responses.
DMC capability demonstrated
This engagement demonstrates DMC’s ability to design and execute assessments across multiple regions, engage rural and underserved populations, combine quantitative and qualitative research, and translate findings into recommendations for public agencies, healthcare systems, foundations and funders.
DMC works with the organizations closest to the challenge, understands residents’ lived experiences within the systems designed to serve them, and translates those insights into practical strategies for improving access, collaboration and community impact.