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Community-Based Prevention

For purposes of brevity and consistency, the committee has chosen to use the term “community-based prevention” to describe community-based prevention policies and wellness strategies. This chapter begins with a discussion of the terms “community,” “community-based,” and “community-placed.” It then identifies important features of community-based prevention, gives a brief history of the development of community-based prevention programs, and describes strategies and a sampling of models used. The chapter also examines the evidence used and the difficulties inherent in the evaluation of effectiveness as well in describing results from some program evaluations.

COMMUNITY

Community means different things to different people in different contexts. For example, Cheadle and colleagues (1997) refer to community as a location or place. Brennan (2002) writes that “community may be a more abstract concept, such as a neighborhood, defined by a sense of identity or shared history with boundaries that are more fluid and not necessarily identified exactly the same by all members.” For some, community may be defined by common beliefs or ideologies (e.g., religion or politics), by activity (e.g., swing dancing or running), by social responsibility, by race or ethnicity, by socioeconomic status, or by a sense of belonging (Israel et al., 1994; Patrick and Wickizer, 1995; Rossi, 2001).



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2 Community-Based Prevention For purposes of brevity and consistency, the committee has cho- sen to use the term “community-based prevention” to describe community-based prevention policies and wellness strategies. This chapter begins with a discussion of the terms “community,” “ ­ community-based,” and “community-placed.” It then identifies important features of community-based prevention, gives a brief history of the development of community-based prevention pro- grams, and describes strategies and a sampling of models used. The chapter also examines the evidence used and the difficulties inher- ent in the evaluation of effectiveness as well in describing results from some program evaluations. COMMUNITY Community means different things to different people in different con- texts. For example, Cheadle and colleagues (1997) refer to community as a location or place. Brennan (2002) writes that “community may be a more abstract concept, such as a neighborhood, defined by a sense of identity or shared history with boundaries that are more fluid and not necessarily identified exactly the same by all members.” For some, community may be defined by common beliefs or ideologies (e.g., religion or politics), by activity (e.g., swing dancing or running), by social responsibility, by race or ethnicity, by socioeconomic status, or by a sense of belonging (Israel et al., 1994; Patrick and Wickizer, 1995; Rossi, 2001). 23

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24 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION For purposes of this report, community is defined as any group of people who share geographic space, interests, goals, or history. A commu- nity offers a diversity of potential targets for prevention and is often con- ceived of as an encompassing, proximal, and comprehensive structure that provides opportunities and resources that shape people’s lifestyle (McIntyre and Ellaway, 2000). A community also offers the potential for pooling re- sources and for collaboration among community-based organizations, some of which are affiliates of state and national organizations that can channel resources to them in support of local initiatives and the evaluation of their innovations (Kreuter et al., 2000). A distinction can be made between community-based prevention and community-placed prevention, or community interventions versus inter- ventions in communities (Green and Kreuter, 2005), although both take a population-based approach. Community-based activity involves members of the affected community in the planning, development, implementation, and evaluation of programs and strategies (Cargo and Mercer, 2008). An example of this type of prevention effort is community-based participatory research, in which academic researchers—who are usually in control of the decisions on the research question, design, methods, and interpretation of results—invite or concede at least an equal partner role to community members in formulating, conducting, and interpreting the research. It is important to note that rarely are all members of a community involved and that for those who are, the level of involvement can vary tremendously. Community-placed activities, on the other hand, are developed with- out the participation of members of the affected community at important stages of the project. While the program may be centrally planned, effort is expended to generate community support. An example of the community- placed approach is the YMCA diabetes prevention program that is being implemented in partnership with YMCAs across the country, some with more tailoring to the localities than others (Ritchie et al., 2010). Although there are distinct differences between these two approaches to prevention, for purposes of this report key domains for valuing (dis- cussed in Chapter 3) are common to both approaches. Therefore, the term “community-based prevention” is used to encompass both community- placed and community-based prevention programs, policies, and strategies. IMPORTANT FEATURES OF COMMUNITY-BASED PREVENTION Over the past 50 years public health practice and research have con- tributed to developing and analyzing the characteristics that distinguish community-based prevention from other forms of action. Community- based prevention interventions focus on population health and, in addition,

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COMMUNITY-BASED PREVENTION 25 may address changes in the social and physical environment, involve in- tersectoral action, highlight community participation and empowerment, emphasize context, or include a systems approach. Community-based prevention is not focused on changing individual characteristics. Rather, the focus is on population health, that is, on “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig and Stoddart, 2003). For exam- ple, implementing nutritional standards for a population is a community- based prevention intervention. Such standards require decision making by a school district and their development may include elected officials, parents, administrators, and students. They affect all of the students and parents in the school district. An individual buying a Stairmaster and using it at home is also taking part in a nonclinical prevention program, but it is not community-based. The owner of the Stairmaster need not consult the neigh- bors before purchasing it, nor are the neighbors helped by the purchase. Changes in social and physical features of the environment constitute valued outcomes for community-based prevention because the distributions of risk factors, health outcomes, and wellness indicators in a population are largely shaped by social and physical environments. Research has shown that social characteristics such as socioeconomic status, social cohesion, social capital, and friendship networks are associated with health and well- being (Adler et al., 2008; Berkman and Kawachi, 2000). The same is true for such features of the natural and built physical environment as poor housing, increased levels of pollution, the presence of green spaces, quality of housing, the safety and pleasantness of the walking infrastructure, and many others (Gauderman et al., 2004; Handy, 2004; IOM, 2000a; Kawachi and Berkman, 2003; Nelson et al., 2006). Research also has demonstrated that intersectoral action is an impor- tant component of interventions aimed at population health (Gibson et al., 2007; Kreisel and Schirnding, 1998). Intersectoral action refers to engaging and coordinating actors from a variety of relevant sectors in the planning, implementation, and governance of interventions. Because most of the social and environmental determinants of population health exist outside the sphere of influence of the health sector, such intersectoral partnerships are key processes by which changes in the main determinants of health can happen (Gibson et al., 2007). The health in all policies (HiAP) approach to address the social deter- minants of health encourages governments to include multiple sectors (e.g., taxation, education, transportation) in programs and policies to improve population health (WHO, 2010). Examples can be found in the Institute of Medicine (IOM) report that examined the role of laws and other poli- cies on the public’s health. That report endorsed the potential of HiAP in population health improvement and provided examples of local, state, and

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26 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION federal-level collaboration among different sectors, including transportation, planning, and community development (IOM, 2011). The report also de- scribed a continuum of applications for HiAP, ranging from “do no harm” (i.e., consider the health effects of proposed policy in non-health areas) to a proactive approach to addressing the most distal determinants of health. Finally, the report recommended local planning processes modeled on the structure and role of the National Prevention, Health Promotion and Public Health Council, and designed to engage a variety of external stakeholders. Community participation refers to the engagement of those affected in the process of transforming those conditions that influence community health. Participation can occur at various stages of the project and can also vary in intensity. It can involve the affected individuals themselves or spokespersons for them. In community interventions, participation often translates into volunteer work and other local resources that increase the potential intensity of the intervention. Adapting community-based interventions to local conditions and con- text is an important feature of effective interventions and increases com- munity ownership and buy in for the intervention (McLaren et al., 2007). However, it is insufficient to assume that community participation will result in change. Change is dependent on who participates and varies as leadership changes. Many times it is the “squeaky wheels” that persist and carry the day whether they are representative or not. These processes take a long time during which many things change, including broad secular changes like the local economy, leadership, availability of funding, etc. While engagement is indeed relevant to successful interventions, it is im- portant to be aware that it is no panacea. Empowerment refers to the ability of individuals or groups to exercise control over the conditions and circumstances that influence health and well-being. Intervention processes that promote empowerment and capacity development are also often participatory (Dressendorfer et al., 2005; Israel et al., 1994). It has been demonstrated that collective empowerment enables communities to better identify and solve their problems through more ef- ficient processes of assessing needs and advocating for policies (Edmundo et al., 2005; Reininger et al., 2005). The context within which community-based prevention is developed and implemented is also important. Intervention means there is an inter- ruption of the normal evolution of events or trajectory, sometimes from outside the community. This outside trigger may be a funding opportunity or a policy or administrative initiative from another level of government or organization that resides outside the community of interest. Funding opportunities may come from various sources and be associated with other types of resources, such as access to technical expertise and knowledge. These triggers are external resources that can be invested in the solution

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COMMUNITY-BASED PREVENTION 27 of a problem or in the improvement of local conditions. Alternatively, the outside event might be a global or national trend, such as global warming or a pandemic that is threatening local communities. Effective mechanisms for community-based prevention do not, how- ever, reside solely in the external resources that constitute or support the intervention. Characteristics of the community in which the intervention will be implemented interact with those resources and include the cultural, social, political, and physical characteristics of the populations that are targeted by the intervention. These characteristics may also be transformed through the intervention process, increasingly blurring the distinction be- tween the intervention (in the sense of the effective transformative mecha- nism), context, and intervention effect. A systems approach is the final feature discussed here. (For more on the systems approach, see Chapter 3.) Comprehensive community-based pre- vention efforts provide for a combination of interventions that predispose, enable, and reinforce the behavioral and social changes that individuals and organizations need to make in order to successfully achieve health outcomes (Green and Kreuter, 2005; Wagner et al., 2000). They also encompass mul- tiple sectors and multiple levels, as with state-level mass media and the local tailoring of interventions. HISTORICAL PERSPECTIVE Community-based prevention efforts aimed at addressing the living and working conditions that affect health are not new. As discussed in Chapter 1, the major causes of morbidity and mortality in the 19th century were communicable diseases. Early attempts to control these diseases focused on community-based prevention aimed at improving personal hygiene, housing and sanitary reforms, and laws to improve living conditions among poor urban dwellers. Other efforts focused on improving food and workplace safety. Population health in the United States improved dramatically be- cause of these community-based efforts. As a result of these efforts as well as improvements in clinical prevention, chronic diseases and injuries have replaced communicable diseases as the leading causes of illness and mortal- ity in the United States. Just as the major causes of morbidity and mortality have changed, so too has our understanding of health and what makes people healthy or ill. In 1974 Marc Lalonde, Minister of National Health and Welfare Canada, presented a white paper that laid out the perspective that health is influenced by environment, lifestyle, human biology, and health care organization. Evans and Stoddart (1990) presented a more complex model of the determinants of health which included behavioral and biological responses to both the social and physical environments. The report Gulf

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28 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION War Veterans: Measuring Health (IOM, 1999) proposed a framework for health that described how individual and environmental characteristics in- fluence health-related quality of life. And a list of major health determinants assembled by Kaplan and colleagues (IOM, 2000b) included pathophysi- ological pathways, genetic and individual risk factors, social relationships, living conditions, neighborhoods and communities, institutions, and social and economic policies. In 2002, the IOM report The Future of the Public’s Health developed a new model, adapted from Dahlgren and Whitehead (1991), that presented an ecological view of the determinants of health, discussed later in this chapter. Research has documented the important effects that social determinants have on health, both directly and through their impact on other health de- terminants, such as risk factors (Berkman and Kawachi, 2000). It has long been known, for example, that people with greater socioeconomic status are healthier than those with lower status; that those with social support fare better, both physically and mentally, than those without; and that one’s neighborhood and built environment affect one’s health (Adler et al., 2008; Antonovsky, 1967; Berkman and Glass, 2000; Cohen et al., 2000; Eller et al., 2008; Kawachi and Berkman, 2001, 2003; Marmot and Wilkerson, 2000; Stansfeld et al., 1999). Such inequalities highlight the importance of focusing on social determinants when intervening to improve the health of individuals and communities. In 1990, McGinnis and Foege (1993) estimated more than 50 percent of the deaths in the United States each year can be traced to tobacco use, alcohol consumption, a sedentary lifestyle, and a diet heavy in salt, sugar, and fat and low in fruits and vegetables. A later analysis by Mokdad and colleagues (2004, 2005) found that for the year 2000, 18.1 percent of U.S. deaths were attributable to tobacco, 15.2 percent to poor diet and physical inactivity, 3.5 percent to alcohol consumption, and other percentages, in decreasing order, were attributable to microbial agents, toxic agents, motor vehicle crashes, incidents involving firearms, sexual behaviors, and illicit use of drugs. Targeting interventions toward the conditions associated with today’s challenges to living a healthy life requires an increased emphasis on the factors that affect these causes of morbidity and mortality, factors such as the social determinants of health. Recent work in community-based prevention has also sought to address the distribution of health and risk factors in populations through programs, policies, and strategies that attempt to reduce social inequalities—or to mitigate their effect on health—and to strengthen the cultural assets of all groups (Bleich et al., 2011). Several approaches to health behavior change, discussed below, have contributed to the way in which current community- based prevention efforts are planned and implemented to address not only

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COMMUNITY-BASED PREVENTION 29 population-wide change, but also a reduction in the disparities among social groups. Health Behavior Change The U.S. Agricultural Extension Service produced a model of commu- nity diffusion and adoption of innovations that continues to inform and guide the planning of community health behavior programs (Brownson et al., 2012; Green et al., 2009; Lionberger, 1964; Rogers, 2002). At the level of individual behavior change, the diffusion model evolved to represent stages in the innovation-diffusion process. The translation of this model to community-based prevention has generally taken the form of interpret- ing each stage in the individual adoption model relative to the community supports it might need or the community efforts required to facilitate each phase (Rogers, 2002), as illustrated in Table 2-1. A model for community-based prevention developed in the 1950s and 1960s grew out of efforts to increase both immunization coverage for mass poliomyelitis protection and mass screening for cancer and tuberculosis (Deasy, 1956; D’Onofrio, 1966; Hochbaum, 1956, 1959). This model, the Health Belief Model, was primarily a psychological model developed from community screening and immunization programs, but it became a part of community intervention models in that it provided a guide to planning the mass media component for recruitment of people for screening or im- munization in community programs (Becker, 1974; Harrison et al., 1992; Janz and Becker, 1984). Another development in the 1960s, which accompanied President Kennedy’s New Frontier initiative and President Johnson’s Great Society, TABLE 2-1  Features of the Organization or Community Supporting States of the Individual Change Process Phase in Psychological Process of Change Supporting Features of Community Exposure Social setting with access to media Attention Interest of family, peers, and other significant persons Comprehension Group discussion and feedback, question and answer sessions Belief Direct persuasion and social influence, actions of informal leaders Decision Group decision making, public commitments, and repeated encouragement, which build self confidence Learning Demonstrated and guided practice with feedback and continued confidence, advice, and direct assistance SOURCE: Green and McAlister, 1984.

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30 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION War on Poverty, and civil rights initiatives, was the promotion of public participation in community health planning. Each legislative act of those initiatives carried the phrase “maximum feasible participation,” which required 51 percent of the planning boards for local program entities to be nonprofessional residents of the community. Insufficient funding for these efforts, however, produced understaffed community agencies and programs. This led many of the agencies and programs to turn to their volunteer com- munity planning participants to help staff the organizations. Daniel Patrick Moynihan (1969) referred to this as “maximum feasible misunderstanding” of the participatory principle. Citizen participation in planning community programs fell into some disrepute as a result, but the stage was set for a later revival of participatory principles in community health assessments, planning, research, and evaluation (Green, 1970b, 1986b). In the 1970s and 1980s, as the growing experience with multisector community approaches took form with community health planning and regional medical programs, the principle of participation evolved from one emphasizing the generation of community support for centrally planned programs to a principle of involving the community in planning programs locally (Green, 1986a). As described by Hackett (1982), “It was from such principles that the modern strategy of community health in countries arose, which was adopted and put into practice by the World Health Organization and was presented at the Alma Ata Conference on Primary Health Care in 1978.” These moves away from individually focused clinical prevention strate- gies were not yet penetrating the chronic disease control field, however. In the 1970s the first trials aimed at reducing the prevalence of behavioral risk factors associated with cardiovascular disease (CVD) were based in clini- cal settings and were directed at patients who were at risk of developing CVD. For example, the Multiple Risk Factor Intervention Trial (MRFIT) randomly assigned about 13,000 men at high risk of coronary heart dis- ease (CHD) either to usual care and medical follow-up or to a series of prevention interventions. However, the prevention interventions mainly consisted of the medical control of high blood pressure, smoking cessation sessions, and dietary counseling for lowering cholesterol level. Although the experimental group showed improvements in the prevalence of risk factors, notably reductions in smoking, such improvements were not significantly different from those observed in the control group. One hypothesis for this minimal difference was that community and mass media activities address- ing these risk factors were taking hold, resulting in pervasive exposures of the control groups to influences as strong as the clinical interventions (Green and Richard, 1993).

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COMMUNITY-BASED PREVENTION 31 While clinical approaches have important contributions to make in addressing risk factors, community-based prevention programs have three distinct strengths: 1. Community-based prevention is aimed at and implemented in a population. Therefore, all members of that population have access to the intervention. Clinical services, however, reach only those individuals who can afford and seek clinical services. 2. Because community strategies are directed at a population, they can reach individuals with varying levels of risk and, in particular, the large group of people who generally fall in the middle of a bell- shaped curve (Rose, 1992). Clinical services tend to be directed at changes for the relatively smaller number of high-risk individuals, those at the high end of the curve. This means they do not prevent individuals who are at lower risk from developing behaviors and lifestyles that will put them at higher risk (Syme, 1994). 3. Lifestyle and behavioral risk factors are shaped by environmental conditions that are not necessarily under the direct control of in- dividuals or of their physicians (Cockerham et al., 1997; Frohlich et al., 2001; Kawachi and Berkman, 2003). Community-based prevention programs can be designed to affect environmental and social conditions that clinical services cannot. The Settings Approach As discussed above, clinical prevention alone is insufficient to mod- ify behavioral risk factors at the level of populations. Complementary c ­ ommunity-based prevention programs and policies can be implemented in workplaces, schools, families, and communities (Poland et al., 2000). Some settings (such as schools) provide a more or less captive pool of identifiable individuals who can be reached easily with an intervention as long as it does not require modifying environmental conditions (Richard et al., 1996). School immunization programs in which school registries and classrooms are used for the identification, gathering, and vaccination of children are an example of such prevention interventions in schools. By contrast, other interventions are designed to modify a setting’s physical and social environ- mental conditions that influence the prevalence of risk factors. Prominent examples have been workplace bans on smoking, which protected workers from the secondhand smoke of other employees or of customers and also began to change norms about the acceptability of smoking in public places. Similarly, the banning of unhealthful products from vending machines in schools, and the construction of bike paths in urban areas has improved the health environments of children and adults.

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32 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION APPROACHES TO COMMUNITY INTERVENTION It is beyond the scope of this report to offer a full review of the ap- proaches to community-based prevention aimed at altering the distribution of disease risk factors. However, this chapter does explore four categories of such efforts: the ecological approach, social marketing and public health education, health promotion, and policy change. Community-based preven- tion programs that combine these four approaches can produce systems changes that are comprehensive and that exhibit significant and durable effects on a population. For more discussion about systems, see Chapter 3. Ecological The first group of strategies is based on an ecological model of pub- lic health interventions. An ecological model (Figure 2-1) published in the report Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century “assumes that health and well being are affected by the interaction among multiple determinants including b ­ iology, behavior, and the environment” (IOM, 2003, p. 32). A recogni- tion of the multiple determinants of health, including the importance of the social and environmental determinants, is a key feature of the ecological approach. For community-based prevention interventions using the eco- logical approach, the interaction between levels of influence creates mul- tiple opportunities for designing interventions to affect successive levels of the community structure (McLaren and Hawe, 2005). Various ecological m ­ odels have been developed which incorporate concepts such as resources, social ecology, the life course and learning processes, and social context in order to demonstrate how the environment shapes individual behavior (Richard et al., 2011). In addition to the development of interventions aimed at changing individual behaviors, the ecological approach can also be applied to affect collective behavior, organizational behavior, and the reciprocal relationship between the various levels via constraints and resources embedded in the structural features of the socio-cultural context (Stokols, 1992). Such a perspective integrates the approaches of individual behavioral interventions and interventions affecting the physical environment in an effort to focus action on the social environment to account for the needs of individuals and the resources available to address those needs (Stokols, 1996; Stokols et al., 1996). Several distinct uses of the ecological perspective have been described in the public health literature (IOM, 2003). They emphasize the need for interventions to target the various systems that influence behaviors (McLeroy et al., 1988; Richard et al., 1996; Stokols, 1996).

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COMMUNITY-BASED PREVENTION 33 a Across the lifespan b Living and working conditions may include •Psychosocial factors •Employment status and occupational factors •Socioeconomic status (income, education, occupation) •The natural and builtc environments •Public health services •Medical care services FIGURE 2-1  A guide to ecological planning of community prevention programs. NOTE: The dotted lines between levels of the model denote interaction effects between and among the various levels of health determinants (Worthman, 1999). a Social conditions include, but are not limited to, economic inequality, urbaniza- tion, mobility, culturalFigure attitudes, and policies related to discrimination and values, 2-1 intolerance on the basis of race, gender, and other differences. b Other conditions at the national level might include major sociopolitical shifts, such as recession, war, and governmental collapse. c The built environment includes transportation, water and sanitation, housing, and other dimensions under the auspices of urban planning. SOURCE: Adapted from Dahlgren and Whitehead, 1991.

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50 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION BOX 2-2 The Case of Tobacco Control Policies as a Template for Successful Community Health Change Policies and programs work better when they are interdependent and syner- gistic, as demonstrated by the CDC’s Office on Smoking and Health (1999, 2007) and others that have concluded from the successes of statewide and community tobacco control programs that comprehensive tobacco control must coordinate policies and programs that depend on each other for success. Such programs and policies emanate from different levels of organizations and government, and each component reaches different segments of the population. For example, states cannot reach effectively into local organizations, and localities cannot afford the cost of mass media placements. An informed and concerned public makes it easier to introduce new policies (Green and Richard, 1993). Informational, educational, and motivational messages through various media and channels facilitate awareness and concern. For youth there is a need for mass media to provide a backdrop of messages and images that are consistent with those they receive from family, teachers, and programs. H ­ ollywood film images of smokers who are protagonists and magazine advertise­ ments with images of glamorous models smoking, for example, send an inconsis- tent message about smoking from those presented in tobacco-cessation programs. The tobacco industry outspends state tobacco control programs at least $10 to $1, and up to 20 to 1 on media and marketing during political campaigns to raise taxes on cigarettes (Begay et al., 1993; Pierce and Gilpin, 2004; Tobacco Education and Research Oversight Committee, 2009; Traynor et al., 1993). In the 1970s most political efforts at state and federal levels to ban smoking in public places were successfully beaten back by tobacco industry, but most city and county initiatives to regulate smoking during that same period passed because the industry could not put out the multiplicity of brush fires at the local level (NCI, 2000). Coordinating local and state policy and program efforts has been key to the notable successes of California and other states and municipalities in smoking- cessation efforts (Best et al., 2007; Tobacco Education and Research Oversight Committee, 2009). When each level of government and voluntary agency action coordinates and divides the labor of comprehensive programs and policies, the synergy produces more successful outcomes. evaluation, many community-based interventions are implemented without adequate evaluation. This has resulted in a scarcity of information about the effectiveness of these interventions. A number of factors have been identified to explain this relative scarcity, including the small number of evaluations undertaken (as mentioned above), methodological difficulties, and a lack of theoretical clarity. One set of factors is related to the fact that few interventions are rig- orously evaluated, relative to the number of past and ongoing efforts in communities across many countries. There are many more or less defined interventions being implemented by various actors in a community with

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COMMUNITY-BASED PREVENTION 51 various levels of resource investments. Most of these interventions are unknown to all except those directly involved. For example, Spinks et al. (2009) commented that, despite the identification of more than 200 com- munities worldwide with a WHO Safe Community status, only a handful in two regions of the world have been subject to controlled evaluation. If little is known, it is partly because the issue has not been widely studied. Another set of factors relates to methodology. Randomized controlled trials, the gold standard in clinical medicine, have proven difficult to un- dertake for the evaluation of community-based interventions. As discussed earlier, randomized controlled trials require adherence to a set protocol, yet a key characteristic of community-based prevention is to make sure that the intervention is tailored to the affected community, usually with significant input from community members themselves. Such adjustment in the intervention makes it difficult to identify control communities for comparison purposes. In addition to these methodological difficulties, there might also be a lack of theoretical clarity about the effective mechanisms operating in such interventions and the full range of potential effects that might be influenced by these interventions (Hawe et al., 2004). Communities have long histories, and their composition in terms of both population characteristics and structural elements is not conducive to rapid change (De Koninck and Pampalon, 2007). Changing the course of such systems is a long-term endeavor and requires a locally valid model of the possible pathways through which such transformations can be spearheaded. Evaluating non-standardized, constantly changing, community-directed, slow-moving changes at all the levels in ecological models from programs to policies presents methodological, logistical, and economic feasibility challenges. It is impossible to determine the relative contributions of all the many moving parts or the active ingredients in the complex interventions (Mercer et al., 2007). Deconstructing complex interventions may not even be advisable, given that ecological models guiding the projects emphasize the need for multi-level interventions and the reciprocal dependency of many of the interventions and policies (­ allis S et al., 2008). The strategic vision of the Office of Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health recognizes that prevailing paradigms focusing on single-cause, single-discipline, and s ­ingle-level-of-analysis models are necessary but insufficient and calls for interdisciplinary and multilevel approaches that integrate biological, be- havioral, and social sciences to address the complex issues that challenge the public’s health (Mabry et al., 2008). Furthermore, the prevailing linear research-to-practice paradigms, while useful for addressing specific clinical or epidemiologic questions, are often inadequate to tackle real-world health

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52 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION problems that are intrinsically imbedded in the widely varying complexities of behavioral, social, and cultural settings (Livingood et al., 2011). As with the earlier academically directed intervention studies, how- ever, even when considering these complexities, evaluations of community- based programs, policies, and strategies cannot assure that an effective intervention in one setting will generalize to another community. Emerg- ing paradigms call for the integration of research and practice, similar to the integrations in applied physical sciences, engineering, and architecture (Livingood et al., 2011). These approaches represent a radical departure from best practice interventions and involve the customization of scientific principles and methods to each situation. They offer a greater degree of credibility about their generalizability insofar as they are carried out in real time by real practitioners and community partners (Green, 2007). The following chapter examines system thinking in greater detail, de- scribing how systems science can be used to explore the complexity of community-based prevention. That chapter also discusses domains of value for community-based prevention interventions. REFERENCES Adler, N., A. Singh-Manoux, J. Schwartz, J. Stewart, K. Matthews, and M. G. Marmot. 2008. Social status and health: A comparison of British civil servants in Whitehall II with ­ uropean- and African-Americans in CARDIA. Social Science and Medicine E 66(5):1034-1045. Alley, D., J. Lloyd, T. Shaffer, and B. Stuart. 2012. Changes in the association between body mass index and Medicare costs, 1997-2006. Archives of Internal Medicine 172(3):277. Anderson, L. M., T. A. Quinn, K. Glanz, G. Ramirez, L. C. Kahwati, D. B. Johnson, L. R. Buchanan, W. R. Archer, S. Chattopadhyay, and G. P. Kalra. 2009. The effective- ness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: A systematic review. American Journal of Preventive Medicine 37(4):340-357. Antonovsky, A. 1967. Social class, life expectancy and overall mortality. Milbank Memorial Fund Quarterly 45(2):31-73. Bartholomew, L. K., G. S. Parcel, G. Kok, and N. H. Gottlieb. 2001. Intervention mapping: Designing theory- and evidence-based health promotion programs. Mountain View, CA: McGraw-Hill. Becker, M. H. 1974. The health belief model and personal health behavior. Thorofare, NJ: Slack, Inc. Begay, M. E., M. Traynor, and S. A. Glantz. 1993. The tobacco industry, state politics, and tobacco education in California. American Journal of Public Health 83(9):1214-1221. Berkman, L., and T. A. Glass. 2000. Social integration, social networks, social support, and health. In Social epidemiology, edited by L. Berkman and I. Kawachi. New York: Oxford University Press. Pp. 137-173. Berkman, L., and I. Kawachi. 2000. Social epidemiology. New York: Oxford University Press. Bernier, N. F., and C. Clavier. 2011. Public health policy research: Making the case for a politi- cal science approach. Health Promotion International 26(1):109-116.

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