An Integrated Framework for Assessing the Value of Community-Based Prevention (2012) / Chapter Skim
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2 Community-Based Prevention
2 Community-Based Prevention
Pages 23-60
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, 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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IMPORTANT FEATURES OF COMMUNITY-BASED PREVENTION Over the past 50 years public health practice and research have contributed to developing and analyzing the characteristics that distinguish community-based prevention from other forms of action. Communitybased prevention interventions focus on population health and, in addition,
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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 wellbeing (Adler et al., 2008; Berkman and Kawachi, 2000)
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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.
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Population health in the United States improved dramatically because 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 mortality in the United States.
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Research has documented the important effects that social determinants have on health, both directly and through their impact on other health determinants, such as risk factors (Berkman and Kawachi, 2000)
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Agricultural Extension Service produced a model of community 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)
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, "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 strategies 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)
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The Settings Approach As discussed above, clinical prevention alone is insufficient to modify 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)
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For community-based prevention interventions using the ecological approach, the interaction between levels of influence creates multiple opportunities for designing interventions to affect successive levels of the community structure (McLaren and Hawe, 2005)
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NOTE: The dotted lines between levels of the model denote interaction effects between and among the various levels of health determinants (Worthman, 1999)
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Awareness and attitude-change programs in public health education have increasingly adopted the principles of social marketing, which is understood as a "process for influencing human behavior on a large scale, using marketing principles for the purpose of societal benefit" (Smith, 2000)
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Health Promotion Health promotion approaches are different from social marketing approaches in that they engage people and organizations in the transformation process and that this engagement in the process constitutes in itself a desired change. Health promotion conceptualizes health as a product of everyday living and proposes values and principles for public health practice (Breslow, 1999; Kickbusch, 2003; Potvin and Jones, 2011)
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This is often a first step in a progression toward full regulation. Social marketing campaigns on the benefits of seat-belt use paved the way for the enactment of direct regulation to impose sanctions on car passengers who did not buckle up.
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The long evolution in tobacco legislation throughout the second half of the 20th century offers an example of all the different policy approaches used together. Starting with the scientific recognition of the negative health impact of tobacco smoking in a public health report in 1964, and moving to various bans on tobacco in public places and increasing taxes on tobacco products, the history of tobacco policy in Western countries has shown that even in the face of valid scientific evidence, influencing the policy-making process is a work of advocacy and political influence, building coalitions, staging the public debate, evaluating comprehensive statewide and community policies and programs, and disseminating the findings of those evaluations to other jurisdictions (Bernier and Clavier, 2011; Breton et al., 2008; Eriksen et al., 2007)
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The Multilevel Approaches Toward Community Health Model The Multilevel Approaches Toward Community Health (MATCH) model (Figure 2-3)
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Phase 4a Phase 3 Phase 2 Phase 1 Intervention Educational Epidemiological, Behavioral, Social Alignment and Ecological and Environmental Assessment Assessment Assessment Precede Evaluation Tasks: Specifying measurable objectives and baselines Health Predisposing Program Genetics Phase 4b Educational Administrative strategies and Policy Reinforcing Behavior Assessment Health Quality of life Policy regulation Environment organization Enabling Proceed Evaluation Tasks: Monitoring and Continuous Quality Improvement Short-term Longer-term Short-term Long-term Input Process Output impact health outcome social impact social impact Phase 5 Phase 6 Phase 7 Implementation Process Evaluation Impact and Outcome Evaluation FIGURE 2-2 PRECEDE–PROCEED model. SOURCE: Green and Kreuter, 2005.
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is a planning and evaluation tool developed by Health Promotion Switzerland and the Institutes for Social and Preventive Medicine in Bern and Lausanne to aid in health promotion efforts. The model is intended to be broadly applied and to provide an overview of activities for planners and evaluators.
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. The Community Development Model The community development model includes three important concepts: decentralization, participatory planning and implementation of programs, and multisectoral involvement.
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New personal and/or social skills 4. Strengthened self-confidence regarding a health-relevant topic or an activity FIGURE 2-4 Overview of the Swiss Model for Outcome Classification in Health Promotion and Prevention.
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. In the United States, community development in health has occurred under the Planned Approach to Community Health (PATCH)
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Key features of the program were • a carefully outlined theoretical framework; • community involvement; • a flexible and dynamic intervention, adapting to naturally occur ring events; • a multifaceted intervention, including innovative media campaigns, health care providers, environmental changes, and industry and policy changes; and • strong leadership and institutional support. The North Karelia project inspired efforts sponsored by the National Institutes of Health to implement and evaluate similar community interventions in California with the Stanford Three-Community and the Stanford Five-Community studies.
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. Reviews by the Task Force on Community Preventive Services as well as the Cochrane reviews have synthesized evidence concerning community prevention efforts.
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All successful interventions included a mix of complementary interventions taking place in various community settings, including schools and media campaigns. The Community Guide to Preventive Services (also known as the Community Guide [www.thecommunityguide.org]
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This suggests that there is a link between programs that address the social determinants of poor health and improved population health. Within the OECD, the United States spends nearly twice as much on health care -- measured as a percentage of GDP -- than other countries, but it ranks in the bottom third in key population health indicators such as life expectancy and infant and maternal mortality (Bradley et al., 2011)
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is difficult to use in evaluating community-based prevention interventions. Another problem for replicability is that the effectiveness of a community intervention is not inherent within the intervention itself (that is, within what is imported from outside)
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Such research is needed to better understand how community interventions work. There exist only a few initiatives worldwide that propose to synthesize the results of evaluations of community-based prevention strategies and wellness policy, including the Cochrane review groups on population and public health, and the CDCfacilitated work of the Task Force on Community Preventive Services.
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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)
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Randomized controlled trials, the gold standard in clinical medicine, have proven difficult to undertake 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.
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American Journal of Preventive Medicine 37(4)
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American Journal of Preventive Medicine 13(4)
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American Journal of Preventive Medicine 38(2)
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1993. The need to combine health education and health pro motion: The case of cardiovascular disease prevention.
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1988. Social marketing and public health intervention Health Education Quarterly 15(3)
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Translating evidence from the North Karelia Project over place and time. Health Education Research 22(3)
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International Quarterly of Community Health Education 25(3)
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In Health behavior and health education: Theory, research, and practice, 4th ed., edited by K Glantz, B
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2000. The Kaiser Family Foundation Community Health Promotion Grants Program: Findings from an outcome evaluation.
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