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Health ExChange Academy

Primary Prevention:

Strategy for Change

Primary Prevention:

Strategy for Change

Foreword
Prevention is a critical but underutilized strategy to help identify and advance changes that will make a difference in the health of Californians. The California Endowment is therefore committed to helping individuals and organizations understand and effectively communicate the need for a prevention-oriented community health model. To that end, The Endowments Program Department and the Center for Healthy Communities have developed the Primary Prevention curriculum as part of the Centers Health ExChange Academy. This curriculum provides an overview of both the theory and practice of primary prevention, with case studies and hands-on exercises that will help you apply what you learn in real-life contexts. We hope that this manual will help you in your efforts to improve health outcomes in Californias most underserved communities, and that you will turn to us for guidance along the way.

Sincerely,

Robert K. Ross, M.D. President and Chief Executive Officer The California Endowment

Curriculum Introduction
Drawing on the experiences and best practices of veteran advocacy organizations throughout California, the Health ExChange Academys Primary Prevention training curriculum presents the concepts of prevention and the determinants of health and provides opportunities to apply this framework to local communities. This manual is guided by the philosophy that primary prevention is critical to addressing health disparities and inequities because it focuses on changes in the economic, social, cultural and physical environments, which has proven to be the most effective way to stop illness and injury before they occur. Primary prevention aims to make changes in the community at the population level rather than at the individual level, one person at a time; by acting in this way, we can positively effect change for more people with less effort. A major goal of the manual and curriculum is to help participants develop the capacity to understand and communicate the value of primary prevention and an environmental approach to improving health outcomes. Primary Prevention: Strategy for Change is organized into two parts: Part One introduces you to the concept of a prevention-oriented community health and safety approach to reducing health inequities and presents a framework for learning how to identify, analyze, and prioritize factors in the community environment that affect health and safety. Part Two focuses on designing strategies to address prioritized factors. You will explore how to develop comprehensive approaches using the Spectrum of Prevention to apply prevention to contemporary health and safety issues. The Spectrum of Prevention is a tool for changing systems, norms and environments and builds on local knowledge about the factors that affect health and safety. Practical and user-friendly, this manual is your guide to the essential concepts, tools and examples that can support your nonprofit organization in its prevention advocacy efforts. The manual can also be shared with colleagues and key stakeholders in your organization or advocacy coalitions. We hope you find it helpful as you work to create healthier communities across California.

Table of Contents
Part One: An Environmental Approach to Promoting Health, Safety and Equity
1. Introduction 2. A Prevention-Oriented Community Health Approach 3.  A Prevention-Oriented Community Health Approach to Reducing Inequities 4. Understanding the Factors in Community Environments that Shape Health and Safety 5. Conclusion 31 35 36 41 45 54 55 62 67 71 19 3 6 13

Part Two: Developing Comprehensive Strategies: Using the Spectrum of Prevention


1. Introduction 2. Developing Comprehensive Strategies 3. Key Aspects of the Spectrum of Prevention 4. Levels of the Spectrum in Detail 5. Conclusion 6. Appendices 7. Glossary 8. Resources 9. Worksheets

PART ONE

An Environmental Approach to Promoting Health, Safety and Equity

Introduction
Good health is precious; it enables productivity, learning, positive relationships and building on opportunities. Poor health jeopardizes independence, responsibility, dignity and self-determination. Good health and poor health are not distributed equally among the population. In fact, disparities* in health among income, racial and ethnic groups in the U.S. are significant and by many measures expanding.1 Put simply, racial and ethnic minorities and low-income populations experience higher rates of morbidity and mortality.2 Poor health is not only a burden on individuals and families. The health of a population is determined by the health status of its least healthy members.3 An excess of people with poor health can overburden the health care infrastructure, increase the spread of infectious diseases and deplete resources. Illness and injury also generate tremendous social and economic costs in the form of lost productivity and expenditures for disability, workers compensation and public benefit programs. Eliminating racial and economic health inequities is imperative both as a matter of fairness and economic common sense. Genetics and medical care influence health outcomes, but the most powerful factors shaping health and safety are behavioral, social, environmental and economic determinants.4, 5 Those determinants play out in the places where people live, work, play and learn. Therefore, improving health for any and all populations should include strategies to improve conditions in communities. In many cases, forces beyond the community play a key role in determining patterns of illness and injurystate and federal policy, broadly employed business practices, racial prejudice, etc. This manual focuses on community-level strategies that complement broader efforts to affect the determinants of placepolicy and practiceand to undo discrimination and bias. Addressing health at the community level requires moving upstream (see sidebar on page 4) to strategically apply prevention before the onset of illness and injury.
*Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups. Health inequities are differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust. Thus, equity and inequity relate to core American values of fairness and justice whereas disparity is a narrow descriptive term that refers to measurable differences but does not imply whether this disparity arises from an unjust root cause. (National Institutes of Health)

 We are still standing on the bank of the river, rescuing people who are drowning. We have not gone to the head of the river to keep them from falling in. That is the 21stcentury task.
Gloria Steinem

Primary Prevention: Strategy for Change

Moving Upstream: An Analogy to Primary Prevention


While walking along the banks of a river, a passerby notices that someone in the water is drowning. After pulling the person ashore, the rescuer notices another person in the river in need of help. Before long, the river is filled with drowning people, and more rescuers are required to assist the initial rescuer. Unfortunately, some people are not saved, and some victims fall back into the river after they have been pulled ashore. At this time, one of the rescuers starts walking upstream. Where are you going? the other rescuers ask, disconcerted. The upstream rescuer replies, Im going upstream to see why so many people keep falling into the river in the first place. As it turns out, the bridge leading across the river upstream has a hole through which people are falling. The upstream rescuer realizes that fixing the hole in the bridge will prevent many people from ever falling into the river in the first place.

That means, for instance, addressing high rates of diabetes by improving access to healthy foods in low-income communities, increasing opportunities for physical activities in schools, reducing inequitable exposure to air pollution and improving the physical environment of a community (sidewalks, parks, bike paths, etc.). In order to move towards eliminating inequities in health and safety and promoting general health and well-being for all, it is first essential to understand and effectively communicate the need for a prevention-oriented community health model. This manual will present the concepts of prevention and the determinants of health and provide opportunities to apply this framework to local communities.

Objectives
Part One of this manual is designed to:  amiliarize grantees of The California F Endowment and other training participants with the conceptual framework of a prevention-oriented community health and safety approach to reducing health inequities  elp participants develop the capacity to H understand and communicate the value of primary prevention and an environmental approach to improving health outcomes  ntroduce a process for identifying, I analyzing, and prioritizing factors in the community environment that can reduce inequities in health and safety

Primary Prevention: Strategy for Change

Introduction

Roots of Prevention: Addressing Health Equity by Changing the Community Environment


In 1965, H. Jack Geiger, physician and civil rights activist, opened one of the first two community health centers in the United States in Mound Bayou, Mississippi. The invention of the double-row cotton-picking machine had recently replaced the need for an entire population of sharecroppers, causing massive unemployment and exacerbating poverty.6 To assess the needs of the community, the Mississippi health center began by holding a series of meetings in homes, churches and schools. As a result of these meetings, residents created ten community health associations, each with its own perspective and priorities. In the beginning, the health center saw an enormous amount of malnutrition, stunted growth and infection among infants and young children. Geiger and his colleagues linked hunger, a health issue, to acute poverty and linked poverty to the massive unemployment that had turned an entire population into squatters. Instead of just treating individual cases, Geiger and his colleagues addressed the problem of malnutrition, first by writing prescriptions for food. Health center workers recruited local black-owned grocery stores to fill the prescriptions and reimbursed the stores out of the health centers pharmacy budget. Once we had the health center going, we started stocking food in the center pharmacy and distributing foodlike drugsto the people. A variety of officials got very nervous and said, You cant do that. We said, Why not? They said, Its a health center pharmacy, and its supposed to carry drugs for the treatment of disease. And we said, The last time we looked in the [Physicians Desk Reference], the specific therapy for malnutrition was food.7 By addressing the roots of illness drawn from community concerns, these health centers pioneered an effective methodology for approaching health care in underserved communities. They explored environmental conditions such as housing, food, income, education, employment, and exposure to environmental dangers and linked them to health outcomes. Then, in an effort to prevent these poor health outcomes, they moved upstream to change the conditions that led to those illnesses in the first place.
From Prevention is Primary: Strategies for Community Well-being, Edited by L. Cohen, V. Chavez & S. Chehimi; Jossey Bass, 2007.

Primary Prevention: Strategy for Change

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Primary prevention is critical in order to address health disparities and inequities.

A Prevention-Oriented Community Health Approach


A Closer Look at Prevention
The allocation of health and safety resources and the mainstream conversation about health reveal a lack of focus on prevention. When prevention is the topic, often the discussion is limited to clinical prevention or efforts to change individual behavior. Both of these are important, but they dont represent upstream solutions that address the factors that lead to illness and injury in the first place. Primary prevention includes actions that take place before the onset of illness or injury and that are focused on environmental changes, targeting the health of the population rather than solely the individual. Examples of primary prevention include: E  nsuring availability of healthy, affordable food in communities to help reduce the frequency of chronic disease Reducing alcohol density in low-income communities Eliminating lead from products, housing and soil Primary prevention results in higher quality of life in communities as rates of illness and injury drop, the cost-effective use of resources (its cheaper to address issues before the fact than through expensive treatments), and decreasing pressure on the health care systemin effect, preempting cases that otherwise require treatment. In addition to decreasing the demands for traditional health care services, primary prevention also reduces the need for other services such as mental health, disability and criminal justice. In order to be most effective, primary prevention needs to be applied in a high-quality manner. QUALITY prevention: 1. Is comprehensiveincludes multiple, mutually supportive strategies (e.g., statewide policies restricting tobacco, increased tobacco fees and a public information campaign)

Primary Prevention: Strategy for Change

A Prevention-Oriented Community Health Approach

2. Improves the community environment makes the healthy choice the easy or default choice (e.g., research has shown that fruit and vegetable consumption goes up for every supermarket in a census tract) 3. Changes normsalters the expected behavior (e.g., restrictions on tobacco consumption) 4. Emphasizes policy and organizational practice changecreates change that has the greatest impact for largest number of individuals (e.g., policies removing lead from paint and gasoline) 5. Is continuousquality prevention effects changes that, once in place, are ongoing for the entire population (e.g., laws prohibiting the use of lead in consumer products).

Prevention Works!
Minimum Drinking Age
One well-known and very successful modern example of primary prevention is the National Minimum Age Drinking Act of 1984, which required all states to raise their alcohol minimum purchase and public possession age to 21 or risk losing major transportation funding.8 The National Highway Traffic Safety Administration (NHTSA) estimates that as a result of minimum drinking age laws 18,220 lives were saved between 1975 and 1999.9

Reducing Toxic Pollution


For two years, West Oakland residents and community partners worked to research and identify 17 indicators to monitor environmental, health and social conditions for their neighborhood. Residents then used the data in the indicators report to issue a formal request that the Bay Area Air Quality Management District (BAAQMD) develop stronger regulations requiring the Red Star Yeast factory (the areas second leading source of toxic emissions) to reduce both pollution and noxious odors. The evidence in the report was also used to build media advocacy, testify at public hearings and garner letters demanding regulation and enforcement from the Department of Public Health and local elected officials. The combination of evidence and pressure led BAAQMD to remove the exemptions that had grandfathered Red Star Yeast into antiquated emissions standards, which resulted in the plant closing.
From A Time of Opportunity, Prevention Institute, 2009.

The Prevention Continuum


There are three different categories of prevention. In addition to primary prevention that occurs before illness or injury and focuses on the health of populations, steps can be taken to intervene once individuals are experiencing symptoms of, or are identified as being at risk for, illness or injury (e.g., screening and support groups for pre-diabetics). This is secondary prevention. Prevention measures applied after onset to reduce the duration and severity of an illness or injury are tertiary prevention (e.g., drugs that reduce the cholesterol of people with heart disease). Primary prevention: Approaches that take place BEFORE illness or injury Secondary prevention: Responses AFTER SYMPTOMS OR RISK of illness or injury Tertiary prevention: Responses AFTER ONSET of illness or injury

Primary Prevention: Strategy for Change

An evocative way to think about these stages comes from young people in Philadelphia who were involved in an initiative to prevent violence. They renamed the stages upfront, in the thick and aftermath. While it is important to emphasize primary prevention, efforts at all three levels are important, mutually supportive and reinforcing. Attention and resources need to be allocated at all three levels to maximize the health of the population.

LEAD on the Prevention Continuum


Here is an example of how to use the prevention continuum to explain the actions that can be taken at the different stages of prevention: primary (upfront), secondary (in the thick), and tertiary (aftermath). In this case we have used lead poisoning prevention as an example.

PRIMARY
(upfront) Dramatic reductions in blood lead levels of U.S. children during 1970 1990 were attributed to populationbased environmental policies that: Banned the use of lead in gasoline, paint, drinking-water conduits, food and beverage containers and other products that created widespread exposure to lead. Primary prevention is the only way to reduce the neurocognitive effects of lead poisoning. (Lee & Hurwitz, 2002)

SECONDARY
(in the thick) Developing screening programs that target at-risk children followed by the treatment of affected children and removal of lead paint from household. Screening may prevent recurrent exposure and the exposure of other children by triggering identification and remediation of sources of lead in children's environments. (New York State Department of Health, 2004)

TERTIARY
(aftermath) Treatment, support and rehabilitation of lead-poisoned children with intractable complications of the disease. Tertiary prevention reduces the morbidity associated with lead intoxication through chelation of lead from the blood and soft tissues of an exposed individual. Chelation can reduce the immediate toxicity associated with acute lead ingestion but has limited ability to reverse the neurocognitive effects of chronic exposure. (Lee & Hurwitz, 2002)

Primary Prevention: Strategy for Change

A Prevention-Oriented Community Health Approach

TYPE II DIABETES
Apply the concepts of prevention just presented and fill out a prevention continuum for type II diabetes. At each stage, write down at least one example of an action that could be taken in response to type II diabetes. Refer to the lead example as a guide for the types of strategies that are appropriate in each category.

PRIMARY
(upfront)

SECONDARY
(in the thick)

TERTIARY
(aftermath)

Primary Prevention: Strategy for Change

Prevention Works!
Mandatory Child Safety Restraints
I walked out on the balcony alone and had a few tears well up. I said By golly, its happened, and if this works it may happen all over the U.S. That is how Dr. Robert Sanders, a soft-spoken Tennessee pediatrician and catalyst for groundbreaking injury-prevention legislation, described his victory in a historic senatorial vote over mandatory car seat use. Today, few parents question the benefits of using a child safety seat. In fact, 99 percent of infants and 94 percent of toddlers nationally are restrained using child safety seats while riding in automobiles.10 Yet what are now norms were once anomalies. In the early 1970s car injuries were the leading cause of death for young children in Tennessee and in many other states, and car seat use was less than 15 percent nationally.11 However, many legislators and citizens saw car seats as an issue of personal freedom and civil liberties, rather than an issue of injury prevention.12 When Dr. Sanders became chair of the Tennessee chapter of the Accident Prevention Committee of the American Academy of Pediatrics, he realized that he had an opportunity and responsibility to address this easily preventable cause of mortality and morbidity through legislation. In 1976, he proposed the nations first mandatory child restraint law, but it was stopped in committee. Opponents vehemently attacked the bill and Dr. Sanders, even falsely accusing him of owning stock in a safety seat manufacturing company. The following year, Sanders redoubled his efforts. He, his wife, and the opposing lawmakers own family physicians began to call legislators homes on weekends in order to enlist their support. An impressive cadre of health professionals distributed fact sheets throughout the state. The bill was finally approved by a margin of two votes in 1978. By 1985 all 50 states had adopted similar legislation.13 Between 1975 and 2004, approximately 7,472 lives were saved by child safety restraint systems (safety seats or safety belts).14 During that same time, risk of injury to children was reduced by 59 percent when compared to children who used only safety belts.15 Sanders efforts not only saved childrens lives in Tennessee and beyond but also established a precedent for using policy to effect broad norms and behavior change. One persons willingness to see beyond current trends in thinking, to take on the often-uncomfortable job of changing norms, and to recognize the power of legislation in altering behaviors resulted in sweeping national change and set a precedent for similar initiatives. Arguably, the successful enactment of similar policies (such as helmet laws, drinking age statutes, and tobacco control regulations) was, at least in part, possible due to Dr. Robert Sanders success.

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Primary Prevention: Strategy for Change

A Prevention-Oriented Community Health Approach

Chapter 2 Recap:
 isparities are differences in the incidence, prevalence, mortal D ity and burden of diseases and other adverse health conditions that exist among specific population groups.  nequities are inequalities. Health inequities are differences in I health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.16  rimary prevention focuses on actions that take place before the P onset of illness or injury and that are focused on environmental changes targeting the health of the population rather than the individual.  rimary prevention is critical in order to address health dis P parities and inequities because primary prevention focuses on changes in the economic, social, cultural and physical environments, which has proven to be the most effective way to reduce health disparities and inequities before they occur. Chapter 2 Discussion Questions: 1. What are two reasons to focus on primary prevention? 2.  Whats an example, from your own experience, of quality prevention? 3.  Jack Geiger offered prescriptions for food and shoes at the community clinic he started in Mississippi. What are some other things medical facilities today could do to focus on preventing illness and injury in addition to current diagnosis and treatment practices? Answers to Chapter 2 Discussion Questions: 1. Two reasons to focus on primary prevention are: 1) It stops illnesses and injuries before they occur, thus reducing suffering and expense. 2) Primary prevention looks to make changes in the community at the population level rather than at the individual level, one person at a time; by acting in this way, we can positively effect change for more people with less effort.

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2.  This answer will vary depending on your specific experience, but the point is to have your example get at comprehensive practices in community environments that are aimed at supporting healthy behaviors. 3.  Medical facilities could host farmers markets, provide fitness centers for client and staff use, establish their business as a smoke-free zone, adopt green building and waste policies, employ people from local communities, and provide healthy and affordable meal options in their cafeterias and vending machines.

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Primary Prevention: Strategy for Change

A Prevention-Oriented Community Health Approach to Reducing Inequities


Chapters 1 and 2 included an overview of disparities, inequities and prevention, and why a prevention-oriented approach to health is critical to reduce inequities. Chapter 3 examines how prevention can be applied to have the greatest affect on health.

3
Behavior and environment have a greater impact on health than genetics and medical care.

EXPOSURES ENVIRONMENT BEHAVIOR

HEALTH

Researchers have consistently concluded that behavior and environment have a greater impact on health than genetics and medical care.17 Behavior and environment are, in fact, closely linked. It is generally understood that there is a direct pathway between environmental exposures and health: unclean air and water contribute to infectious and chronic disease and broken sidewalks contribute to falls. What is less clearly understood is the power the environment has to shape behaviors that affect health. For example, the prevalence of liquor stores in a community environment affects outcomes such as motor vehicle crashes, liver disease, depression and violence. After the Community Coalition worked to close over 200 liquor stores in the South Central neighborhood of L.A., they were able to document a 27 percent reduction in crime and violence within a four-block radius of the closed stores.18 As another example, African Americans fruit and vegetable intake has been shown to increase by 32 percent for each additional supermarket in a census tract.19 Poverty, racism and lack of educational and economic opportunities are among the fundamental determinants of poor health, lack of safety and health inequities, contributing to chronic stress and building upon one another to create a weathering effect, whereby health greatly reflects cumulative experience rather than chronological age.20 Further, continued exposure to racism and discrimination may in and of itself exert a

The Super Sizing of America


Our social and physical environments have been steadily transforming to make healthy choices more difficult. For instance, the average portion size of a majority of prepared foods has been steadily increasing. If all of our portions are super sized so that becomes what is normal, how can we expect kids or adults to eat healthy-sized portions that arent as big?

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Beyond Brochures
There are no examples of widespread health issues being solved solely by providing information. Despite the available evidence, many prevention efforts focus on health education and counseling efforts while ignoring the larger environmental factors that can work against the educational message. Behavioral change is not only motivated by knowledge, but also by a supportive social environment and access to facilitative services,23 support from other societal mechanisms,24 and an emphasis on setting up social conditions that promote health.25

great toll on both physical and mental health.21 Chronic stress may contribute to other poor health outcomes, such as cardiovascular disease and some forms of cancer. For example, one study found that children who hear gunshots are more likely to experience asthmatic symptoms.22 Providing information that encourages individuals to engage in healthy behavior is important. However, such information will only be effective if the community environment enables the healthy action and supports the healthy choice. As the Institute of Medicine has stated, It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural and physical environment conspire against such change.26 As a result, it is vital to examine those forces in order to understand where to apply primary prevention strategies. A systematic way to get at the underlying community determinants of health is to begin with a health condition that is an acknowledged problem, and then take two steps to prevention.

Take 2 steps to prevention


HEALTH CARE SERVICES

ENVIRONMENT

EXPOSURES & BEHAVIORS

Take Two Steps to Improve Health: From Health Care Services to Exposures and Behaviors to the Environment
Imagine that an individual shows up in a doctors office complaining of chest pain. The doctors immediate question is, What is causing this individuals symptoms? They will likely be able to come up with a diagnosis of, in this imagined case, severe heart disease. At this point, the individual is potentially looking at expensive, painful, restrictive treatments. But how did he end up with heart disease in the first place? Decades of poor nutrition and limited physical activity played a significant role. Clearly, part of the answer lies in the choices he made. But what shaped those choices, and why are there patterns of disease based
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Primary Prevention: Strategy for Change

A Prevention-Oriented Community Health Approach to Reducing Inequities

on race, economic status and where someone lives? In order to understand what contributes to illness and injury, we can step back first from the medical condition (e.g., heart disease) to exposures and behaviors (e.g., poor nutrition and limited physical activity) and then take a second step back to the environment that shapes the exposures and behaviors.

Why Health Care Services Alone Cannot Reduce Health Inequities


Improving access to and quality of health care services is critical for improving community health, but too often is the only strategy applied to a health issue. Consider a physician who recommends regular exercise for a diabetes patient who lives in a community without facilities for exercising or safe sidewalks. Reducing inequities in health and safety requires focusing attention on the community environment along with health care services because: 1. Health care services are not the primary determinant of health. Of the 30-year increase in life expectancy since the turn of the century, only about five years of this increase are attributed to health care interventions. Even in countries with universal access to care, people with lower socioeconomic status have poorer health outcomes.27 2. Health care services treat one person at a time. By focusing on the individual and specific illnesses as they arise, medical treatment does not reduce the incidence or severity of disease among groups of people because others become afflicted even as some are cured. 3. Health care intervention usually happens after the onset of illness or injury. Health care services are usually sought after people are sick. Todays most common chronic health problems, such as heart disease, diabetes, asthma, and HIV/AIDS, are incurable. Therefore it is extremely important to prevent them from occurring in the first place.

Lets take a step...


EXPOSURES & BEHAVIORS HEALTH CARE SERVICES

The First Step: From Health Care Services to Exposures and Behaviors This first step back is from Health Care Services to Exposures and Behaviors. Limiting unhealthy exposures and behaviors enhances health and reduces the likelihood and severity of disease. Through an analysis of the factors contributing to medical conditions that cause people to seek care, researchers have identified a set of nine behaviors and exposures strongly linked to the major causes of death (see following page). These exposures and behaviors are linked to multiple medical diagnoses, and thus addressing them can lead to reductions in rates of multiple medical conditions. For example, tobacco use is associated with health conditions including lung cancer, asthma, emphysema and heart disease. Diet and activity patterns are associated with cardiovascular and heart disease, certain cancers, and diabetes, among other illnesses. Alcohol consumption is associated with liver disease, violence and mental health conditions. It is also important to analyze exposure to stressors such as poverty, racism and lack of opportunity. These stressors affect low-income communities and people of color disproportionately, are contributing factors in virtually all health conditions, and present key opportunities for actions to improve health.

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THE ACTUAL CAUSES OF DEATH


In 1993 two researchers, McGinnis and Foege, completed an analysis of the causes of death listed on U.S. death certificates.29 The certificates listed ultimate reasons for death (cancer, heart disease homicide, etc.), but McGinnis and Foege were interested in the underlying causes. They identified a set of nine factors strongly linked to the major causes of death (see table below) and labeled these factors The Actual Causes of Death. Each of them is linked to multiple health care outcomes. For instance, tobacco is associated with lung cancer but also with asthma, emphysema and heart disease, to name a few. McGinnis and Foeges work not only provided groundbreaking insight into premature death in the U.S., it also supports a paradigm shift in the consideration of applying resources further upstream.

Actual Causes of death


Tobacco

RELATED HEALTH PROBLEMS and MEDICAL CONDITIONS


Cancer, cardiovascular disease, asthma, emphysema, low birth weight, burns Cardiovascular and heart disease, cancer, diabetes

Diet and Activity Patterns Alcohol

Injuries (motor vehicle, home, work, burns and drowning), cancer, homicide, HIV infection, hepatitis Pneumococcal pneumonia and other bacterial infections, hepatitis, HIV and other viral infections Cancer, cardiovascular disease and diseases of the heart, lungs, kidneys, bladder and neurological system Homicide, suicide, unintentional injury

Microbial Agents*

Toxic Agents

Firearms

Sexual Behavior

Hepatitis B and HIV infection, excess infant mortality rates, cervical cancer Injury and death to passengers and pedestrians

Motor Vehicles

Illicit Use of Drugs

Infant deaths, suicide, homicide, motor vehicle injury, HIV infection, pneumonia, hepatitis, endocarditis

* Microbial agents refer to the bacteria and viruses that lead to infectious and parasitic diseases.

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Primary Prevention: Strategy for Change

A Prevention-Oriented Community Health Approach to Reducing Inequities

Lets take another step...


ENVIRONMENT

EXPOSURES & BEHAVIORS

Examples of Community Conditions


People affected by health inequities more frequently live in environments with:  Toxic contamination and greater exposure to viral or microbial agents in the air, water, soil, homes, schools and parks  I nadequate neighborhood access to health-encouraging environments including affordable, nutritious food; places to play and exercise; effective transportation systems and accurate, relevant health information  Violence that limits the ability to move safely within a neighborhood, increases psychological stress and impedes community development  Joblessness, poverty, discrimination, institutional racism and other stressors Schools with limited resources  T argeted marketing and excessive outlets for unhealthy products including cigarettes, alcohol and fast food  C ommunity norms that do not support protective health behaviors

The Second Step: From Exposures and Behaviors to the Environment The second step back is from Exposures and Behaviors to Environment. The environment includes both root factors (poverty, discrimination, etc.) and community conditions (economic, social and physical). Focusing on the environment presents a tremendous opportunity to prevent illness and injury before onset; the places where people live, work, learn and play have a great influence on health. As a result, the community is a key venue for analysis and intervention. The economic, social and physical elements of communities shape health: community is where policies and practices play out, and communities are a venue in which groups of people can work together to identify and address priority health concerns. Exposures and behaviors can be systematically tracked back to elements in the environment. For instance, tobacco use is related to advertising, the availability of products, economic opportunities, etc. (The specific factors in the community environment are detailed in Chapter 4). In the same way that exposures and behaviors are associated with multiple health conditions, elements in the environment shape multiple exposures and behaviors. For instance, Whats Sold & How Its Promoted is associated with tobacco use, alcohol consumption, diet and activity patterns, and the presence of firearms. By focusing on factors in the community environment, multiple exposures and behaviors can be addressed, improving the health and safety of the entire community.

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Chapter 3 Recap:

Prevention Works!
Smoking Restrictions
In the early 1980s two cities limited smoking in sections of restaurants and public spaces, and these laws in Berkeley and San Francisco were initially dismissed as fringe tactics from out-of-the mainstream communities. Then a coalition formed to change the law in a more moderate county and its 18 different cities. Before long, the partnership between public health, the American Cancer Society, and the American Heart and Lung Associations became a model replicated in numerous spots across California, and then throughout the United States. Organizations and businesses started voluntarily restricting smoking, something they previously would have been reluctant to do. Although the initial regulation of space was limited (e.g., restaurant smoking areas), these efforts signaled a new norm.

 e environment shapes exposures and behaviors which Th influence health and safety outcomes.  aking two steps to prevention means taking a step back T from health care services (specific illnesses and injuries) to exposures and behaviors. From exposures and behaviors take another step back to the environmentroot causes and community conditionsto get to the root of health disparities and inequities in health and safety.  Two steps demonstrates how the environment holds the biggest opportunity for reducing health disparities and promoting health equity because the environment directly contributes to or shapes exposures and behaviors that can lead to illness and injury. Chapter 3 Discussion Questions: 1.  Why is it important to look at the environment as well as behaviors? 2.  Why are health care services alone not sufficient to substantially reduce inequities? Answers to Chapter 3 Discussion Questions: 1.  It is important to look at the environment as well as behaviors because the environment directly affects health and safety and behaviors are influenced by the environment. If we take a step back from behaviors to the environment, we can make changes at the population level instead of focusing on individual change. By doing this, we can create healthier situations for the entire community at the same time. 2.  Medical care alone cannot reduce inequities. It is not the primary determinant of health, it only treats one person at a time, and it is usually used once a person is already sick or injured.

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Primary Prevention: Strategy for Change

Understanding the Factors in Community Environments that Shape Health and Safety
Taking two steps leads to the community environment. But how do we begin to understand the environment and its affect on health? Prevention Institute has identified the most critical factors that determine the health of communities. Through an extensive review of literature and research, interviews with key informants and the engagement of a national expert panel, a set of community health factors was identified. The framework, including factors organized into four clusters, is described below. Having all of the factors within these clusters in place in all communities is the goal of prevention-oriented community health, and a vital step toward eliminating health inequities.

4
How do we begin to understand the environment and its affect on health?

COMMUNITY HEALTH FACTORS

Equitable Opportunity

Place

People

Health Care Services

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Equitable Opportunity
This cluster refers to the level and equitable distribution of opportunities and resources. Health goals are advanced when people of all races and ethnicities have equitable opportunities, living-wage jobs and ownership of community assets, and quality education.
1. Racial Justice is characterized by policies and organizational practices in the community that foster equitable opportunities and services for all. It is evident in positive relations between people of different races and ethnic backgrounds.

2. Jobs & Local Ownership is characterized by local ownership of assets, including homes and businesses; access to investment opportunities; job availability and the ability to earn a living wage.

3. Education is characterized by high-quality and available education and literacy development for all ages.

Example of Relationship to health Increases in locally owned businesses are associated with reduced crime, and achieving living wages may be correlated with reduced stress levels and better housing. These factors promote local access to resources, the opportunity to increase local capital that can be reinvested into the community, and stability among residents.

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Primary Prevention: Strategy for Change

Understanding the Factors in Community Environments that Shape Health and Safety

People
This cluster refers to the social and cultural environment, including relationships between people, level of civic engagement and norms, all of which influence health and safety outcomes.
4. Social Networks & Trust is characterized by strong social ties among all people in the community, regardless of their role. These relationships are ideally built upon mutual obligations, opportunities to exchange information and the ability to enforce standards and administer sanctions.

5. Participation & Willingness to Act for the Common Good is characterized by local leadership, involvement in community or social organizations, participation in the political process and a willingness to intervene on behalf of the common good of the community.

6. Norms/Customs are characterized by community standards of behavior that suggest and define what the community sees as acceptable and unacceptable behavior.

Example of Relationship to health Strong social networks and connections correspond with significant increases in physical and mental health, academic achievement and local economic development, as well as lower rates of homicide, suicide, and alcohol and drug abuse. One study showed that children were mentally and physically healthier in neighborhoods where adults talked to each other.

Primary Prevention: Strategy for Change

21

Place
This cluster refers to the physical elements of the community environment in which people live, work, play and go to school.
7. Whats Sold & How Its Promoted is characterized by the availability and promotion of safe, healthy, affordable, culturally appropriate products and services (e.g., food, books and school supplies, sports equipment, arts and crafts supplies, and other recreational items) and the limited promotion and availability, or lack, of potentially harmful products and services (e.g., tobacco, firearms, alcohol and other drugs). 8. Look, Feel & Safety is characterized by a well-maintained, appealing, clean and culturally relevant visual and auditory environment that supports and enhances a public safety presence through collaborative efforts that promote safe routes throughout the neighborhood, blight removal, adequate lighting, quality-of-life concerns and overall community well-being. 9. Parks & Open Space is characterized by safe, clean, accessible parks; parks that appeal to interests and activities of all age groups; green space; outdoor space that is accessible to the community; and natural/open space that is preserved through the planning process.

10. Getting Around is characterized by the availability of safe, reliable, accessible and affordable methods for moving people around. This includes public transit, walking and biking.

11. Housing is characterized by the availability of safe and affordable housing to enable citizens from a wide range of economic levels and age groups to live within the communitys boundaries.

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Primary Prevention: Strategy for Change

Understanding the Factors in Community Environments that Shape Health and Safety

12. Air, Water & Soil is characterized by safe and non-toxic water, soil, indoor and outdoor air, and building materials. Community design should help conserve resources, minimize waste and promote a healthy environment.

13. Arts & Culture is characterized by a variety of opportunities within the community for cultural and creative expression and participation through the arts.

Example of Relationship to health Poor and inadequate housing is associated with increased risk for injury; violence; exposure to toxins, molds, viruses, and pests; and psychological stress. Alternatively, adequate safe, affordable housing can promote positive health, perceived and real safety, livability within a community and social interaction.

Health Care Services


Adding health care services as the fourth cluster of factors supports a comprehensive and holistic understanding of community health. The two steps framework does not focus on health care services because treating illnesses one person at a time is not the most effective way to positively change the health outcomes of communities. However, equitable access to health care, including for preventive services, whenever it is needed is extremely important. Ensuring that people have access to high-quality, culturally competent care is the final ingredient in fostering healthy communities. Factors in the Health Care Services cluster include preventive services, access, treatment quality, disease management, inpatient services, alternative medicine, cultural competence, and emergency response.

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23

These four clusters constitute a dynamic web of community health factors that operate synergistically to produce the health and safety outcomes within communities. The focus in this manual is on the three non-medical clusters because these are the determinants of health that are most overlooked in prioritizing strategies to improve health and reduce inequities. They are, in fact, complementary with efforts to improve health care access and treatment and provide the most direct route to affect the health of the population. Case studies illustrating the Equitable Opportunity, People and Place clusters can be found in Appendix B on page 57.

Chapter 4 Recap:
 e community environment can be described with four clus Th ters: 1) Equitable Opportunity, 2) People, 3) Place, and 4) Health Care Services.  ithin the four community health clusters, there are 21 factors W that describe specific elements of the community environment. Identifying these specific factors in your community can help you to focus your attention on the factors in the community environment that require prioritized attention.  hile action or attention can be focused on a particular factor W or cluster of factors in the community environment, all factors and clusters operate synergistically to produce healthy and safe communities. Chapter 4 Discussion Questions: 1.  How can a single community health factor consistently have an impact on multiple health conditions? 2.  Looking at the list of community health factors, which ones do you consider to be central to your work? Are there any on which you would like to place more of a focus?

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Primary Prevention: Strategy for Change

Understanding the Factors in Community Environments that Shape Health and Safety

Answers to Chapter 4 Discussion Questions: 1. The community health factor Whats Sold & How Its Promoted in the Place cluster has an impact on multiple health conditions because it involves, for instance, whether a community has access to fresh, healthy and affordable food like fruits and vegetables. Eating easy-access processed foods that are high in fat, calories and sugar without much nutritional value can contribute to the prevalence of health conditions such as heart disease, cancer, stroke and diabetes. 2. Any and all of these factors can be central to the work you do. But you can choose to focus your efforts on a particular community health factor to effect focused change. For example, in Boyle Heights, a neighborhood in Los Angeles, Look, Feel & Safety was an issue. People were not out and about in the community because they didnt have a place where they felt safe to be physically active or socialize. So a local coalition took strides to establish a rubberized jogging path around the local cemetery. Now, more than 1,000 people a day use the path to jog, walk and socialize.

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Exercise: Taking Two Steps to Prevention


Here you can apply what youve just learned about 3. In column B, circle the exposures and behaviors taking two steps and the community health fac- that are most clearly related to the issue. tors. Refer to the instructions and the sample chart 4. In column C, circle the community health facbelow for guidance. tors that are most closely related to the exposures Fill out the chart on the next page using the fol- and behaviors you circled in column B. lowing steps as a guide: 5. Use column D to list elements in a specific community that are examples of the community health 1. Review the completed sample below. factors you circled in column C. For example, if 2. In column A, choose and circle a health issue you circled Arts and Culture in column C, com(Asthma, Depression, High Blood Pressure or munity needs could include a community mural Violence against Youth). project, after-school dance programs and community-organized trips to the theater for seniors.

SAMPLE: DIABETES
A. HEALTH ISSUE
Choose and circle a health issue.

B. EXPOSURES & BEHAVIORS


Circle the factors below that are most closely related to your health issue.

C. COMMUNITY HEALTH FACTORS


Circle the factors below that are most closely related to your health issue.

D. COMMUNITY NEEDS
List specific examples of the community health factors you circled in column C. Choose up to three examples for each factor.

Diabetes

Tobacco use/smoking Diet & inactivity Alcohol Microbial agents Toxic agents Firearms Sexual behavior Motor vehicles Illicit use of drugs Poverty Discrimination

Getting around Parks & open space Arts & culture Social networks & trust Participation & willingness to act for the common good Norms/customs Look, feel & safety Housing Air, water & soil Whats sold & how its promoted Racial justice Jobs & local ownership Education

Getting around:  Drive because there is limited public transportation  Dont walk because no sidewalks  No bike lanes, dont want to get hit by car Parks & Open Space:  Gangs hang out at the park, so I dont feel safe exercising There arent any Whats sold/how its promoted: No supermarkets close by  Corner stores dont have fresh produce  McDonalds is cheaper and more convenient than any healthy option.

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Primary Prevention: Strategy for Change

Understanding the Factors in Community Environments that Shape Health and Safety

A. HEALTH ISSUE
Choose and circle a health issue.

B. EXPOSURES & BEHAVIORS


Circle the factors below that are most closely related to your health issue.

C. COMMUNITY HEALTH FACTORS


Circle the factors below that are most closely related to your health issue.

D. COMMUNITY NEEDS
List specific examples of the community health factors you circled in column C. Choose up to three examples for each factor.

Asthma Depression High Blood Pressure Violence Affecting Youth

Tobacco use/smoking Diet & inactivity Alcohol Microbial agents Toxic agents Firearms Sexual behavior Motor vehicles Illicit use of drugs Poverty Discrimination

Getting around Parks & open space Arts & culture Social networks & trust Participation & willingness to act for the common good Norms/customs Look, feel & safety Housing Air, water & soil Whats sold & how its promoted Racial justice Jobs & local ownership Education

Primary Prevention: Strategy for Change

27

Activity: Communicating Prevention Putting The Framework Together And Making It Your Own
Now that you have had the opportunity to think about prevention, a two steps approach, and the factors in communities that produce health inequities and health outcomes, this activity gives you the chance to put these concepts together. Putting the Framework Together On this page are seven talking points. On the facing page are seven images. Match the image to the best-suited talking point. Weve done the first one for you; only six left!

 systematic process that promotes healthy behaviors and environments and reduces the likeliA hood or frequency of an injury or illness.  ealth inequities are not the result of different illnesses or different injuries, but rather the same H injuries and illnesses, only more severe and more frequent.  n order to substantially reduce health inequities and improve the health of communities, it is I necessary to take two steps back from health care services to exposures and behaviors that shape patterns of illness and injury, and then to the factors in the environment that influence exposures and behaviors.  onsideration of the effect of the environment on health tends to focus on toxins in the air we C breathe, the water we drink and the soil in which we grow our food. But the environment also has a profound influence on behavior, which in turn affects health.  ese are five of the leading Causes of Death in the United States and, not incidentally, five Th of the leading sources of disparities. Each of these conditions can be traced back to exposures and behaviors.  ere are four clusters of factors that shape the community health environment. This framework Th provides an overview of what needs to be in place in healthy communities and also a tool for identifying community priorities.  xposures and behaviors influence multiple illnesses and injuries. Applying resources to E improve exposures and behaviors results in improved outcomes for multiple conditions.

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Primary Prevention: Strategy for Change

Understanding the Factors in Community Environments that Shape Health and Safety

A
Equitable Opportunity Place

B
EXPOSURES ENVIRONMENT BEHAVIOR

HEALTH

People

Health Care Services

MORE SO
E
DIET & ACTIVITY PATTERNS

The SAME INJURIES AND ILLNESS, ONLY

PRIMARY PREVENTION
F

HEART DISEASE CANCER

Tobacco

STROKE DIABETES

Take 2 steps to prevention


ENVIRONMENT EXPOSURES & BEHAVIORS HEALTH CARE SERVICES

XXXXXXX

INJURY & VIOLENCE

HEART DISEASE CANCER STROKE DIABETES INJURY & VIOLENCE

Primary Prevention: Strategy for Change

29

Making It Your Own Now that you have had the chance to match images with talking points, create a short presentation advocating for a prevention-oriented approach to community health using these seven images. Think about how you want to start, possibly include a personalized introduction, and dont be constrained by the given talking points. Feel free to be as creative as you wantconnect the concepts to work being done at your organization, tell a personal story or rework concepts from this manual. (Sample order: E B C G F A D)

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Primary Prevention: Strategy for Change

Conclusion
Promoting health equity is imperative: it is fundamentally an issue of morality and equality. Health is the foundation of functioning families, communities and economies, and inequities in health undermine individual potential and ability to participate politically, socially and economically. How do we improve the health of everyone in communities, particularly those in communities with the most severe and frequent poor health and safety outcomes? In order to create lasting change, we need a new way of thinking about health. Health care services are vital to maintaining health but cannot be our sole investment. The most efficient and effective process for improving the health of all of Californias diverse populations is to address the factors in our environments that are causing illness and injury in the first place. For instance, rising rates of type II diabetes are due to changes in diet and activity patterns. Those diet and activity patterns, in turn, are shaped by factors in our environments such as access to healthy food, walkability of streets and norms of behavior. With diabetes, as with so many conditions, strategies that improve community environments have a positive impact on those with the disease, those at high risk and those at low risk, and also have a positive effect on other diseases (a welldesigned park is a venue for physical activity for all members of a community and a strategy to reduce diabetes, heart disease, stroke, etc.). This is an emerging way to think about health and, as such, requires new language and carefully constructed processes to develop strategy and engage the diverse set of necessary stakeholders. Part Two of this manual builds upon the foundation laid in Part One by exploring more specifically the development of comprehensive and strategic approaches to address contemporary health issues.

5
In order to create lasting change, we need a new way of thinking about health.

Primary Prevention: Strategy for Change

31

ENDnotes: PART ONE


1. House & Williams, 2002. 2. The Future of the Publics Health in the 21st Century. Institute of Medicine, 2003. 3. Ibid. 4.  Adler, N.E.; Newman, K. Socioeconomic Disparities in Health: Pathways and Policies. Health Affairs, 21(2): 6076, 2002. 5. Blum, H., 1983. 6.  C aplan, R.; Rodberg, L. Rx: Federal Support for Community Health: An Innovative, Community-Based Approach to Preventive Health. In Context, p. 58, 1994. 7. Geiger, H.J. The Unsteady March. Perspectives in Biology and Medicine, 48: 19, 2005. 8. U.S. Department of Transportation, 1999. 9. Ibid. 10.  S ixth Report to Congress, Fourth Report to the President: The National Initiative for Increasing Safety Belt Use. Washington, D.C.: National Highway Traffic Safety Administration (NHTSA), June 2004. 11. Kahane, C.J. An Evaluation of Child Passenger Safety: The Effectiveness and Benefits of Safety Seats . Washington, D.C.: National Highway Traffic Safety Administration, 2001. 12. Solomon, Lead & Nissen, 2001. 13. NHTSA, 2002. 14. National Center for Statistics and Analysis, 2004. 15. New York State Department of Health, 2006. 16. Whitehead, M. The Concepts and Principles of Equity and Health. Copenhagen: WHO Regional Office for Europe, 1990. Available at: http://whqlibdoc.who.int/ euro/-1993/EUR_ICP_RPD_414.pdf. Accessed on May 1, 2009. 17. Adler & Newman, 2002. 18. Build Environment Profiles, PI. 19.  Morland, K.; Wing, S.; Diez Roux, A.; Poole, C. Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places. American Journal of Preventive Medicine, 22: 239, 2002. 20.  G eronimus, A.T. Understanding and Eliminating Racial Inequalities in Womens Health in the United States: The Role of the Weathering Conceptual Framework. J Am Med Womens Assoc, 56:1336, 149 50, 2001. 21.  Mental Health: A Report of the Surgeon General . Rockville, MD: U.S. Department of Health and Human Services, 1999. Supplement: Mental Health: Culture, Race, and Ethnicity. 22.  Husain, A. Psychosocial Stressors of Asthma in InnerCity School Children. APHA poster presentation at: Putting the Public Back into Public Health: 130th APHA Annual Meeting, Philadelphia, PA, November 913, 2002. 23.  McGinnis, J.M.; Foege, W.H. Actual Causes of Death in the United States. Journal of the American Medical Association, 270(18): 22012, 1993. 24.  Blum, H.L. Social Perspectives on Risk Reduction. Family and Community Health, 3: 4150, 1981. 25. Giles & Liburd, 2007. 26.  Institute of Medicine. Promoting Health: Intervention Strategies from Social and Behavioral Research . Washington, D.C.: The National Academies Press, 2000. 27.  Bunker, J.P.; Frazier, H.S.; Mosteller, F. Improving Health: Measuring Effects of Medical Care. The Millbank Quarterly, 72(2): 22558, 1994. 28. Institute of Medicine, 2000. 29. McGinnis & Foege, 1993.

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Primary Prevention: Strategy for Change

PART TWO

Developing Comprehensive Strategies: Using the Spectrum of Prevention

Introduction
Part One focused on identifying factors that shape inequities in health and safety in communities; Part Two focuses on designing strategies to address prioritized factors. You will explore how to develop comprehensive approaches using the Spectrum of Prevention* to apply prevention to contemporary health and safety issues. The Spectrum of Prevention is a tool for changing systems, norms and environments and builds on local knowledge about the factors that affect health and safety.

1
Intellectuals solve problems; geniuses prevent them.
Albert Einstein

Objectives
Part Two is designed to:  iscuss the importance of comprehensive strategies and success D ful examples  ntroduce the Spectrum of Prevention as a tool to design strate I gies that have the greatest impact on reducing health inequities  uild skills in utilizing the Spectrum of Prevention to develop a B multifaceted, comprehensive plan

* The Spectrum of Prevention was originally developed by Larry Cohen in 1983 while working as director of prevention programs at the Contra Costa County Health Department. It is based upon the work of Dr. Marshall Swift in preventing developmental disabilities.

Primary Prevention: Strategy for Change

35

2
In order to achieve change that substantially improves health and safety, comprehensive strategies that engage a broad array of stakeholders are essential.

Developing Comprehensive Strategies


Multiple factors determine the health and safety of communities. In order to achieve change that substantially improves health and safety, comprehensive strategies that engage a broad array of stakeholders are essential. Multifaceted activities and multisectoral partnerships can operate synergistically to support healthier communities.

A Contemporary Example
The change in rates of breastfeeding is an example of synergy that can develop among multiple activities. Breastfeeding is beneficial for boosting an infants immune system, is considered the best form of nutrition for infants, and has been correlated with lower rates of a number of conditions later in life, including diabetes and asthma.i A century ago, nearly 100 percent of babies were breastfed. By 1971, only 24 percent of mothers initiated breastfeeding.ii Rates declined dramatically for a number of reasons, including lack of accommodations for working mothers who were breastfeeding, social mores about the acceptability of breastfeeding in public, the advice of clinicians, and the development and marketing of baby formula as a primary source of infant nutrition.iii Today, the rates of breastfeeding have rebounded, with the percentage of infants who were ever breastfed at over 70 percent.iv What changed? Write down three factors that you think have contributed to recent changes in rates of breastfeeding: 1. 2. 3. There are many potential answers to this question. Some of the key factors include changes in awareness about the health benefits of breastfeeding, community advocates creating support networks for breastfeeding mothers, improved technology (e.g., pumps), policies that support breastfeeding in the workplace, and changes in practices at hospitals.
36

Primary Prevention: Strategy for Change

Developing Comprehensive Strategies

Making progress requires more than simply helping mothers develop the skills to successfully breastfeed. It requires a comprehensive approach that not only changes parental skill levels and experiences with clinicians, but also creates environments that support breastfeeding.

Persistent Inequities
The movement to improve breastfeeding rates is far from over. Comparative statistics demonstrate that there are inequities in breastfeeding among racial, ethnic, and economic groups. For instance, in California, the rate of exclusive breastfeeding among white women (63.6%) is nearly twice the rate for African American (33.1%) and Hispanic (32.4%) women. Studies have demonstrated that hospital policies directly influence breastfeeding rates and that economic and racial inequities in breastfeeding are reflected in the policies of hospitals that tend to serve more affluent mothers versus those that serve lower-income women of color.v Outside of the hospital, factors such as limited maternity leave and community facilities without breastfeeding accommodations may create barriers disproportionately for women from low-income neighborhoods and communities of color. As sociologist John Retsinas noted, While it is known that breastfeeding is better, our society is not structured to facilitate that choice.vi Groups such as WICthe Special Supplemental Nutrition Program for Women, Infants and Children funded by the U.S. Department of Agriculture to improve birth outcomes and early childhood healthhave prioritized breastfeeding for low-income women and children.vii

The Influence of Marketing


Advocates cite corporate advertising as one of the barriers to increasing breastfeeding rates. Corporations have invested heavily in the promotion of formula as providing superior infant nutrition and meal-time convenience; Dr. Derrick Jellife coined the term commerciogenic malnutrition to describe the impact of industry marketing practices on infant health (Baby Milk Action, n.d.). The international Nestle boycott, and the media attention it engendered, created large-scale awareness of the role that formula producers played in changing norms around breastfeeding and pointed out that shifting rates were not simply a matter of unfettered individual choice.

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Introducing the Spectrum of Prevention


The Spectrum of Prevention offers a systematic framework for developing effective and sustainable primary prevention approaches. The Spectrum identifies six levels of intervention and helps advocates, professionals and policymakers advance beyond employing a single tactic to address a complex problem. The Spectrum is a framework for a comprehensive understanding of prevention that moves from providing information to changing norms, systems and environments. At each level, the most important activities that can achieve specific prevention goals should be identified. As these activities are identified they can help inform interrelated actions at other levels of the Spectrum.

SPECTRUM LEVEL
6. Influencing Policy and Legislation Developing strategies to change laws and policies to influence outcomes in health and safety 5. Changing Organizational Practices Adopting regulations and procedures to improve health and safety and create new standards for organizations

4. Fostering Coalitions and Networks Convening groups and individuals for broader goals and greater impact

3. Educating Providers Informing providers who will transmit skills and knowledge to others or become advocates for your goal 2. Promoting Community Education Reaching groups of people with information and resources to promote health and safety 1. Strengthening Individual Knowledge and Skills Enhancing an individual's capacity to prevent injury or illness and promote health and safety

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Primary Prevention: Strategy for Change

Developing Comprehensive Strategies

Applying the Spectrum to a Contemporary Issue


Breastfeeding is affected by a variety of complex factors including social norms, economic circumstances and institutional policies and practices. As covered in Part One, changing behavior requires changing environments. With that in mind, consider environments that promote breastfeeding and answer the following questions about developing strategies at each level of the Spectrum.

SPECTRUM LEVEL
6.  Influencing Policy and Legislation What is one example of a local or state policy that supports breastfeeding? (Challenge yourself: identify a potential new policy that would promote positive breastfeeding environments) 5. Changing Organizational Practices What is one potential hospital practice and one potential workplace practice that would support breastfeeding? 4.  Fostering Coalitions and Networks Who are four potential members of a local coalition striving to create work sites that support breastfeeding? 3. Educating Providers Who are two different groups of providers that could have a substantial impact on breastfeeding environments?

EXAMPLE
1.

1. 2.

1. 2. 3. 4. 1. 2.

2.  Promoting Community Education What is one potential strategy to reach large groups of people with the message that breastfeeding is important? 1.  Strengthening Individual Knowledge and Skills What is one potential strategy to strengthen knowledge and skills that support new mothers in initiating breastfeeding?

1.

1.

Primary Prevention: Strategy for Change

39

SPECTRUM LEVEL
6.  Influencing Policy and Legislation What is one example of a local or state policy that supports breastfeeding? (Challenge yourself: identify a potential new policy that would promote positive breastfeeding environments) 5. Changing Organizational Practices What is one potential hospital practice and one potential workplace practice that would support breastfeeding? 4.  Fostering Coalitions and Networks Who are four potential members of a local coalition striving to create work sites that support breastfeeding?

SAMPLE ANSWERS
1. Lactation accommodations in workplaces 2. Subsidized breast pumps 3. Tax breaks for breastfeeding mothers 4. L  ocal, state and federal policies to protect a womans right to breastfeed in public

1. Break time for employees to pump 2. Unless medically necessary, no formula provided at hospitals 3. Adequate maternity leave

1. Labor union 2. Public health department 3. La Leche League 4. Doctor 5. Hospital 6. Parents

3. Educating Providers Who are two different groups of providers that could have a substantial impact on breastfeeding environments?

1. Employers 2. Nurses 3. Day care providers 4. Grandparents 5. Childrens store employees

2. P  romoting Community Education What is one potential strategy to reach large groups of people with the message that breastfeeding is important? 1. S  trengthening Individual Knowledge and Skills What is one potential strategy to strengthen knowledge and skills that support new mothers in initiating breastfeeding?

1. Breastfeeding posters in workplaces 2. Hold feed ins in restaurants, parks and other highly visible venues

1. Training community lactation consultants 2. Support groups for new parents 3. Training employers on effective strategies for supporting breastfeeding employees

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Primary Prevention: Strategy for Change

Key Aspects of the Spectrum of Prevention


Developing Comprehensive Strategies The Spectrum is not intended for use sequentiallyidentify actions from levels 1 to 6 in ascending order or vice versa; it is a tool for developing a comprehensive set of actions that can be employed together to achieve goals and objectives. Comprehensive strategy means a multifaceted set of activities at multiple levels of the Spectrum that collectively drive substantial changefor instance, a city-wide bike to work day (organizational practice) will be much more successful if a coalition of bicycle advocates is out conducting workshops and publicizing the day (community education) and employers and law enforcement fully support and encourage participation (educating providers). Norms Change The Spectrum can be a powerful tool for designing efforts that change norms. Norms are tipping factors that lead to behavior change. More than habits, often based in culture and tradition, norms are regularities in behavior with which people generally conform.viii Norms rarely, if ever, change based on information and education alone: it requires multifaceted strategies, and policy is often the tipping factor that leads to norms change. Policy change can trigger norms change by altering what is considered acceptable behavior, encouraging people to think actively about their own behavior, and providing relevant information and a supportive environment to promote change.ix The emergence of new norms can result in enduring, sustainable change in health and safety across the population. Data and Evaluation Inform the Spectrum Data and evaluation inform all levels of the Spectrum. Any proposed activity should be based on data showing 1) the issue is important, 2) the target population is appropriate, and 3) the intervention is promising. To develop a successful approach, it is essential to first review the data and determine an appropriate set of objectives. During implementation, ongoing evaluation of the overall approach and the individual activities at each level of the Spectrum will provide the information necessary for making adjustments to the activities in order to meet overall objectives.

3
The Spectrum can be a powerful tool for designing efforts that change norms.

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41

Synergy of the Spectrum A well-designed strategy, while responsive to opportunities at specific levels of the Spectrum, always considers action at all levels. This doesnt necessarily mean that every organization engages in action at every level; organizations can identify their areas of expertise and action and then form relationships with others who can take complementary action. Engaging in activities at multiple levels simultaneously produces a synergy that results in greater effectiveness than would be possible by implementing any single activity or linear initiative; the activities build off one another by creating messages and engagement among different constituencies and creating the momentum for change from multiple directions. The efforts of the Community Coalition in South L.A., described in the following sidebar, are a good example of synergy: multiple strategies mutually reinforcing one another. The Spectrum is a Tool for Both Strategy Development and Evaluation The Spectrum can be used both to develop an initial response to a problem and also to evaluate existing prevention efforts. As information and data become available about the relative success of strategies, the Spectrum can be used to examine the strategies used and identify gaps (such as the need for greater coordination), and emerging opportunities (such as new policies or potential partnerships).

CHAPTER 3 RECAP:
 e Spectrum of Prevention is a tool to develop comprehensive Th strategies to change the community environment.  e Spectrum of Prevention is a tool to change norms and envi Th ronments.  e Spectrum is a tool for both strategy development and evalu Th ation. Data and evaluation inform the Spectrum. There is synergy across levels of the Spectrum.

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Primary Prevention: Strategy for Change

Key Aspects of the Spectrum of Prevention

Community Coalition, Los Angeles, California


First Steps for Change
In 1990, Karen Bass, a long-time civil rights activist, was working as a physicians assistant at L.A. County General Hospital. Bass realized she was spending her days and nights sewing up bullet wounds and decided something had to be done. A conference on the impact of crack in African American communities brought people together, both strengthening individual knowledge and promoting community education, and participants joined Bass in forming a coalition. The Community Coalition began to look for possible solutions and went straight to community residents for advice. They promoted community education by distributing flyers, talking to people door-to-door, researching the liquor store industry, and holding neighborhood meetings. They educated providers by approaching liquor store owners to let them know about community complaints and ask them to clean up or close stores that had high levels of crime, violence or vice associated with them and sent a petition with 30,000 signatures to Mayor Tom Bradley. They developed individual knowledge and skills by training advocates to write letters, understand the permitting process and pressure elected officials.

Objectives Achieved
In 1992, every single one of the 24 liquor stores slated for presentation to the planning committee for revocation of permits was burned down in the L.A. riots. The citys response to the destruction of businesses was the Rebuild LA Campaign, which aimed to fast track rebuilding by removing bureaucratic barriers. The Community Coalition focused on influencing policy by discouraging the city from pursuing redevelopment for liquor stores. That approach is okay with churches, schools and housing, but not with liquor stores, says Harris-Dawson. In only three years, the Community Coalition prevented the re-opening of the 24 liquor stores it had originally targeted before the 1992 L.A. riots, and shut down nearly 200 operating liquor stores in South Los Angeles.

Engaging the Community in a Solution


Using a door-to-door survey of nearly 30,000 residents, the Community Coalition asked community members what they thought should be done to reduce drug- and alcohol-related crime and violence. Much to the Coalitions surprise, respondents overwhelmingly recommended reducing the number of liquor stores in the community. As interim Executive Director Marqueece Harris-Dawson explained, We were surprised. The staff fully expected the issues to be around drug houses or gang-related violence. We wouldnt even have looked at liquor stores if we didnt do a resident survey. (Data informing action)

Knowledge Moving to Action


Prior to the Coalitions work, South L.A. (population 820,000; 71.3 square miles) had over 700 liquor storesmore than the entire state of Pennsylvania (population 12,281,054; 44,820 square miles). Looking to influence policy, the group decided to take advantage of Los Angeles Countys conditionaluse permits for liquor stores to seek closures of nuisance establishments. Based on neighborhood dialogues and evidence of crime and illicit behavior, they quickly identified 24 liquor stores as primary targets, and then launched a grassroots/direct advocacy campaign to get decision makers to act.

Evaluation
An analysis of public statistics indicated that there has been an average 27 percent reduction in violent crime/felonies, drug-related felonies or misdemeanors, and vice (e.g., prostitution) within a four-block radius of each liquor store that was closed.

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Chapter 3 Discussion Questions: 1.  What is the relationship between policy change, norms, and behavior? 2. Why is Changing Organizational Practices important? 3. Why employ strategy at multiple levels of the Spectrum? 4. When should the Spectrum be utilized? Answers to Chapter 3 Discussion Questions: 1.  Policy change often operates as the tipping factor in changing norms and norms, in turn, are a tipping factor for changing behavior. 2.  Changing Organizational Practices is important because key organizations, such as law enforcement, health departments, media, faithbased institutions, businesses and schools, make decisions and have practices that affect the health and safety of the greater community. This is often the least understood and most ignored component of the Spectrum, yet this level has enormous potential. By changing internal regulations and norms, organizations can affect the health and safety of their members, employees, customers, etc. and can set a precedent for other institutions. 3.  In order to create sustainable change that affects the community environment, it is necessary to employ a multifaceted strategy wherein activities at multiple levels of the Spectrum have synergy and build off each other. 4.  The Spectrum can be utilized to a build a new strategy to address a health, safety or equity issue or to evaluate and improve an existing strategy. It can also be used by single organizations to strategize and evaluate or by collaboratives and coalitions.

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Primary Prevention: Strategy for Change

Levels of the Spectrum in Detail


Strengthening Individual Knowledge and Skills
This level focuses efforts on activities that bolster individual knowledge and skills. One example is ensuring that information about preventing illness and injury is readily available; literature (including brochures, curricula and manuals on preventing violence) has built individual knowledge and skills around what aggressors, victims and bystanders can do to prevent violence. A more active way to convey information would be to provide training and create dialogue rather than simply providing literature. However, action at this level also includes building the capacity of individuals to take action to change their environments. For instance, training community members on how to write letters to the editor and how to advocate with elected officials leads to broader community-level change. A Look at Strengthening Individual Knowledge and Skills In Los Angeles, Community Action to Fight Asthma (CAFA) identified slum housing as a primary cause of both lead poisoning and asthma. As Jim Mangia, CEO of St. Johns Well Child and Family Center and director of the Los Angeles affiliate of the statewide CAFA network put it, Our children are essentially being poisoned to death, and there is a percentage of landlords who are making money off the poisoning of our children. Only by criminalizing slum housing, by making that policy shift happen, are we going to make a real impact. CAFAs Los Angelesbased coalition has trained and organized tenants to advocate for change and to file lawsuits (with the Los Angeles City Attorney) holding landlords accountable for slum housing conditions. As a result, numerous repairs and renovations have been completed.

4
In many cases, important state and national policy begins as local policy.

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Opportunity for Application: Identify two actions that could be taken at this level of the Spectrum to reduce violence against teens in a community: 1.

2.

PROMOTING COMMUNITY EDUCATION


This level entails reaching an entire population with information and resources in order to promote health and safety. Typically, many health education initiatives focus on holding health fairs and conducting community forums and events. Such one-time exposures can be a valuable element of a broader campaign, but often dont create lasting change on their own. Other options for community education include public messages encouraging healthy behavior (e.g., signs encouraging taking the stairs), holding attention-grabbing events (e.g., Berkeley, Californias Public Health Department sponsored an event to enter the Guinness Book of World Records for the largest number of breastfeeding mothers in history), and using media (not only the mainstream news media) and the arts. A Look at Promoting Community Education Ivan Juzang of MEE Productions points out that word-of-mouth can be a powerful and effective tool: Its the best advertising money cant buy. Creating positive word-of-mouth allows prevention messages to live on, even after a formal campaign is over, as community members take ownership of the message and begin to initiate their own activities that support it.x Opportunity for Application: Identify two actions that could be taken at this level of the Spectrum to reverse increasing rates of HIV/AIDS in a community: 1.

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2.

EDUCATING PROVIDERS
This level of the Spectrum involves educating and enlisting the support of providersthose who through formal professional roles, or sometimes more informal positions or relationships, provide services or support, and can be key actors in improving conditions, policies and practices that support health, safety and equity. Because health care providers are seen as a primary source for health-related information, they are often identified as a key group to reach with strategies for prevention. Teachers and public safety officials are also frequent targets for outreach. However, the notion of providers, who can have a role in creating environments that prevent illness and injury, can be approached more broadly. Providers extend beyond the usual suspects to also include faith leaders; postal workers and other public servants; business, union, and community leaders; barbers; cashiers; bartenders; produce managers; and so on. A Look at Educating Providers In a small town in Texas, WIC (Special Supplemental Nutrition Program for Women, Infants and Children) caseworkers realized that many of their clients were not using their food vouchers. The caseworkers responded by interviewing women in the program. They found that one of the consistent factors was the stigma associated with using vouchers. For example, grocery store clerks would have negative body language when women used the vouchers and make comments that made clear their displeasure at having to process the vouchers. In response to this finding, WIC staff developed training for local grocery store employees that started from the perspective, Do you care about the young moms and their kids? How would you like to do something to support them? WIC staff educated clerks about the services that WIC provided for women and children, emphasizing its value in supporting healthy children in the community. They trained clerks specifically on how to positively reinforce the use of vouchers by smiling and saying kind words as women were checking out at the cash register. Clerks were also trained to provide nutritional information to encourage healthy choices.

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Opportunity for Application: Identify two actions that could be taken at this level of the Spectrum to increase the consumption of fresh fruits and vegetables in your community: 1.

2.

FOSTERING COALITIONS AND NETWORKS


Level four of the Spectrum, Fostering Coalitions and Networks, focuses on collaboration and community organizing. Collaborative approaches bring together the participants necessary to ensure an initiative's success and increase the "critical mass" behind a community effort. Coalitions and expanded partnerships are vital in efforts to address complex health, safety and equity issues. The metaphor of a jigsaw puzzle is fitting: each piece has value, but they take on a greater significance when put together. Collaboration is not an outcome per se, like the other levels of the Spectrum, but rather a method used to achieve an objective. Collaborations may have participants from several levels: (a) at the community levelincluding grassroots partners working together in community organizing; (b) at the organizational levelincluding nonprofits working together to coordinate the efforts of business, faith or other interest groups; and (c) at the governmental level, with different sectors of government linking with one another. Often the most effective coalitions and networks are made up participants from all three levels coordinating action. A Look at Fostering Coalitions and Networks The Violence Prevention Coalition of Greater Los Angeles (VPCLA) is a network of organizations and individuals dedicated to addressing violence as a public health epidemic. Formed in May 1991 by the Los Angeles County Department of Health Services, the coalition represents a cross-section of concerned individuals from public and private organizations including public health agencies, schools, universities, law enforcement, the judiciary, community-based organizations, the medical community, hospitals, entertainment, media and the community. The
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What Do a Walking Group of Latino Parents and an Obesity Prevention Task Force Have in Common?
When Get Moving Kern, a coalition of organizations focused on healthy eating and active living, was chosen as the community partner for The California Endowments Central California Regional Obesity Prevention Program (CCROPP) in October 2006, it was required to set up a task force including local residents to work with the local health department. I didnt want to just set up a task force of organizations and then ask a few residents to come be a part of our group after an agenda had already been set, says Jennifer Lopez, healthy living outreach facilitator for Get Moving Kern. I really wanted to start with a coalition of residents. So, I looked around at what was already happening in our community and I found a group of parents who first met at a nutrition class and had decided that a good way to keep in touch was to start walking together. Out of an initial conversation, two walking group leaders stepped up to meet the challenge of leading a resident task force, the Greenfield Walking Group. They began inviting more residents to join them to discuss the kind of policies or changes to their environment that would make it easier to eat healthy and be active. The group decided to conduct a walkability assessment of the local park. Everyone had a horror story about the park. The walkability assessment gave them an opportunity to share their stories with the people who could help them develop solutions, remarked Lopez. Participants mapped out where they had encountered barriers to walking and playing in the park with their families: rampant graffiti, street lights and park lights shot out, stray dogs, hypodermic needles, gang recruitment, dangerous traffic and violence. The Greenfield Walking Group worked with city staff to address these issues. Relationship building was crucial. It helped the residents get to know the people they would need to call on from animal control, graffiti abatement, parks and recreation, law enforcement and public works in order to maintain park improvements. Greenfield Walking Group members also partnered with their local school district and identified a need for after-school physical activity opportunities for children in kindergarten to third grade. The group sat down with school district administrators and after-school staff, and what emerged was the adoption of new policies to increase opportunities for healthy eating and active living throughout the district. Lopez feels that things seem to be coming together so quickly for the Greenfield Walking Group because the families are at the center of identifying the problems and their solutions. It is a power shift for us as professionals in the field to consider these neighbors as the true experts of their communities, but if we can respect that, the motivation for change is powerful on all fronts, advises Lopez. As the group worked to address barriers to physical activity, they also identified other key issues undermining the health and safety of community residents such as poor air quality, unhealthy food, and lack of affordable health insurance. As a result, group members have also made their voices heard on statewide legislation that could improve air quality, make health care affordable and require restaurants to post nutrition information on menus. The Greenfield Walking Group now provides technical assistance to residents and organizations throughout Kern County on how to transform their communities.

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coalition seeks to identify social policies and processes that can prevent, control and reduce this costly health problem. The major accomplishments of the coalition range from creating a 900-member base representing the private and public sectors, public activities such as Dance for Peace and basketball tournaments, and playing an instrumental role in the passage of the first ban on .50 caliber sniper rifles in the city of Los Angeles. Opportunity for Application: Identify two actions that could be taken at this level of the Spectrum to prevent the onset and therefore reduce high rates of type II diabetes in a community: 1.

2.

CHANGING ORGANIZATIONAL PRACTICES


Organizational Functions
Each of these functions presents an opportunity for analysis and potentially changes in practice that support health, safety and equity: Governance Personnel Training Programs and services  Outreach, communications and external relations Contracting and purchasing Advocacy  Resource development/ Revenue generation

Changing Organizational Practices deals with reshaping the general practices of key organizations that can have widespread impact by affecting health and norms. Such change reaches, and serves as a model for, the members, clients and/or employees of the organization as well as the surrounding community. In many cases, changing organizational practices is more easily or immediately achievable than policy change and can provide the testing ground for broader public policy. Government and health institutions are key places to make change because of their role as standard setters. Other critical arenas include media, business, sports, faith organizations, and schools. Nearly everyone belongs to or works in an organization, so this approach provides collaborators an immediate place to initiate change. A Look at Changing Organizational Practices Health Care without Harm is a campaign for environmentally responsible health care comprising more than 440 organizations worldwide. Their goal is to transform the organizational practices of the health care industry so that it is no longer a source of harm for people and the environment. Some of the campaigns objectives include making medi-

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Levels of the Spectrum in Detail

cine mercury-free, reducing waste produced by hospitals, using safer plastics and closing incinerators. These shifts in hospital practice can have a profound impact on the health of the communities in which health care institutions are located, both directly by reducing harmful exposures and indirectly by communicating standards of healthy practice to other community institutions. As very visible health institutions, hospitals and medical offices can play a key role in supporting healthy norms by setting an example that other institutions will follow. Opportunity for Application: Identify two actions that could be taken at this level of the Spectrum to prevent triggers and reduce high rates of asthma in low-income communities: 1.

Library Cards for All


In response to the correlation between illiteracy and violence, the libraries and schools in the city of Salinas, California adopted simple yet innovative changes in practice that resulted in more young people reading, engaging in meaningful opportunities, having a safe place to gather and connecting with their community. The libraries and schools partnered to provide all students with library cards, free of charge and applicationfree. Further, the libraries eliminated fines and fees for the first year to enable students to learn about using the library. Since the change, the libraries have seen a significant increase in library usage by young people and their families. Moreover, changes such as those enacted have the potential to create a stronger sense of the importance of libraries in the community, a constituency for libraries, and a norm that young people and their families read together. When the city considered cutting funding to libraries the community response was swift, and bolstered by the argument that libraries are a violence-prevention strategy.

2.

INFLUENCING POLICY AND LEGISLATION


The sixth level of the Spectrum, Influencing Policy and Legislation, has the potential for achieving a broad impact across a community. Policy is the set of rules that guide the activities of government or quasi-governmental organizations. As noted in a 2000 report by the Municipal Research and Services Center of Washington, Policy making is often undervalued and misunderstood, yet it is the central role of the city, town, and county legislative bodies. Thus, policy sets the foundation or framework for action. By mandating what is expected and required, sound policies can lead to behavior change on a community-wide scale that may ultimately become the social norm. Over the course of the last several years, major health and safety improvements have occurred as a result of policy change, including a reduction in diseases associated with tobacco consumption, a decrease in workplace injuries and roadway crashes due to dramatically greater use of safety equipment, and reductions in exposure to lead.

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Although policy is frequently thought of as either state or federal, highly effective prevention policy can be developed on the local level, and that local policy development can be integral to improving health and safety. In fact, in many cases, important state and national policy begins as local policy. A Look at Influencing Policy and Legislation The city of Richmond, California, is one of the first cities in the country to draft a comprehensive general plan element that addresses the link between public health and community design. Nearly 40 percent of Richmonds residents live in poverty and over 60 percent are African American and Latino. This draft element addresses health impacts of community design decisions, such as zoning, on all Richmond residents as well as the historic impacts on low-income communities and communities of color, which share a disproportionately higher burden of negative health impacts. The Richmond General Plan considers factors such as physical activity, nutrition, non-motorized travelers safety, hazardous materials and contamination, air and water quality, housing quality, preventive medical care, homelessness and violence, among others. General plans are mandated for every city and county in California and typically cover a 20- to 30-year time period. Local authorities, either the planning commission and city council for cities, or the board of supervisors for counties, must adopt a general plan. In practice, most local authorities appoint committees of residents to inform the process. In California, the Governors Office of Planning and Research issues guidelines for development of these plans, including the various elements that must be involved. Other states have similar requirements (and often refer to these plans as Master Plans). To date, elements directly addressing the health and justice implications of community design have never been included in the guidelines, but they are gaining attention. Opportunity for Application: Identify two actions that could be taken at this level of the Spectrum to prevent type II diabetes in youth: 1.

2.

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Levels of the Spectrum in Detail

Community Engagement and the Spectrum of Prevention


Community engagement is a critical component of any effort to achieve health equity and, therefore, community members should be engaged in identifying priorities and strategies at every level of the Spectrum. Too often, community engagement is tacked on to initiatives in a superficial manner, whereas it should be built in from the beginning of any comprehensive effort. Community-based organizations, the faith community, local businesses, and community residents including youth and grassroots activists all have a vital role to play in efforts to improve health. Their engagement, input and leadership are critical from the outset in defining the problem and prioritizing strategies. Then, participation in implementation helps ensure accountability and that planning, programming and policies align closely with community needs. America Braccho, executive director of Latino Health Access, is a leading advocate for the role of community participation in moving a public health agenda forward and improving the lives of people in underresourced communities. Below are excerpts of her comments on a panel presentation marking the release of Health for All: California's Strategic Approach to Eliminating Health Disparities. When we talk about community participation, and when we really truly involve the community in these strategies, the community keeps us more accountable than anything elseNo one can make a promise more accountable than a mom who is committed to a program for her kids. When they are involved, this is not going to disappear when funding goes away. So this really is what makes programs accountable. Community participation, when its real, is your main investment in accountability. Its your main investment in sustainability. So community participation is when, truly, you involve people in creating a mechanism for themselves to define change. When we stop defining change completely, and we become part of the team defining change. When we acknowledge that there is a group of residents that live in that community that has asthma, and is dying of injuries and all of that, and we think that they could have a voice, and need to have a voice, and define the change. Community participation, when its done right, also creates a mechanism for people to share assets and talents, to make change possible. Community participation helps people with a voice, helps people with creating mechanisms, helps people to think, which is critical. Communities need to think, so they can engage in action. And what happens when we engage in action is that people think again. And then people engaged in actions are more focused, more directed, with more resources, because now they are learning. And you know what happens when people think and change and things actually change? Then people become hopeful. Nothing of what we are doing can be done if we remain without hope in these communities. What fuels the interventions in these communities is the hope of that mom or of that dad.

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5
Sustainable change is possibleprevention does work.

Conclusion
Substantially improving health outcomes in communities is a complex task. There are often financial, historical, ideological and cultural barriers to change, not to mention the power of inertia. Nonetheless, sustainable change is possibleprevention does work. It requires attention to the underlying factors that are shaping patterns of illness and injury, and the development of comprehensive strategies. Both of these steps require careful planning and prioritization and strong partnerships: taking the time to build relationships and to clarify direction and purpose. The tools and frameworks presented in this manual can help to achieve that clarity, to evaluate ongoing efforts, and to provide a framework for sust ainable changes to nor ms and c ommunit y environments.

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Appendices
Appendix A: Seven Key Disparity Facts
1. Racial Differences in Health Are Large  In 1999 blacks had higher death rates than whites for heart disease, stroke, diabetes, kidney disease, homicide, cancer, accidents, flu and pneumonia, septicemia, cirrhosis of the liver and hypertension), 11 out of 15 of the lead causes of death in the U.S. R  acial differences in mortality reflect higher incidence of disease, earlier onset of disease and poorer survival of those groups with higher mortality rates. A  frican Americans, American Indians (and Native Hawaiians and other Pacific Islanders) tend to have poorer health outcomes than whites throughout life, and these differences are remarkably persistent across place and time. R  acial disparities in health persist in the context of overall improvements in health. 2. In the Last 50 Years, Although Overall Health Has Improved, Racial Differences in Health Are Unchanged or Have Widened  This is marked by infant mortality rates (the difference between blacks and whites has widened between 19502000). Th  e difference between black and white mortality rates from all causes was greater in 2000 than it was in 1950. 3. Racial Differences in Health Are Not Primarily Caused by Genetic Factors Race is a social construct that is not genetically based. G  roups with similar physical characteristics can be genetically very different. (A 1995 study, An International Collaborative Study of Hypertension in Blacks, shows that seven groups of blacks of West African origin living in different regions have very different rates of hypertension.)

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4. Socioeconomic Status Is a Central but Incomplete Explanation of Racial Differences in Health SES IS CENTRAL E  ducation and income are generally more strongly associated with health status than race. R  acial differences in health status between blacks and whites decrease substantially when blacks and whites with similar levels of socioeconomic status are compared. A  t every ascending level of income, education or occupation, there is a corresponding improvement in health. SES IS INCOMPLETE Th  ere are still racial differences when SES factors are taken into account. 5. All Indicators of Socioeconomic Status Are Not the Same across Racial/Ethnic Groups  The poorest 20 percent of whites are significantly richer than the poorest blacks and Hispanics, and the richest 20 percent of whites are richer than the richest 20 percent of Hispanics, who are also richer than the richest 20 percent of blacks. 6. In Addition to Socioeconomic Status, Other Factors Linked to Race/Ethnicity (Including Racism) Are an Added Burden  Institutional discrimination can restrict access to desirable goods and services and socioeconomic attainment, which in turn affects health. I  nternalized racism (acceptance of societys negative characterization) can adversely affect health. R  acism can increase exposure to traditional stressors (e.g., unemployment) and experiencing discrimination may be neglected as a psychological stressor. 7. Place Makes an Added Contribution to Health  In the 171 largest cities in the U.S., there is not even one city where whites live in ecological equality to blacks in terms of poverty rates or rates of single-parent households. R  acial differences at the neighborhood level in availability of jobs, family structure, opportunities for marriage, and concentrated poverty underlie racial differences in crime and homicide.

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Appendices

A  ssociation between family structure and violent crime is identical in significance and magnitude for blacks and whites. Th  e elimination of segregation would eliminate black/white differences in earnings, high-school graduation rates and unemployment (and reduce single motherhood by two-thirds).
Modified from David R. Williams Racial/Ethnic Differences in Health: 10 Key Facts.xi

Appendix B: Sample Case Studies Community Health Factors in Action


The following case studies provide examples of the three non-medical clusters of community health factors described in Part One, Chapter 4 of this manual.

Equitable Opportunity Cluster: Case Study


Boston Public Health Commissions Undoing Racism, Boston, Massachusetts Recognizing that undoing racism and embracing cultural diversity are keys to eliminating persistent health disparities in the city of Boston, the Boston Public Health Commission undertook a multifaceted initiative that began with the simple but crucial first step of looking inward. Their from the inside out approach began with an institutional assessment in which the Commission asked the question, How is racism at play here? With the knowledge and awareness they gained from the assessment, the Commission could develop policies to dismantle institutional racism and mechanisms to assure they would be implemented, and serve as a model for the rest of the city. The core framework they adopted included: 1) Building and supporting community partnerships; 2) Promoting anti-racist work environments; and 3) Re-aligning external activities to address racism. Key to this initiative were ongoing workshops designed to educate, challenge and empower staff, contractors, community residents and public health practitioners to undo institutional racism (racial justice). The Commission focused on resident participation, leadership and decision-making in a community needs assessment process that examined issues related to racism, as well as in designing, implementing and evaluating programs and services that are culturally and linguistically accessible. This emphasis on resident involvement and leadership was critical to creating effective services, and also increased resident capacity for effecting change (participation and willingness to act for the common good). In addition, the Commission focused on assessing workforce

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composition, developing strategies for increasing diversity at all levels, and working with community residents, medical schools, teaching hospitals and health centers to support pipeline efforts to create a more diverse workforce (jobs and local ownership). For more information: Boston Public Health Commission: (617) 534-5395; www.bphc.org.

People Cluster: Community Example


Decreasing Community Violence, South Los Angeles, California xii At the peak of the violence epidemic in the 1990s, drive-by shootings were common in some neighborhoods in South Los Angeles, a predominantly African American area of the city. Fearing their children would be shot in crossfire, parents would not let their children play outside. On streets that were particularly affected, neighbors came together to make their streets safe again. Residents worked together on a number of activities, including outreach to local gangs. In taking collective action, they significantly reduced instances of gang-related gun violence in their streets and parents felt safe letting their children play outside again and move throughout the community. Major outcomes include: 1) Reduced risk of death and injury from firearms through collective action (participation and willingness to act for the common good); and 2) Increased opportunities for children to play outside and move around throughout the community (parks and open space; look, feel and safety), which can reduce the risk of chronic disease.

People Cluster: Community Example


LIFETIME, Oakland, California LIFETIME is a nonprofit organization based in Oakland, California that helps single mothers on welfare to obtain higher education and remain off welfare and out of poverty permanently. Founder and director Diana Spatz, who had completed her B.A. while raising her daughter on welfare, established LIFETIME in 1996. LIFETIME began as a servicelearning class at the University of California at Berkeley that Spatz taught to other student welfare mothers like herself, instructing them on their rights as welfare recipients, and forming support systems for them while they worked toward their degrees. Spatzs momentum grew, and soon her class became LIFETIME, the organization. Parent members participate in political education, leadership development, and advocacy training in order to become effective advocates for the policies that affect their lives.
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LIFETIME has accomplished multiple outcomes that are related not only to promoting educational outcomes but also to engaging lowincome mothers in political advocacy. Outcomes include: 1) Trained single mothers on welfare as advocates for their educational rights to ensure that they are able to obtain a higher education and remain off welfare and out of poverty permanently (jobs and local ownership); 2) Provided services to over 400 parents to help them reach their higher education goals (education); and 3) Involved these parents in advocating on behalf of policies that affect them under welfare law (participation and willingness to act for the common good). The parents civic engagement efforts resulted in the changing of welfare policies in all of Californias 58 counties, thereby increasing CalWORKs parent transportation support services (getting around), increasing parents access to education (education), and winning accommodations for learningdisabled parents (place). For more information: ://www.geds-to-phds.org

Place Cluster: Community Example


Fruitvale Transit Village, Oakland, California Fruitvale is a low-income, predominantly minority community in Oakland, California. In 1991, Bay Area Rapid Transit (BART) unveiled its plan to construct a large parking structure that would separate the Fruitvale BART station from the surrounding community. Upon hearing this news, the Unity Council (a community development corporation within Oakland created to provide space for working on issues affecting the Latino community within Fruitvale) organized community opposition to BARTs plan. The Council and residents of Fruitvale insisted that there was a better way to develop the Fruitvale station. BART listened, and began working with the Unity Council to develop a new plan. In 1992, the Unity Council held meetings to bring together various stakeholders. The success of the Fruitvale Transit Village Project has been attributed to the amount of collaboration that took place among stakeholders. Participants in these meetings were asked to name specific goals for the project. These included: improved public safety, increased availability of jobs in Fruitvale, increased number of services within the community, affordable housing, and improved air quality within the community through reducing pollutants from traffic. As a result of resident input, two new buildings were constructed for housing and office space, and a pedestrian walkway was built connecting the BART station area with the greater Fruitvale area.
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The following outcomes were achieved as a result of the Fruitvale Transit Village Project: 1) Businesses were brought into the area and increased the availability of local jobs (jobs and local ownership); 2) Availability of public services; 3) Reduction of air pollution resulting from traffic (air, water and soil); 4) Engaged residents as part of the solution (participation and willingness to act for the common good); 5) Affordable housing was located next to a major transportation site (housing, getting around); and 6) The project was designed with community input in the process and aesthetics were integrated into the planning process (look, feel and safety).

Place Cluster: Community Example


East Bay Center for the Performing Arts, Richmond, Californiaxiii In 1968, five Richmond teachers searching for lasting and meaningful responses to deeply entrenched disparities in social justice and educational opportunities got together to establish the East Bay Music Center to provide music lessons for 45 students in a rented church. Since then the center has continued to grow (it changed its name in 1976 to reflect its expanded vision), offering art and performance instruction in the belief that, when sensitively taught, the arts can become a powerful tool for helping individuals and communities achieve their greatest potential. Its founders also recognized that the arts could serve as a vehicle for social reconciliation and a practical model for meaningful collaboration. To date, the East Bay Center for the Performing Arts (EBCPA) has served more than 700,000 people. The East Bay Center for the Performing Arts is an educational institution that integrates the vigor of a nationally recognized arts training and producing center with a strong commitment to serving people from the local community. It provides quality programming and deep respect for community integrity, and its staff and students work together in a positive spirit imbued with joyfulness and hope. Theater production, private and group music lessons and performance opportunities, filmmaking classes, and ethnic dance classes and troupes are offered, and scholarships are awarded on a sliding scale based on financial need, motivation and commitment. EBCPA has expanded to offer classes at area schools, focusing especially on schools made up of students with limited resources and opportunities for arts education.

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Appendices

By making the arts available to anyone who wishes to participate (students range from age 5 to 80), EBCPA has become a cornerstone in the broader communitys cultural and artistic life. EBCPA students and faculty have produced more than 42 original theater and film works on topics such as date rape, gang violence, race relations, substance abuse, AIDS, teen pregnancy and youth achievement. The EBCPAs programs 1) provide positive in-school, after-school, and summer arts programs (arts and culture); 2) increase the physical activity of young people in an exciting and culturally appropriate manner (look, feel and safety); 3) bring young people together in a neutral location and promote positive interaction in a community rife with neighborhood turf issues (social networks and trust); and 4) help to foster a collective appreciation of cultural diversity and strengths, and celebrate the communities diverse ethnic heritage and cultural history (racial justice). For more information: The East Bay Center for the Performing Arts; 339 11th Street, Richmond, CA 94801; Tel: (510) 234-5624; Fax: (510) 234-8206; www.eastbaycenter.org.

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Glossary
Actual Causes of Death: The Actual Causes of Death were identified by researchers McGinnis and Foege to determine the true underlying causes of death in the United States. In most cases, cause of death is attributable to a medical condition or event; e.g., lung cancer, for example. The actual cause of death, however, in many of these cases is tobacco. Advocacy: The act of arguing in favor of, or advancing, something, such as a cause, idea or policy, using multiple means, including, but not limited to, press conferences, briefing papers, legislative testimony and demonstrations. Behavioral Factors: Those factors that are characterized by, or attributed to, how individuals behave. Built Environment: Refers to the man-made surroundings that provide the setting for human activity, from the largest-scale civic surroundings to the smallest personal place. Community Empowerment: The ability of people who live in a community to gain understanding and control over their personal, social, economic and political forces and to take action to improve their life situation. Community Factors: Those factors that are characterized by, or attributed to, a place or larger grouping of people. Within the health disparities framework, community factors refers to a specific set of elements within a community that hold the most potential for affecting health outcomes. These community factors include, but are not limited to, social networks and trust, housing, what is sold and how it is promoted, jobs and local ownership, and parks and open space. Community Health: The state of wellness or well-being in a defined community; affected by forces in addition to health care services, including adequate housing, quality of schools, safe streets, economic stability and the environment. Community Health Improvement: The betterment of the health status of a community, especially deriving from those activities that

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Glossary

focus on the prevention of illness and disability, and the creation of conditions that promote the well-being of community residents. Disparity: Difference. Health disparities refers to specific populations and communities experiencing unequal (higher) rates of the same diseases affecting the country as a whole. Environment: Far more than air, water and soil, the environment is anything external to individuals shared by members of the community, including community behavioral norms. According to the American Heritage Dictionary, it is the totality of circumstances surrounding an organism or group of organisms. Environmental Change: Refers to changes in the social, cultural, physical and political environments, at the community level. Equal Access to Healthy Environments: A term that arises from documented environmental injustice as a result of race and class. Instances of environmental injustice include low-income communities and communities of color being disproportionately targeted for facilities that have negative health impacts and also include the lack of clean-up of known but unintentional toxins, and lack of adequate emergency preparedness and response in those same communities. Equity: Fair and just. Equity in health is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/ disadvantage; i.e., wealth, power or prestige. Equity is an ethical principle; it also is consonant with and closely related to human rights principles. (See also Inequity.) Healthy People 2010: A statement of national health objectives by the U.S. Department of Health and Human Services designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. www.healthypeople.gov Inequity: Unfair and unjust. Health inequities are differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.xiv Thus, equity and inequity are based on core American values of fairness and justice whereas disparity is a narrow descriptive term that refers to measurable differences but does not imply whether this disparity arises from an unjust root cause.

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Interdisciplinary: Of, relating to, or involving two or more academic or professional disciplines that are usually considered distinct. Norms: Regularities in behavior with which people generally conform. Often based in culture and tradition, they are attitudes, beliefs and standards that are taken for granted. Norms are behavior shapers. Oppression: The negative outcome experienced by people targeted by the arbitrary and cruel exercise of power in a society or social group. The term itself derives from the idea of being "weighted down." The term oppression is primarily used to describe how a certain group is being kept down by unjust use of force, authority or societal norms. When this is institutionalized formally or informally in a society, it is referred to as "systematic oppression." Oppression is most commonly felt and expressed by a widespread, if unconscious, assumption that a certain group of people is inferior. Organizational Practices: Refers to how organizations conduct their work on an ongoing basis. These could be practices that arose out of the organizational culture or that are governed by company policy or regulation. Pathway: The sequence of outcomes or events that occur in order to reach a long-term goal. Most initiatives have multiple pathways that lead to the long-term goal. The health disparities trajectory describes a pathway through which root factors interplay with behavioral and environmental factors and medical conditions to result in health disparities. Place-based: That which is location-specific, be it neighborhood, city or region. Policy: A code or set of regulations governing actions or procedures; generally can be found in statutes (laws) and regulations, and may be reflected in budgets, mission statements and organizational cultures. Generally, policy refers to officially agreed-upon regulations voted for by cities, counties, etc., but it may also be developed by other legal entities such as corporate boards of directors. Organizational practices and other, less formally set decisions are sometimes referred to as policies as well, although this is technically inaccurate. Policy Change: A shift in the formal operations of organizations and/ or governmental institutions that allows new or different activities to occur and thrive. These shifts may arise from information sharing,

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Glossary

community participation, professional input, compromise, and consensus building and are usually the result of effective advocacy. Primary Prevention: Taking action before a problem arises rather than treating or alleviating its consequences. Priority Medical Issues: The California Campaign to Eliminate Racial and Ethnic Disparities in Health identified nine Priority Medical Issues that cause significant morbidity and/or mortality among people of color and are associated with the achievable objectives outlined in Healthy People 2010. They are: 1) cardiovascular disease, 2) breast cancer, 3) cervical cancer, 4) diabetes, 5) HIV/AIDS, 6) infant mortality, 7) asthma, 8) mental health, and 9) trauma (including intentional and unintentional injury). Resilience: Often refers to the ability of a person or community to positively adapt and develop in the face of new or different experiences and environments. Fostering resiliency in people has been shown to improve academic, emotional, social and cognitive outcomes. Further, building community resilience factors or assets can counteract the negative effects of risk factors. Research shows that, like risk, resiliency factors can accumulate such that those with more assets are less likely to engage in high-risk behaviors. Risk: In an endangered state, especially from lack of proper care; the possibility of suffering a harmful event; a factor or course involving uncertain danger, as with smoking. Risk Factor: Something that may increase the likelihood of a person becoming sick, injured or harmed in any way. Risk factors can be caused or exacerbated by individual behavior (e.g., smoking) and by the environments in which we live (lack of safety in the neighborhood). Root Factors: Underlying issues and dynamics in society that contribute to inequality and ultimately lead to disparities in health, as well as other detrimental outcomes. Social Capital: The connections among individual-social networks and the norms of reciprocity and trustworthiness that arise from them, as well as standards for behavior that are socially dictated. Social Determinants of Health: The social determinants of health encompass the multitude of social conditions in which we live that have an impact on health. Three broad categories of social determi-

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nants are: 1) social institutions, including cultural and religious institutions, economic systems and political structures; 2) surroundings, including neighborhoods, workplaces, towns, cities and built environments; and 3) social relationships, including position in social hierarchy, differential treatment of social groups and social networks. Social and health policies and programs can potentially alter these. Strategy: A thoughtful, planned, general method undertaken to achieve an outcome; the way to get things done effectively. A strategy often describes a variety of activities, who will do them and how they will work together, and a timeline or sequence of these efforts. Systems Change: A permanent change to the policies, practices and decisions of related organizations or institutions in the public and/or private sector. Sustainability: Ensuring that an effort or change lasts. Note: sustainability is often misunderstood as securing further or ongoing funding for a program that otherwise would end. It is important to understand that sustainability can be achieved without ongoing funding by changing policies, norms, attitudes, etc. Trajectory: A route or direction. In relation to health disparities, a trajectory illustrates the route from which root factors such as racism, oppression and inequality negatively influence the broader environment and individual behavior and lead to illness and injury.

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Resources
THRIVE (Toolkit for Health and Resilience in Vulnerable Environments) THRIVE is a tool to help people understand and prioritize the factors within their own communities that can help improve health and safety. The tool identifies key factors and allows a user to rate how important that factor might be in the community. It also provides information about how each factor is related to health outcomes and some direction about what to do to address the factor and where to go for more information. http://www.preventioninstitute.org/thrive/index.php ENACT (Environment Nutrition and Activity Community Tool) ENACT is a concrete menu of strategies designed to help improve nutrition and activity environments on a local level. These strategies have been organized into seven environments that were carefully selected for their importance in individual and community health. Each ENACT strategy presents useful information based on current research and practice and includes model policies and programs, hands-on tools, articles and other publications, and resources. The strategies are structured to be interactive so that implementation can become a reality. The Strategic Alliance developed ENACT to offer community members realistic ways to create positive change in their food and activity environments. ENACT was designed to complement current education and community efforts and to empower local action to address priority issues. Working locally can make healthy eating and regular activity a realistic option for everyone, and can bubble up to affect state and national policy. http://www.preventioninstitute.org/sa/enact/members/index.php Good Health Counts Good Health Counts: A 21st-Century Approach to Health and Community for California synthesizes findings from nearly 100 community report cards and indicator reports from throughout the country and broadens understanding of all the elements that contribute to community health. The report, prepared by the Prevention Institute with funding from The California Endowment, helps make the connection

RESOURCES

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between factors in the environmentincluding equitable opportunities, strong social ties, the ability to buy healthy foods, perceptions of safety to walk or play in the park, and affordable, quality medical servicesand their impact on health. http://www.preventioninstitute.org/documents/GoodHealthCounts_ Final.pdf Unnatural Causes This documentary series was produced to draw attention to the root causes of health and illness and to help reframe the debate about health in America. Unnatural Causes and its companion tools help people work towards better health by illustrating how economic justice, racial equality and caring communities may be the best medicines of all. http://www.unnaturalcauses.org/ Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County This report takes an in-depth look at health inequities and underlying social inequities in Alameda County based on local data. Part One describes the nature and magnitude of health inequities in the county. Part Two describes social inequitiesthe root causes of health inequitiesand proposes policies to address them. Sections include: segregation, income and employment, education, housing, transportation, air quality, food access and liquor stores, physical activity and neighborhood conditions, criminal justice, access to health care, and social relationships and community capacity. http://www.acphd.org/user/services/AtoZ_PrgDtls.asp?PrgId=90 Health for All The California Strategic Approach delineates how the resources of diverse governmental and private institutions can be marshaled to work with communities to make significant progress towards eliminating health disparities in California. It illuminates the critical pathways that affect health and the key points for intervention to ensure health for all. http://thrive.preventioninstitute.org/pdf/H4A_ MAIN_1Scites_021304.pdf

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King County Equity and Social Justice Initiative This initiative takes aim at long-standing and persistent local inequities and injustices. Government and local communities are better prepared than ever before to address these challenges. http://www.kingcounty.gov/exec/equity.aspx Reducing Health Disparities through a Focus on Communities This report presents evidence from research and practice of the key role that neighborhood factors play in determining health outcomes and explores the relationship between the communities in which people live and their health. The report also proposes principles and strategies to reduce health disparities that focus not only on individuals, but also on the neighborhoods and communities in which they live. http://www.policylink.org/pdfs/HealthDisparities.pdf

RESOURCES

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Worksheets
Using the Spectrum of Prevention A. Thinking Comprehensively Using the Spectrum of Prevention (BLANK WORKSHEET) B. Using the Spectrum of Prevention: Cultivating Peace in Salinas (SAMPLE WORKSHEET) 73 72

C. Evaluation Questions D. Thinking Comprehensively Using the Spectrum of Prevention (BLANK WORKSHEET) 74 75 INSTRUCTIONS: 1.  Select a community need on which to focus developing strategy. The Two Steps to Prevention activity earlier in this manual concludes with community needs that would work well for this exercise. Be sure to pick something specific selecting a broad need such as reduced rates of diabetes makes it very difficult to generate a coherent, comprehensive plan. 2.  On Worksheet A, fill in actions at each level of the Spectrum of Prevention that could collectively lead to addressing the need. 3.  Focus on actions that complement one another and that have the potential to change norms and the community environment.
WORKSHEETS

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A. Thinking Comprehensively Using the Spectrum of Prevention


SPECTRUM LEVEL
6.  Influencing Policy and Legislation Developing strategies to change laws and policies to influence outcomes in health and safety

ACTIVITIES/STRATEGIES

5. Changing Organizational Practices Adopting regulations and procedures to improve health and safety and create new standards for organizations

4.  Fostering Coalitions and Networks Convening groups and individuals for broader goals and greater impact

3. Educating Providers Informing providers who will transmit skills and knowledge to others or become advocates for your goal

2.  Promoting Community Education Reaching groups of people with information and resources to promote health and safety

1.  Strengthening Individual Knowledge and Skills Enhancing an individual's capacity to prevent injury or illness and promote health and safety

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B. Using the Spectrum of Prevention: Cultivating Peace in Salinas


In an effort to improve health outcomes for children, youth and families, the City of Salinas joined together with the Violent Injury Prevention Coalition (VIPC) and their foundation Partners for Peace to launch a community collaborative planning process. The resulting framework, Cultivating Peace in Salinas, focuses primarily on reducing youth violence through the strategies below.

SPECTRUM LEVEL
6.  Influencing Policy and Legislation Developing strategies to change laws and policies to influence outcomes in health and safety

ACTIVITIES/STRATEGIES
Translate report recommendations into an action plan for the ballot  Develop public policies to address alcohol as a risk factor for violent behavior Develop public policies to address gun regulations in Salinas

5. Changing Organizational Practices Adopting regulations and procedures to improve health and safety and create new standards for organizations

Increase after-school and recreation opportunities Prioritize economic development and job training for youth Implement measures to reduce truancy Promote family-friendly practices among employers

4.  Fostering Coalitions and Networks Convening groups and individuals for broader goals and greater impact

 Develop collaboration between city, county and school districts to implement this plan Continue VIPC as violence prevention coordinating group Establish an intergovernmental youth services board Collaborate to produce an annual report card and share data

3. Educating Providers Informing providers who will transmit skills and knowledge to others or become advocates for your goal

Develop a strategy to reduce gang violence Support practitioners who work in violence prevention

2.  Promoting Community Education Reaching groups of people with information and resources to promote health and safety

Develop initiatives that promote positive community values  Enhance positive media messages and reduce the impact of negative messages Encourage more positive role models and mentors for youth Convene community-wide dialogue on discipline Invest in early childhood and parent support initiatives Improve literacy rates for children and adults

WORKSHEETS

1.  Strengthening Individual Knowledge and Skills Enhancing an individual's capacity to prevent injury or illness and promote health and safety

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C. Evaluation Questions
1. How do the stated activities achieve your stated goal?

2. How would the activities generate synergy if employed together?

3. Would the activities shift norms?

4. Are multiple sectors involved in the strategy?

5. Which outside the box providers are included?

6. H  ow do the Community Education and the Individual Knowledge and Skills activities support changing the environment?

After reviewing your answers in Worksheet A, fill in the Spectrum of Prevention a second time in Worksheet D with the above criteria/evaluation questions as a guide.

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D. Thinking Comprehensively Using the Spectrum of Prevention


SPECTRUM LEVEL
6.  Influencing Policy and Legislation Developing strategies to change laws and policies to influence outcomes in health and safety

ACTIVITIES/STRATEGIES

5. Changing Organizational Practices Adopting regulations and procedures to improve health and safety and create new standards for organizations

4.  Fostering Coalitions and Networks Convening groups and individuals for broader goals and greater impact

3. Educating Providers Informing providers who will transmit skills and knowledge to others or become advocates for your goal

2.  Promoting Community Education Reaching groups of people with information and resources to promote health and safety

WORKSHEETS

1.  Strengthening Individual Knowledge and Skills Enhancing an individual's capacity to prevent injury or illness and promote health and safety

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ENDnotes: PART TWO


i. Davis, M.K. Breastfeeding and Chronic Disease in Childhood and Adolescence. Pediatr Clin North Am , 48:12541, ix, 2001. ii. Ryan, A.S.; Rush, D.; Krieger, F.W.; and Lewandowski, G.E. Recent Declines in Breast-Feeding in the United States, 1984 through 1989. Pediatrics, 88: 719727, 1991. iii. Wolf, J.H. Low Breastfeeding Rates and Public Health in the United States. Am J Public Health, 93: 20002010, 2003. iv. National Center for Health Statistics. National Health and Nutrition Examination Survey Questionnaire Data. Diet Behavior and Nutrition (DBQ) section. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 19992006. Available from: http://www.cdc.gov/nchs/about/major/ nhanes/datalink.htm. Accessed on February 20, 2008. v. California WIC Association, 2008. Retrieved from http:// www.calwic.org/docs/pk!/2008/bfhospital2008.pdf. vi. Wright, A.; Schanler, R. The Resurgence of Breastfeeding at the End of the Second Millennium, Journal of Nutrition, 131: 421S425S, 2001. vii. Ahluwalia, I.B.; Tessaro, I.; Grummer-Strawn, L.; MacGowan, C.; Benton-Davis, S. Georgia's Breastfeeding Promotion Program for Low-Income Women. Pediatrics, 105(6): E85, 2000. viii. Edna Ullmann-Margalit. Revision of Norms. Ethics, 100(4): 756-767, 1990. ix. Schlegel, A. Response to Ensminger & Knight. Current Anthropology, 38: 1819, 1997. x. MEE/CANfit. Obesity in the Hip-Hop Generation Workshop, November 2022, 2002. xi. Williams, D.R., Ph.D., M.P.H.. University of Michigan, Institute of Social Research. Source: http://ncrhp.uic.edu/ healthdisparities/Syllabi/Williams%27%20Minnesota%20 Disparities.ppt. Accessed on September 18, 2008. xii. A Community Builders Tool Kit. The Institute for Democratic Renewal and Project Change Anti-Racism Initiative, 1998. xiii. Creative Community : The Art of Cultural Development. The Rockefeller Foundation, 2001. xiv. Whitehead, M. The Concepts and Principles of Equity and Health. Copenhagen: WHO Regional Office for Europe, 1990. Available at: http://whqlibdoc.who.int/euro/-1993/ EUR_ICP_RPD_414.pdf. Accessed on May 1, 2009.

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