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1
Introduction
This chapter begins by describing the scope of work for the study,
then defines the terms the committee used to conduct its work, and,
finally, discusses why community-based prevention is important
and how it differs from other health improvement efforts. Some
individuals believe the existing frameworks for valuing community-
based prevention are flawed and prone to understating its benefits;
others disagree or are uncertain. Committee members brought
very different perspectives and areas of expertise to the discussion,
with backgrounds that included public health, community health
promotion, ethics, economics, workplace wellness, and government
budget analysis. This report attempts the difficult task of blending
those perspectives.
COMMITTEE CHARGE
Four foundations—the California Endowment, the de Beaumont
Foundation, the Robert Wood Johnson Foundation, and the W.K. Kellogg
Foundation—asked the Institute of Medicine to convene an expert com-
mittee to develop a framework for assessing the value of community-based,
non-clinical prevention policies and wellness strategies, especially those
targeting the prevention of long-term, chronic diseases. The committee’s
task was as follows:
• Define “community-based, non-clinical prevention policy and well-
ness strategies”;
13
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14 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
• Define “value” for community-based, non-clinical prevention pol-
icy and wellness strategies;
• Analyze current frameworks used to assess the value of
c
ommunity-based, non-clinical prevention policies and wellness
strategies, including
o the methodologies and measures used and
o the short- and long-term impacts of such prevention policy
and wellness strategies on communities, including health care
spending and public health; and
• If warranted, propose a new framework or frameworks that cap-
ture the breadth and complexity of community-based, non-clinical
prevention policies and wellness strategies, including interventions
that target specific behaviors and health outcomes.
The framework should
• consider the sources of data that are needed and available;
• consider the concepts of generalization, scaling up, and sustain-
ability of programs; and
• address national and state policy implications associated with im-
plementing the framework.
The committee assembled to respond to the charge from the spon-
sors was composed of experts spanning different disciplines ranging from
economics and program evaluation to community-based providers. Over
the course of this 20-month study the committee met six times in person,
participated in many conference calls, and held three information-gathering
workshops. During the workshops, committee members heard from mem-
bers of the prevention community as well as experts in the field of valuing
different types of interventions, including interventions in the fields of
education and housing.
DEFINITIONS
The committee’s charge directs it to define “community-based, non-
clinical prevention policy and wellness strategies” and also to define “value”
for these policies and strategies. Through the course of its work the com-
mittee also used several other terms that may require clarification; in such
cases definitions have been given in both the text of the report and in the
glossary in Appendix A.
The phrase “community-based, non-clinical prevention policy and well-
ness strategies” appears in the Statement of Task. This phrase has been
shortened for the purposes of this report to community-based prevention.
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INTRODUCTION 15
Community-based prevention includes programs and policies that are
aimed at
• preventing the onset of disease,
• stopping or slowing the progress of disease,
• reducing or eliminating the negative consequences of disease,
• increasing healthful behaviors that result in improvements in health
and well-being, or
• decreasing disparities that result in an inequitable distribution of
health.
Community-based prevention is not primarily based on clinical ser-
vices, although it may involve services provided by health professionals in
clinical settings. The charge to the committee requested that special atten-
tion be given to the prevention of long-term, chronic diseases. Such a focus
does not negate the fact that other community-based prevention efforts,
such as those directed at unintended and intended injuries and mental
health, are also important areas for attention.
The value of an intervention, for the purposes of this report, is defined
as its benefits minus its harms and costs. There is an expanded discussion
of the concept of value at the end of this chapter and in Chapter 4.
Community has been defined in a variety of ways. The committee uses
the term community to mean any group of people who share geographic
space, interests, goals, or history. It includes the built environment, social
networks, and the organizations and institutions that sustain the individual
and collective life of the community. Chapter 2 contains an expanded dis-
cussion of the concept of community.
A community-based prevention program is a coordinated activity or set
of activities, such as an educational campaign against smoking, improve-
ments to the built environment to encourage physical activity, a chronic
disease education and awareness campaign to improve self-management,
or a combination of such interventions, that is intended to accomplish a
health objective or outcome. A policy is a rule or set of guidelines, such as
nutritional standards for school lunches. An intervention is an umbrella term
used to mean either a program or a policy with the goal of improving health.
A strategy is the method through which programs are implemented, such as
television advertisements warning of the dangers of smoking, construction
of a bike path, or conducting disease management workshops in churches.
WHY IS COMMUNITY-BASED PREVENTION IMPORTANT?
Early health-promotion efforts emphasized meeting basic human needs
for clean water, adequate nutrition, and shelter. In 1900 a third of all deaths
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16 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
in the United States were due to pneumonia, tuberculosis (TB), diarrhea
and enteritis, and diphtheria. Children suffered high rates of morbidity
and mortality, with 40 percent of deaths from those four causes occurring
among children under five (CDC, 1999), and children under five accounting
for a third of all deaths from all causes.
Over the past century major strides were made in improving the health
of the public through population-level efforts that were implemented in
individual communities. The reduction in premature mortality from TB
brought about by community-based prevention is a dramatic example.
In 1900 mortality rates from TB were 194 per 100,000. By 1940, before
antibiotics for TB were available, the rate had dropped to 46 deaths for
every 100,000 people living in the United States. The decrease was due
to community-level infection control measures instituted by local health
departments combined with improvements in housing (including reducing
the level of crowding) and better nutrition (CDC, 1999). Large-scale public
health initiatives, such as public sewer projects, chlorination of public water
supplies, and food safety requirements, greatly reduced the exposure of the
public to infectious organisms and reduced the incidence of such diseases
as cholera, typhus, and TB (Turnock, 2009).
In the mid-20th century a new approach to improving health was made
possible by the development of effective antibiotics and a new generation
of vaccines combined with the professionalization of medicine. Since then,
society has invested substantially in clinical interventions and strategies
to improve health. This investment includes everything from the training
of physicians, nurses, and other health professionals to the financing of
expansions of hospital capacity and the development of new drug thera-
pies, medical devices, and surgical techniques. Researchers have developed
and fine-tuned frameworks such as randomized controlled trials and cost-
effectiveness analysis for assessing the value of these clinical activities.
Decent housing, clean air and water, effective sanitation, and food
safety have become such a part of our culture and public infrastructure that
they are no longer thought of as health endeavors. Yet, the initiatives that
led to these conditions brought about dramatic improvements in health. As
we begin the 21st century there is growing recognition that the next stage
of improving health and preventing disease will involve a renewed emphasis
on population-level, non-clinical strategies. The committee expects that in
the coming decades health practitioners and scholars will propose, develop,
and implement more programs and policies designed to improve health at
the community level; thus, a framework to evaluate their success and to
compare them to other interventions is needed.
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INTRODUCTION 17
HOW IS COMMUNITY-BASED PREVENTION DIFFERENT?
Community-based prevention requires cultural, social, and environ-
mental changes, much like the extensive changes in water, sanitation and
housing, and nutrition that occurred in the first half of the 20th century. As
discussed earlier, improving health and preventing disease does not occur
solely in the patient’s examination room; it also takes place in the com-
munity of patients and their families, friends and neighbors, employers,
teachers, and storekeepers. People’s socioeconomic status, social context,
and physical and cultural environment influence their health both directly
and, through behavioral changes and lifestyle development and reinforce-
ment, indirectly (Box 1-1) (Adler et al., 2008; Berkman and Glass, 2000;
Berkman and Kawachi, 2000). In addition, these factors can moderate and
mediate the effects of clinical interventions on health (IOM, 2006).
During the second half of the 20th century, much of the focus of
chronic disease epidemiology and prevention research was on individual
lifestyle and behaviors, with the notable exception of tobacco control. In
recent decades, however, research has demonstrated that behavioral choices
are shaped and modulated by the environments in which individuals live
(Adler et al., 2008; Antonovsky, 1967; Berkman and Glass, 2000; Cohen et
al., 2000; Eller et al., 2008; Kawachi and Berkman, 2001, 2003; Marmot
and Wilkinson, 1999; Stansfeld et al., 1999). Thus, for example, efforts
to prevent obesity-related conditions might have limited success if they do
not take into consideration the social and built-environment characteristics
that might act as incentives or barriers to the dietary and physical activ-
ity choices that individuals make, and, indeed, recent initiatives in obesity
control have been doing exactly that (e.g., Mercer et al., 2003; Sallis et
al., 2006; Storey et al., 2003). Likewise, suicide, the 10th-leading cause of
death among Americans, is tied to mental illness, also a long-term chronic
disease that is clearly influenced by environment and social determinants
(Galea et al., 2005; Huey and McNulty, 2005; Woo et al., 2012).
Clinical preventive interventions such as screening for conditions prior
to the appearance of symptoms are important preventive services. For
example, colonoscopies and mammograms have succeeded in identifying
the potential for disease and led to early treatment to prevent occurrence.
Screening, however, identifies problems that exist after the disease or its
precursors are present (e.g., polyps in the colon or lumps in the breast) and
is directed at individuals. Primary prevention, which addresses risk factors
before disease occurs, is increasingly recognized as important (Haddix et
al., 2003). It is more desirable to prevent obesity than to treat diabetes, yet
delivering community-based prevention interventions is often more difficult
to fund and staff than providing clinical interventions.
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18 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
BOX 1-1
Disparities in Health
Chronic disease and its precursors are not distributed evenly across the
population but are more likely to be present in minority and lower socioeconomic
status (SES) populations (IOM, 2009, 2011). For example, significant differences
in life expectancy remain between blacks and whites (CDC, 2011). Racial and
ethnic disparities in health have more to do with differences in physical and social
contexts than with individual biology and behavior. Some researchers have con-
cluded that individuals’ zip codes have a greater impact on their health than their
genetic codes (RWJF, 2008). For example, in 2001 Diez-Roux and colleagues
found that the neighborhood of residence had an impact on the risk of coronary
heart disease even after controlling for income, education, and occupation (Diez-
Roux et al., 2001).
The social determinants that lead to poor health—poverty, lower levels of
education, poor housing and nutrition, limited health literacy—are more likely to be
present in populations marginalized by prejudice and poverty. The risk factors that
arise from these determinants—obesity, tobacco and drug use, stress, depres-
sion, occupational and other environmental exposures—are also more prevalent,
as are the diseases that result (RWJF, 2008).
Even when other risk factors have been accounted for, however, SES ap-
pears to have an effect on health. The Whitehall II Study of British civil servants
by Michael Marmot and colleagues (1991) demonstrated that, despite universal
access to health care, there was a stepwise gradient of health, with the higher-
grade civil servants having better health and persons in the top ranks of Whitehall
being the healthiest of all. The researchers discovered that about 20 percent of
the variance in health status and life expectancy between grades could not be
explained by the usual risk factors for poor health. This relationship between social
status and health is referred to as the social gradient in health. Further analysis of
the data on the effect of biological and behavioral factors on the risk of coronary
heart disease within the Whitehall cohort showed that only about 60 percent of
the social gradient could be explained by these factors (Marmot, 2004). Potential
social explanations for these differences include the concepts of self-efficacy and
empowerment, but uncertainty remains about the biological pathways that might
underlie the influence of such social factors on health.
WHY IS IT SO HARD TO ASSESS THE VALUE OF
COMMUNITY-BASED PREVENTION?
Policies and programs to avoid further deterioration of health or death
once a person is ill are generally seen as reasonable. However, preventing
illness requires that society invest the financial and other resources neces-
sary to make the required changes in individual and community life before
someone becomes sick, and this means that some of the persons who receive
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INTRODUCTION 19
the intervention—and share the costs for it—would never have become sick
anyway. Thus it can be easier to make the case for improving an individual’s
health, where the cost–benefit relationship is clearer, than it is to make the
case for community-based prevention, especially to individuals who per-
ceive their own risk of illness as low.
In contrast to individuals who need treatment because they are ill, those
who avoid an illness due to a prevention program are not individually iden-
tifiable and thus may not realize that they have benefited. The costs of these
programs are immediate, but the benefits are often deferred to the future.
Furthermore, members of the community can vary in their priorities and
principles. Disagreements over the merits of a program or policy objectives
and disputes about the methods used to implement a program also hinder
funding of some community activities.
The Concept of Value
Assessing the value of something requires first defining value conceptu-
ally and then measuring it. On both counts, community-based prevention is
complex (see Box 1-2). The committee identified several conceptual issues
that make defining value difficult.
BOX 1-2
Issues in Valuing Bicycle Lanes
It is not easy to value the implementation of bicycle lanes in a city. There
are several benefits and costs, some of which are monetary and others of which
are not.
One potential benefit, for example, is that cyclists receive enjoyment and ex-
ercise riding their bikes to work and other destinations. This may improve cyclists’
general and mental health and lower their risks of long-term chronic diseases.
Also, cyclists pay less for driving and other forms of transportation. Others benefit
because if cyclists drive cars less, there are fewer cars on the roads, which lowers
congestion and travel times. Cycling also produces less air and noise pollution
as well as fewer greenhouse gas emissions, thereby improving the environment
for the entire community. Cycling may also add to community cohesion through
interactions among bicyclists (Pucher et al., 2010).
However, the costs of implementing this intervention are more than just the
direct costs of reconfiguring the road to construct the dedicated bicycle lanes.
There are the monetary costs of operating a bicycle for the cyclists and the
potential increase in the risk of injury due to cycling accidents, for example. Fur-
thermore, the presence of cyclists imposes changes in driving habits and walking
patterns that may have both benefits and costs for the drivers of cars, buses, and
trucks as well as for pedestrians (de Nazelle et al., 2011).
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20 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
Whose values? The value of an intervention depends on one’s perspec-
tive and on one’s beliefs and priorities. A program may have a very different
value depending on whether the perspective is that of the federal budget, of
a specific employer, of specific segments of society or a particular commu-
nity, or of society in general. For example, the success of tobacco control is
partly due to smoking restrictions in such places as workplaces, restaurants,
and airplanes. To a nonsmoker with a generally positive view of regulation,
such restrictions are valuable. To others, such as business owners who fear
losing customers, such restrictions can be seen as harmful.
Values diverge on other dimensions as well. Consider needle exchange
programs. Public health workers may support such programs because re-
search has shown that they reduce the transmission of HIV (NIH, 1997).
But others in the community may object because they view these programs
as facilitating illegal drug use. Both groups want to discourage these activi-
ties but evaluate the trade-offs between the benefits and harms differently.
To be successful, complex programs require the collaboration or at least co-
operation of many sectors and organizations that may have differing values.
To monetize, or not to monetize. One approach to assessing the value
of something is to measure, in dollar terms, its impacts in terms of benefits
and costs. Some things are naturally monetized, such as the time spent by
a paid community health educator. Other things are much more difficult,
but not necessarily impossible, to monetize, such as the value of increased
social cohesion. To some, the monetized approach allows a straightforward
assessment of whether an intervention is worth undertaking. Monetization
strikes others as misguided or wrong.
To summarize, or not to summarize. Policy makers crave simple sum-
maries of a proposal’s impact—for example, how many lives will be saved
and how many dollars the intervention will cost. Community-based preven-
tion efforts are difficult to summarize since their effects can span financial,
social, environmental, business, and ethical domains. The value of an inter
vention also depends critically on where and how well it is carried out.
A ROADMAP FOR THE REST OF THE REPORT
In this chapter, the committee has discussed the committee charge,
defined important terms, examined why community-based prevention
is important and how it differs from other prevention approaches, and
explored the concept and issues involved in valuing such programs and
policies. Chapter 2 expands on the discussion of community, provides
a brief historical perspective of community interventions, discusses four
approaches to community-based prevention, reviews the models for imple-
mentation that represent the current state of the field, identifies key features
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INTRODUCTION 21
of community-based prevention, and examines issues associated with evalu-
ating the effectiveness of such programs.
In Chapter 3 the committee examines how methods from systems sci-
ence can be applied to community-based prevention, discusses how such
methods can be used to clarify and quantify the relationships among vari-
ables, and identifies outcomes or domains of value for community-based
prevention. Chapter 4 provides a list of elements that a framework for
assessing value should possess, examines how a framework for valuing re-
sides within a decision-making context, reviews eight frameworks currently
used to assess community-based prevention, and discusses the strengths and
limitations of each for addressing the special characteristics of community-
based prevention. In Chapter 5 the committee lays out its vision for the
future of valuing community-based prevention.
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