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3
Community-Based Prevention:
More Than the Sum of Its Parts
This chapter discusses how the methods of systems science can
help increase understanding about the complexity of community-
based prevention intervention by disentangling important features
and associated variables, clarifying whether and how each of the
variables changes over time, identifying causal relationships among
the variables, quantifying the variables and the causal relationships,
and simulating how changes to the system affect the variables
and causal relationships in the system. Domains of value (health,
community well-being, and community process) and illustrative
elements within each domain are discussed, as are issues in valuing
resources and costs of community-based prevention.
As discussed in Chapter 2, community-based prevention interventions
cover a broad spectrum of types, from those directed at a specific health
condition (e.g., high blood pressure or diabetes) to those aimed at a much
broader and more complex array of conditions, including the prevalence
of chronic and infectious diseases; the social, economic, and environmental
determinants of population health; and health disparities and inequities ex-
perienced by lower income, lower educational status, and racial and ethnic
minority populations. Chapter 2 also discussed the ecological model and
pointed out the existence of multiple determinants of health at multiple lev-
els that interact and link with each other. However, prevailing approaches
to funding, research, and practice associated with community-based pre-
vention interventions often fail to recognize their inherent complexity. For
instance, categorical funding programs promote a one-disease-at-a-time
61
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62 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
vision (with an accompanying set of interventions) for improving popula-
tion health behaviors and health outcomes. Similarly, many research and
evaluation questions seek to identify the best intervention or to examine
interventions in the context of a single behavioral or health outcome. And,
in the field, approaches to policy and practice change often reflect the inter-
ests of the institutions or organizations leading the efforts (e.g., government
agencies, community-based organizations, or advocacy groups).
Current approaches tend to focus on individual rather than compre-
hensive interventions, to attribute changes in health behaviors and health
outcomes to specific interventions instead of multiple or synergistic efforts,
to not assess effectiveness and costs in terms of the collective value of multi-
component intervention approaches, and to guide decisions about priorities
and allocate resources intervention by intervention in line with these types
of evidence. As such, prevailing approaches fall short in depicting the col-
lective impact of community-based prevention efforts (Hanleybrown et al.,
2012; Kania and Kramer, 2011).
However, there has been a growing amount of attention paid to new
approaches to address these dynamic and complex systems (Homer and
Hirsch, 2006; Luke and Stamatakis, 2012; Mabry et al., 2008; Madon et
al., 2007). Examples include the community transformation grants from the
Centers for Disease Control and Prevention (CDC); intervention and ap-
plied research efforts such as community-based participatory research; the
dissemination and implementation research supported by the NIH National
Heart, Lung, and Blood Institute and the Office of Behavioral and Social
Sciences Research; and cross-sector and multidisciplinary interventions,
such as the CDC Communities Putting Prevention to Work program and
the Healthy Kids Healthy Communities program (BSSR/NIH, 2012; CDC,
2012a,b; Horowitz et al., 2009; NHLBI/NIH, 2012; RWJF, 2012).
Systems science methods have the potential for overcoming some of the
problems with current approaches. Systems science is the study of dynamic
“
interrelationships of variables at multiple levels of analysis (e.g., from
cells to society) simultaneously (often through causal feedback processes),
while also studying the impact on the behavior of the system as a whole
over time.”1 For purposes of this report, a system will refer to the inter
relationships of relevant elements, resources, and processes that characterize
community-based prevention. Systems science approaches excel at identi-
fying nonlinear relationships, bidirectional feedback loops, time-delayed
effects, emergent properties of systems, and oscillating system behavior
(Mabry et al., 2010).
1 s defined by the Office of Behavioral and Social Sciences Research at the National Insti-
A
tutes of Health: http://obssr.od.nih.gov/scientific_areas/methodology/systems_science/index.
aspx (accessed July 5, 2012).
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COMMUNITY-BASED PREVENTION: MORE THAN THE SUM 63
Systems thinking is increasingly associated with community-based pre-
vention, notably in obesity control. Of major importance from a systems
science perspective is the context in which those interventions take place,
that is, the social systems that are imbedded in and interacting with other
social systems. Second, there is a growing literature that uses the system
metaphor to describe the structure and functioning of the intervention
itself (IOM, 2010; Livingood et al., 2011; Trickett, 2009). Because of the
complexity, comprehensiveness, and intersectoral, and context-responsive
nature of the broader community-based prevention efforts, a systems per-
spective is well equipped to provide needed analytical descriptions and
evaluations of the multiple transformations targeted by such programs,
policies, and strategies.
Using a systems science approach to think about community-based
prevention can help people think through all the links that may be involved
in and affected by a change in the community, whether that change comes
from a deliberate intervention or a trend, (such as more smoking or less
exercise) caused by forces that may lie outside the community. Furthermore,
systems science can help further elucidate
• the pathways through which policy, system, and environmental
changes operate to affect population health.
• important ingredients that are needed to implement effective
c
ommunity-based prevention interventions as well as the imple-
mentation fidelity and “dose” of these activities (Carroll et al.,
2007; Glasgow et al., 1999; Linnan and Steckler, 2002).
• methods needed to capture multi-component and dynamic com-
munity trends and to triangulate different qualitative and quanti-
tative data sources (Patton, 2002; Rossi et al., 2004; Teddlie and
T
ashakkori, 2009; Ulin et al., 2005).
• the extent to which scale-up and spread of evidence-based inter-
ventions may be limited by the need to customize these strategies
to local political or environmental circumstances, resource con-
straints, populations (e.g., race and ethnicity, poverty, urban versus
rural, youth versus adult), and settings (e.g., home, child care,
school, work, community).
• the challenges posed by political, social, and economic forces to the
structures (e.g., partners, resources) and processes (e.g., participa-
tion, decision making) associated with collaborative community
approaches to planning, implementing, enforcing, evaluating, and
sustaining these prevention interventions.
Systems science methods are designed to deal with complexity and
could prove particularly useful in analyzing community-based prevention
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64 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
interventions and their impacts (Hammond, 2009; Huang et al., 2009).
Results of the application of systems science methods could prove useful in
valuing community-based prevention because they can provide information
about not only the intervention programs, policies, and associated out-
comes but also the contextual conditions, the multi-cause nature of change,
and the dynamic interactions among all of the factors.
APPLYING SYSTEMS SCIENCE TO
COMMUNITY-BASED PREVENTION
Systems science methods can be used to explore the various pathways
leading from community-based prevention interventions to improvements
in population behavioral and health outcomes, such as the influence of a
sugar-sweetened beverage tax on the purchase and consumption of foods
and beverages. Such methods can also capture the variation in these path-
ways associated with contextual factors (such as population characteristics,
concentration of fast food restaurants, employment opportunities, and liv-
ing wages) and detect changes in the overall system as new interventions
surface.
Systems science methods can address both detail and dynamic complex-
ity. With respect to detail complexity, these methods can clarify assump-
tions about public health problems, local community context, and change
strategies and processes by identifying the variables and the underlying
causal relationships among the variables. At the same time these methods
are designed to examine how causal structures change over time, including
the effect of changes in the type or number of interventions implemented,
changes in social norms and community practices, changes in leadership or
staff, and so on. Examining these causal structures can help identify the sys-
tem leverage points that have the greatest potential for affecting behavioral
and health outcomes, can increase understanding about intended effects
and unintended consequences of the interventions implemented, and can
identify facilitating factors and challenges influencing community change
processes (Meadows, 1999; Sterman, 2000; Ulrich, 2000).
For examples of systems science approaches to valuing community-
based prevention interventions, see Appendix B.
VALUING COMMUNITY-BASED PREVENTION:
DOMAINS AND ELEMENTS
Policy makers, funders, and relevant stakeholders make decisions about
the value of community-based interventions. Traditional approaches to
assess value tend to focus solely on health impacts, to value interventions
in isolation, to overlook community processes, and to fail to monitor
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COMMUNITY-BASED PREVENTION: MORE THAN THE SUM 65
pathways toward progress. The committee was asked to develop a frame-
work for assessing the value of community-based prevention. Because of the
way in which community-based prevention is designed and developed (e.g.,
often to address the social and environmental determinants of health), the
committee concluded that impacts of these interventions go beyond health
effects. Therefore, a framework for valuing community-based prevention
needs to take into account not only the outcomes in the domain of health,
but also the outcomes in areas other than health. A framework that does
not take into account and value non-health outcomes would be counting
all the costs but not all the benefits, thereby providing an inaccurate and
inadequate picture of the value of community-based prevention. To assess
the true value of community-based prevention, therefore, decision makers,
funders, and stakeholders would benefit from an approach that looks not
just at health impacts, but at other impacts as well.
A major task facing the committee, then, was determining what do-
mains should be included in a framework to value community-based pre-
vention interventions. As a first step, each committee member was asked
to list the outcomes he or she thought could result from community-based
prevention interventions. The list generated included more than 100 items
and all acknowledged that not everything that could be valued appeared
on the list. As a next step, the committee decided to group the items into
major categories. Clearly, a major outcome of community-based prevention
is its impact on health. Therefore, health was identified as a major domain
of interest.
However, there were a number of other items on the list that did not
fall neatly into a health domain, for example, education, income, green
space, crime, social support, and workplace safety. Initially, the commit-
tee identified six major categories under which these other items could be
grouped: social environment, physical environment, economics, equity, em-
ployment, and education. Yet, as the committee discussed these items and
reviewed the literature, it became clear that these elements were all elements
related to well-being. Therefore, the committee identified a second major
domain as the domain of community well-being.
There were a number of items that did not fit readily into either the
health category or the well-being category but which the committee identi-
fied as important items of value, including such things as leadership, skill
building, and civic participation. An examination of the history of com-
munity health efforts demonstrates that various process elements (such
as skill building, leadership, and participation) are features that account
for the relative success of community-based programs. Early efforts in the
first half of the 20th century involved engaging stakeholder organizations
and affected populations in first, the support of planned programs, then
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66 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
in actually planning programs, then in evaluating programs, and finally in
community-based participatory research (CBPR) (Green, 1986).
Based on the literature of CBPR (e.g., Minkler and Wallerstein, 2008)
the committee deliberately decided to identify community process as a spe-
cific area of valued outcomes for community-based prevention.
Elements in the community process domain inherently affect outcomes
upstream (e.g., civic participation) that, in turn, affect outcomes down-
stream (e.g., policy adoption and implementation), further downstream
(e.g., equitable access to environments or resources to support health), fur-
ther downstream (e.g., healthy behaviors of citizens in these environments
or use of these resources), further downstream (e.g., healthy lifestyle choices
of citizens), and, ultimately, health (although health feeds back to greater
capacity for civic participation). Therefore, the committee concludes com-
munity process should be identified as a separate domain because in many
cases, community empowerment and community capacity have been shown
to be valued by communities in their own right (Sandoval et al., 2011).
Also, because process elements are intermediary outcomes that increase
well-being and health interventions (Minkler et al., 2008; Viswanathan
et al., 2004), failing to recognize the increase of such potential as a valued
outcome will further disadvantage those communities whose structural and
population characteristics put them at increased risk of health and well-
being deficit. It is important to note that without a solid grounding in sci-
ence, community process, as is the case with any democratic process, could
lead to worse outcomes with respect to health and well-being.
This section of Chapter 3 describes in more detail the wide array of ef-
fects that community-based prevention can have, grouping them under the
three distinct but interrelated categories of outcomes, or domains of value:
health, community well-being, and community process. The committee is
aware that health is a component of well-being but for purposes of this re-
port the health component is separated from other elements of community
well-being because health is a particular outcome of interest. The goal in
valuing these domains is to account for all of the potential harms and ben-
efits of community-based interventions as well as the possible savings and
costs associated with the interventions. This section introduces the domains
of value as well as associated elements.
It is important to note that the list of elements included in each domain
below is meant to be illustrative. The actual elements selected for valuing
will depend on the particular intervention and its implementation. It is un-
likely that any given intervention will have value in all elements listed, and
there may well be other elements not listed here that should be included.
The committee has identified one element, equity, that crosses all domains.
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COMMUNITY-BASED PREVENTION: MORE THAN THE SUM 67
Health
Physical health includes mortality, morbidity, and functional capability.
Mental health includes cognition, individual resilience or emotional re-
serves, mortality due to such causes as suicide, morbidity (e.g., depression),
and socio-emotional health-related quality of life (e.g., stress, behaviors,
injuries, and perceptions of health). The promotion of mental and physical
health includes several elements, in particular, reductions in the incidence
and prevalence of disease, declines in mortality, and increases in health-
related quality of life. Equity is another important element in the health
domain. It is well documented that significant health disparities exist by
race, ethnicity, and socioeconomic status (SES) (AHRQ, 2012; APHA, no
date; IOM, 2003). Health inequalities across demographic groups (e.g.,
by race, ethnicity, gender, and SES) may be caused by inequalities in ac-
cess to health care, by the unequal effect of public measures aimed at risk
reduction, or by the unequal distribution of various social determinants
of health (e.g., education, income and wealth, opportunity and liberty)
(AHRQ, 2012; IOM, 2003, 2009). It may be, however, that the two goals
of health policy—improving population health in the aggregate and distrib-
uting health fairly—are in tension. For example, some efforts that improve
population health in the aggregate may increase health inequalities between
groups, for example, a campaign to improve prenatal care that primarily
reaches middle to higher income women and is not effective among lower
income women may well increase health disparities. Reasonable people may
disagree about when to give priority to one goal over the other. However,
when assessing value, health inequalities are one element to consider.
The charge to the committee specified a focus on the prevention of
long-term chronic diseases. As noted throughout the report, long-term
chronic illnesses are often the result of a complex, extended interaction
between genetics, individual behaviors, and environments. This complex-
ity can make the task of valuing more difficult. For example, behaviors,
such as eating foods with minimal nutritional value and participating in
sedentary activities that can lead to obesity and related chronic diseases, are
generally the result of lifestyles shaped in part by an individual’s environ-
ment. Lifestyle interventions aimed at preventing certain diseases, such as
cardiovascular disease (CVD) and diabetes, have been shown to be effective
(Saha et al., 2010). However, lowering the prevalence of CVD and diabetes
is an outcome that takes a long time to realize. Interventions aimed at such
outcomes can produce intermediate markers, such as decreased insulin
resistance or lower blood pressure. For long-term outcomes such as the pre-
vention of chronic disease, it will be important to identify intermediate or
proximal outcomes as part of the valuation and determination of progress.
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68 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
Community Well-Being
Community well-being is a valued outcome in and of itself. Independent
of the health of individuals in a community, the concept of community well-
being has been used to account for elements associated with community
context, or the social, economic, and physical environments characterizing
the community (IOM, 2009). Elements of community well-being include
wealth and income, education, employment, safety, transportation, hous-
ing, worksites, food, health care, and recreational spaces, among others.
These elements are produced, reproduced, and transformed by the practice
of individuals in the community. Their benefits accrue to both individuals
and the community as a whole.
Physical Environment
Frumkin (2003) writes of the “atmosphere of a place, the quality of its
environment” and the effect that it can have on both health and well-being.
He identified four aspects of the built environment that may have an impact
on human health and community well-being: nature contact, buildings,
public spaces, and urban form. The built environment includes how land
is used, the quality of housing and other buildings, transportation, and
other design features “that together provide opportunities for travel and
physical activity” and, more broadly, an environment that “is designed and
constructed by humans” (IOM, 2001; TRB/IOM, 2005).
Land use, urban form, and green space The composition of the built envi-
ronment, Frumkin’s “urban form,” has been associated with a number of
health effects. For example, physical characteristics of neighborhoods have
been found to be associated with lower levels of physical exercise and an
increased risk of obesity (Ewing et al., 2006; Lopez, 2004; Nelson et al.,
2006). The presence or absence of amenities, particularly the opportunities
to buy healthy affordable food, can also have an effect on health (Bodor
et al., 2010; Leung et al., 2011; Michimi and Wimberly, 2010; Morland et
al., 2006; Powell et al., 2007). Access to—or even the presence of—green
space is associated with increased physical activity, better perceived general
health, mitigation of the effects of stressful life events, and lower prevalence
of some illnesses (Ellaway, 2005; Maas et al., 2006, 2009; Ulrich, 1984;
Van Den Berg et al., 2010).
Urban form also has effects beyond those on health. For example, areas
with a high degree of “walkability” are perceived to be more aesthetically
pleasing and are associated with more unplanned interactions with others
and a greater sense of community (Wood et al., 2010). Trees in cities allow
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COMMUNITY-BASED PREVENTION: MORE THAN THE SUM 69
for greater energy conservation and lower heating and cooling costs for
buildings (McPherson et al., 1997).
Transportation Numerous studies have found that using public transit
increases physical activity (Besser and Dannenberg, 2005; Lachapelle and
Frank, 2009; Weinstein and Schimek, 2005; Wener and Evans, 2007).
MacDonald and colleagues (2010) found that commuting to work by light
rail was associated with a reduction in body mass index and reduced odds
of becoming obese. Active travel, such as walking and cycling, along with
increasing physical activity can also lead to a decrease in vehicle emissions,
thereby improving air quality (de Nazelle, 2011). Investment in public
transportation has other benefits as well—for example, bringing jobs and
economic activity to communities (Weisbrod and Reno, 2009).
Building quality (indoor air) Housing is another area that has effects on
both health and community well-being. People spend most of their time
indoors, making buildings a component of the built environment that can
have a significant impact on an individual’s health. Indoor air can contain
radon, environmental tobacco smoke, and thousands of other chemicals
and biological contaminants that pose serious risks to health (EPA, 2001).
Children, in particular, are at risk of harm from indoor and outdoor air
pollution, and the impact can be lifelong (Barakat-Haddad et al., 2012;
EPA, 2001). A 2011 IOM committee found that “poor indoor environ-
mental quality is creating health problems today and impairs the ability of
occupants to work and learn” (IOM, 2011a, p. 7). In addition to its health
benefits, providing quality housing also brings benefits to the community
in the form of such things as improved educational outcomes and reduced
crime (Carlson et al., 2011).
Social and Economic Environments
Education Extensive research has demonstrated the link between education
and health outcomes throughout the life course (IOM, 2006a; Lleras-Muney,
2005). Researchers have also documented the relationship of education and
well-being (i.e., higher earnings, higher percentages of home ownership and
second-car ownership, reduced crime, reduced welfare, reduced unemploy-
ment and reduced poverty (Barnett, 1985, 1996; Gorey, 2001; Schweinhart
et al., 1993).
Employment/unemployment Unemployment is positively associated with
mortality from all causes, with both physical and mental illness, and with
the increased use of health care services (Haan and Myck, 2009; Jin et al.,
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70 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
1995; Rueda et al., 2012; Strully, 2009; Wilkinson and Marmot, 2003).
Employment also has numerous non-health effects. For example, it is as-
sociated with more marriage, less divorce, more marital happiness, and
greater child well-being (White and Rogers, 2000). Decreases in the un-
employment rate have been found to be associated with declines in prop-
erty crime rates (Raphael and Winter-Ebmer, 2001). Rising unemployment
increases the incidence of foster home placement (Catalano et al., 1999).
Crime/safety Research has associated increased physical activity with in-
creased feelings of neighborhood safety (Harrison et al., 2007). Conversely,
those living in high crime areas were more likely to smoke and to report
poorer health, poor sleep habits, and less exercise (Johnson et al., 2009;
Shareck and Ellaway, 2011). In terms of non-health effects, crime and the
fear of violence can interfere with social interaction and trust among com-
munity members. For example, crime or the fear of crime has been found
to limit women’s movement around their environment and to increase
levels of mistrust and fear, (Keane, 1998; Ross and Jang, 2000). Milam
and colleagues (2010) found that math and reading achievement in schools
decreased significantly with increasing neighborhood violence.
Social support and social networks Social networks are defined as webs
of person-centered ties (Berkman and Glass, 2000). Numerous research
studies have shown the relationship of social support and social networks
to both physical and mental health (Berkman and Glass, 2000; Berkman
and Kawachi, 2000; Cohen et al., 2000; Cornwell and Waite, 2009;
Kawachi and Berkman, 2003; Marmot and Wilkinson, 1999; Maulik et
al., 2009; Stansfeld et al., 1999). However, in addition to their relation-
ship to health, social networks and social support are important in and
of themselves. For example, Skogan (1989) found that neighborhoods
in which residents have organizations and social support resources upon
which to draw have more opportunity for action in “defense of their
community.” Research has also shown that positive academic outcomes
are promoted by social support (Garnefski and Diekstra, 1996; Malecki
and Demaray, 2007).
Social cohesion Social cohesion has been characterized by Marmot and
Wilkinson (1999) as including “mutual trust and respect between different
sections of society.” Social cohesion has been shown to be positively associ-
ated with health and levels of physical activity (Cradock et al., 2009; Kim
et al., 2008; Lindén-Boström et al., 2010; Marmot and Wilkinson, 1999).
But social cohesion also has important effects beyond those on health. For
example, areas with higher levels of social cohesion are associated with
lower levels of crime, with increasing contributions to group goals, and
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COMMUNITY-BASED PREVENTION: MORE THAN THE SUM 71
with economic prosperity (Hirschfield and Bowers, 1997; Shimizu, 2011;
Stanley, 2003).
Equity As mentioned previously, equity is an important element that
crosses all three domains. Elements of community well-being are often not
equitably distributed in a community. For example, both education and
wealth, which are elements of the social environment, are often distributed
unequally by race, and considerable attention has been given in recent lit-
erature to growing inequalities in income and wealth. The same point may
be made for social trust: Levels may vary across various groups in a society,
and some practices may weaken trust across groups. The built environment
in a society may also be inequitable in its impact on different groups—
neighborhoods may vary in the quality of housing, green space, transpor-
tation, or even access to fresh food. It is important in valuing community
well-being to focus not only on aggregate measures, but also on how com-
munity well-being is distributed. Inequity in the distribution of these aspects
of community well-being may lead to inequities in the distribution of health
and may also contribute to inequities in community processes.
Community Processes
Community-based prevention involves decisions among groups of peo-
ple about how to live in society, how cities are built, what food is served
in schools, and so on. Therefore, it is important that the process by which
an intervention is adopted and undertaken be treated as a valued outcome.
With a vaccination, effectiveness does not depend on whether the patient
trusts the doctor. In contrast, the success of a healthful eating campaign
may hinge on the level of trust in the process.
Community processes refer to several elements that have a distinc-
tive influence on community participation in the decision making as well
as in the design and implementation associated with community-based
interventions. These elements include civic engagement, local leadership
development, community participation, trust, skill building, transparency,
and inclusiveness. Community processes typically have a sequence of ac-
tivities that incorporate learning about various options available for health
improvement, deliberations associated with the selection of one or more
options, consideration of the appropriate methods to implement the health
improvement initiatives, and critical reflection on the entire process. The
way that decisions are made and carried out not only can be important to
the success of a strategy or policy—and thus to community well-being—but
also can have a direct impact on well-being through benefits of broad partic-
ipation and buy-in to decisions (Minkler and Wallerstein, 2008; Wallerstein
and Duran, 2010). Community processes also support local adaptation and
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78 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
Various governmental and nongovernmental groups recommend—or
require—specific discount rates, but there is no general agreement among
them on what the discount rate should be (Jawad and Ozbay, 2006). For
example, the Office of Management and Budget recommends a real (ad-
justed for inflation) discount rate of 7 percent per year, with 3 percent as
an alternative to test the sensitivity of an evaluation’s results to the discount
rate (OMB, 2003). The Panel on Cost-Effectiveness in Health and Medicine
recommends a real rate of 3 percent for cost-effectiveness analyses and the
National Institute of Health and Clinical Excellence in the United Kingdom
requires a real rate of 3.5 percent.
DATA SOURCES AND INDICATORS FOR
VALUING COMMUNITY-BASED PREVENTION
There are a variety of sources of data on health, including surveys
(e.g., the National Health Interview Survey and the Behavioral Risk Factor
Surveillance System), cohort studies (e.g., the Framingham Heart Study),
registries, health services data, vital statistics, and data collected by state
public health agencies. Unfortunately, there are several limitations on using
these data for local, community-based measurement (IOM, 2011b). For
example, national surveys are unable to provide the detailed data needed
for local estimates without specifically designing local data collection. Reg-
istries and health services data provide information only about those who
seek and receive health services, cohort studies are resource intensive,
and vital statistics are subject to coding errors (IOM, 2011b). To collect
information to measure baseline health and changes in health at the local
level may require developing and implementing local surveys aimed at the
specific health issues of interest.
Identifying measures and sources of information for community well-
being and community process elements is even more challenging than
collecting such information about health. Table 3-2 lists elements and
indicators that could be used in the three domains of interest: health, com-
munity well-being, and community process. As stated before, these are
examples only. The actual elements and indicators chosen will depend on
the community-based prevention intervention being considered.
Applying methods from systems science to community-based preven-
tion efforts can help increase our understanding of the complex interre-
lationships among factors important to building healthy populations and
healthy communities. The following chapter discusses how a framework for
valuing resides 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.
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COMMUNITY-BASED PREVENTION: MORE THAN THE SUM 79
TABLE 3-2 Domains and Examples of Elements and Indicators for
Valuing Community-Based Prevention Interventions
Value
Component Elements (examples) Possible Measures (data sources)
Health Overall Overall
1. Quality of life 1. Quality-adjusted life year (QALY)
or health-adjusted life expectancy
(HALE)
2. Perceived health 2. Self-reported health status
Physical Physical
1. Mortality (overall and per cause) 1. Deaths
2. Morbidity 2. Rates of conditions or diseases of
interest, unhealthy days
3. Functional capability 3. Level of activities of daily living,
exercise
4. Injuries 4. Rates of injuries
Mental Mental—Change in rates
1. Cognition 1. Cognitive Abilities Screening
Instrument (Adult), Dementia
Rating Scale (Adult), Differential
Abilities Scale (Children)
2. Morbidity 2. Self-reported unhealthy days
mental
3. Depression 3. Self-reported healthy days mental
Anxiety
Stress
Perceived well-being
4. Suicide rates 4. Rates of suicides
Community Built environment Built environment
Well-Being 1. Land use 1. Number and quality of facilities—
schools, libraries, housing
2. Transportation 2. Number of sidewalks for walking,
bike paths, buses, metro/trains,
automobiles.
3. Building quality (indoor air) 3. Levels of pollutants (e.g., radon,
tobacco smoke, chemicals)
4. Food systems 4. Grocery stores with healthy
choices, farmer’s markets
continued
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80 ASSESSING THE VALUE OF COMMUNITY-BASED PREVENTION
TABLE 3-2 Continued
Value
Component Elements (examples) Possible Measures (data sources)
Natural physical environment Natural physical environment
Green space Parks, preserved open spaces, beauty
Social and economic environments Social and economic environments
1. Social support and social 1. Number, type, frequency of
networks contact
2. Social cohesion 2. Trust, respect
3. Education 3. Number and quality of schools
a. Resources a. Books, computers, play
equipment, class size
b. Achievement b. 3rd-grade reading level, high
school and college graduation
rates
c. Health literacy c. Change in level of health
literacy
4. Employment 4. Employment/unemployment rate
a. Safe work places a. Physical environment and job
effort
b. Stress b. Job demand versus control, job
effort versus rewards
c. Income c. Wages, food stamp use
5. Crime/safety 5. Rates for various crimes
6. Access to health care and health 6. Number and type of health care
insurance facilities, rate of uninsured
Community 1. Local leadership development 1. Elected leaders reflect community
Process diversity, number and type of
community activists
2. Skill building 2. Number and type of peer
counselors and community
organizers
3. Civic engagement or participation 3. Voting rates, volunteering,
participation in clubs or other
local organizations
4. Community mobilization 4. Involvement in civic activities (e.g.,
town hall meetings)
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COMMUNITY-BASED PREVENTION: MORE THAN THE SUM 81
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