Building a Thriving Nation

Prevention Institute: Advancing Health, Equity, and Community Well-Being

When I began working on prevention more than 30 years ago, it was frequently trivialized and misunderstood as mainly handing out brochures at public events. I quickly learned that the optimal strategies for prevention must go beyond brochures: Health counseling and education certainly play a role, but they are insufficient. We need to focus on making healthy environments the default and the norm in our communities. This can only be accomplished through a spectrum of prevention strategies.

I founded Prevention Institute (PI) in 1997 to provide a national focal point for the growing attention to prevention, with a vision of improved environments for all and an emphasis on equity. PI is devoted to developing cutting-edge public health and prevention strategies for organizations, practitioners, and policymakers; supporting community-led initiatives; and promoting policy and organizational practice changes on the local, state, and federal levels. When we work with organizations and communities to advance prevention, we also learn new strategies and examples that become part of our ever-growing understanding of the best ways to practice prevention. Identifying the best strategies for any community can be challenging. PI has designed a series of practical tools to help communities’ leaders work together to tailor and implement the strategies that will be most effective for addressing local needs. (Several are described below.)

The Community Prevention Movement

Over the last generation, well-developed approaches for effectively addressing the community factors that shape our health have been emerging; together, they can be called community prevention. Emphasizing the community as a unit of analysis is important. Clearly, family and individual well-being is ultimately the goal, but community conditions are critical in determining an individual’s or family’s health. Community action also is often the impetus of national-level decisions that vitally shape individual and community well-being—that is, local policy bubbles up.

Community prevention strategies create lasting changes at the community level by addressing specific policies and practices in the environments and institutions that shape our lives and our health—from schools and workplaces to neighborhoods and government. The focus on community prevention has steadily grown in the past 40 years as the lessons learned from efforts such as reducing HIV transmission, curbing tobacco use, minimizing DUIs (driving under influence), and creating opportunities for healthy eating and physical activity have confirmed the effectiveness of community approaches. Essentially, a focus on changes to the social, cultural, and physical environment effectively alters health behaviors and norms and generates positive health outcomes (Smedley & Syme, 2000; Ullmann-Margalit, 1990; U.S. Department of Health and Human Services, 2012).

We can see the flip side of this in racially and economically segregated communities that have experienced decades of neglect and have been exposed to practices and policies that have diminished quality of life. Such environments do not fully support health. Continued exposure to racism and discrimination exert a toll on physical and mental health (U.S. Department of Health and Human Services, 1999). Residents face limited economic opportunities; a lack of healthy options for food and physical activity (Grills, Villanueva, Subica, & Douglas, 2014); increased exposure to environmental hazards; substandard housing with greater prevalence of safety hazards and lead; lower-performing schools; higher rates of crime and incarceration; and higher costs for goods and services. The phrase, “it’s not your genetic code: it’s your zip code,” is an apt one where health and well-being are concerned.

These inequities in health affect all U.S. residents, as they lower cities’, states’, and the entire nation’s quality of life and productivity. As the authors of the book Unequal Treatment noted (Nelson, 2002), “All members of a community are affected by the poor health status of its least healthy members.” Of course, poor health hits disenfranchised populations the hardest, including people of color, immigrants, those with low income, people with disabilities, and LGBTQ people. It is essential to facilitate a deeper collective understanding of how root causes—such as poverty, racism, and other prejudice and oppression—shape community environments and norms that, in turn, influence outcomes for health, safety, and health equity. What is more, we must translate this understanding into effective community strategies and governmental policies to address and redress the inequities.

Taking Two Sttif to Prevention: Identifying the Underlying Influencers of Health

One key to community prevention is discovering the specific health-deterring elements of the community environment that enable behaviors and conditions that contribute to disease or injury and, alternately, that enhance health and resilience factors. To make this clear and useful, it can be easier to start with an illness and injury, and take one step backward to the contributing behaviors and conditions, then take another step backward to the community conditions and norms that lead to those behaviors and conditions in the first place. PI calls this “Taking Two Sttif to Prevention” (see Figure 1; Prevention Institute, 2006, 2009).

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Figure 1.

Two Steps to Prevention.

When most people think of a medical condition, such as a heart attack, they immediately think of the medical interventions and drugs needed to treat the condition. That, of course, is critical for the individual patient, but if we do not want an ever-continuing stream of patients, we need to understand how to reduce the number of people who have heart attacks in the first place. Taking the first step back from a heart attack identifies risky behaviors, such as eating poorly and being sedentary. Taking the second step back reveals the environment that shapes the behaviors—perhaps there is no safe place for physical activity, and unhealthy food is all that is available in the neighborhood. Uncovering these community factors clarifies the kinds of community change that would be beneficial, such as creating safer parks or encouraging healthier food outlets to locate to the neighborhood.

Through an extensive and deliberate research process, combined with experience in the field and expert review, PI has identified the main community determinants linked to the leading causes of death, illness, injury, and inequity. Once those elements in a community are identified, community members and leadership can implement strategies for enhancing the factors that promote health. PI’s THRIVE (Tool for Health and Resilience in Vulnerable Environments) is both a tool and process for assessing the status of community conditions and prioritizing actions to improve health, safety, and health equity (see Figure 2; Prevention Institute, 2004).

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Figure 2.

The THRIVE elements of community health.

The Spectrum of Prevention

Quality community prevention involves comprehensive and synergistic activities. Individual behavior change (e.g., stopping smoking) may be a goal of prevention activities, but achieving that goal for the broader population requires changing community norms around the behavior. Typically, changing norms requires altering organizational practices and policies/laws, because these help transform the community environment and have the greatest impact on the full population. Efforts to influence policies like public smoking bans are also more likely to succeed when public awareness and support are garnered through individual and community education, and when a variety of partners in different sectors work together to effect the desired change.

For example, people used to expect to smoke or encounter smoke on airlines; now we expect the opposite. Our expectations and norms for behavior have changed. We have made not smoking the default through comprehensive approaches from changing organizational practices (e.g., pharmacies not selling tobacco products) and changing policies (e.g., creating tobacco-free parks and public spaces) to discouraging tobacco purchases (e.g., taxes) and providing supportive information to the public to underline the risks and combat the industry’s persuasive advertising (e.g., distributing information on the dangers of secondhand smoke).

To ensure successful implementation of all these activities, PI’s signature tool the Spectrum of Prevention (Prevention Institute, 1999) helps communities identify and implement comprehensive solutions for modifying the range of conditions that contribute to health or that lead to illness and injury. Prevention activities can be implemented at any of the Spectrum’s six levels, but when all Spectrum levels are applied as part of a cohesive plan, the effect can be transformative (see Figure 3).

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Figure 3.

Spectrum of Prevention.

Effective Coalition Building: The Eight-Step Guide and Collaboration Multiplier

After uncovering community environmental determinants and shaping an initial set of potential strategies, it takes the effort of many groups working together to spur changes that improve health. By coordinating efforts, groups can achieve broader success and accomplish outcomes that none could achieve alone. Building an effective coalition is challenging, however, so PI created an eight-step guide—a detailed framework to engage individuals, organizations, and governmental partners in addressing community concerns (see Figure 4; Prevention Institute, 2002).

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Figure 4.

Developing effective coalitions: The eight-step process.

Over the past decade, it has become increasingly understood that as well as working with different groups from the same sector, working across sectors can bring about significant, sustainable improvements in health and equity outcomes. For example, higher rates of breastfeeding are not achievable without the deliberate participation of health care, business, media, public health, government, and community-based organization. PI’s interactive Collaboration Multiplier (Prevention Institute, 2011) tool can help in analyzing and planning efforts across fields. The tool is designed to guide organizations in better understanding which partners are needed—and how to engage them—to achieve specific solutions. It also helps coalitions identify the activities necessary to achieve a common goal, delineate partner perspectives and contributions, and leverage expertise and resources (see Figure 5). ¹

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Figure 5.

The Collaboration Multiplier.

Putting Community Prevention Into Practice: Reframing the Nutrition and Physical Activity Debate in California

At the turn of the millennium, very few people talked about eating and physical activity being influenced by the environment—focusing instead on individual behavior. PI and several California-based leaders set out to change that by forming the Strategic Alliance network in 2001 (Aboelata & Gibson, 2013). Recognizing the urgent need for a change in approach, Strategic Alliance explicitly stated that its goal was to reframe the perspective on eating and activity from individual choice to a focus on corporate and government practices. Strategic Alliance member organizations and numerous others joined forces to advance a singular purpose: emphasize cutting-edge policies and practices to improve eating and activity opportunities for all Californians.

Over the past decade-and-a-half, Alliance members have mobilized their considerable network to improve community conditions and this effort has translated discussion into practical outcomes in California at the state and local levels. Alliance members have advocated for state laws and local actions that have established nutrition guidelines for beverages served in child care settings; increased breastfeeding support; established a Healthy Food Financing Initiative fund; brought Safe Routes to School programs to underserved communities; and encouraged shared-use initiatives (e.g., the use of school space for community recreation after school hours). The success of the Strategic Alliance is a testament to the power that coalitions and networks can wield when focused on a common goal. Notably, its approach of partnering to effect community-wide change, its insistence that activity and food issues be linked and mutually supporting, and its broad reframing of healthy eating and activity as requiring systemic not individual solutions have catalyzed broad national efforts and served as a model for the nation.

Community-Centered Health: Transforming Health Care to Truly Incorporate Prevention

The United States currently spends 17.4% of its GDP (gross domestic product) on providing health care to its residents (Center for Medicare and Medicaid Services, 2013). Only 3% of that health care sum goes to prevention. This focus on health care treatment with a dash of prevention is not working so well: the United States ranks 26th among 36 OECD (Organization for Economic Co-operation and Development, 2013) countries in life expectancy. Iatrogenic conditions (caused by treatment errors and pharmaceutical effects) are the third-leading cause of death in our country (Starfield, 2000). And 7 in 10 deaths in the United States are related to preventable chronic diseases such as diabetes, high blood pressure, heart disease, and cancer, as well as injuries (Gerberding, Marks, Mokdad, & Stroup, 2004; McGinnis & Foege, 1993; National Center for Chronic Disease Prevention and Health Promotion, 2009)—inflicting intense suffering on our families, taxing our medical delivery system, and draining our coffers.

To change these statistics, we must shift the way we perceive and approach health, expose our overreliance on individual solutions and medical services, and transition to a culture of health that embraces primary prevention to keep all people healthy and safe. PI has created a strategy for community-centered health to emphasize that the health system should better incorporate community prevention. We are encouraged by the growing conviction by health care leaders that prevention can improve quality and reduce demand and cost, as well as the beginning of a shift in rules and payment structures away from simply paying for health care for people who are already sick.

Our effort began with the development of a model called Community-Centered Health Homes (CCHHs; Cantor et al., 2011)—an expansion of the well-known patient-centered health home concept that many in the medical field have embraced. CCHHs integrate high-quality medical care with prevention strategies for improving community conditions. We expanded the focus from “patient” to “community” because, as we have seen, community is the primary determinant of health. Research has shown that while 10% of health is determined by medical care and 20% by genetics, 70% is determined by behaviors and environment (Lee & Paxman, 1997). Importantly, the same environmental conditions that enable patients to restore their health also keep people healthy in the first place. For example, a farmers market, fewer junk food and alcohol advertisements, or a safer park where people can walk and play not only benefit patients with diabetes or heart disease—they help everyone to stay healthy.

CCHHs engage doctors, nurses, and the entire health system in making use of their day-to-day patient work to identify the underlying conditions that contribute to poor health in their neighborhoods and cities—and to change those conditions for the better. They may, for example, notice a trend of asthma in patients who live in a particular housing complex, and report it to the city. The credibility and institutional leverage of health care professionals, as well as the nature of their interaction with the public, engenders successful partnering with community entities to change upstream factors that influence public health.

There is no question this transformation will be difficult. However, effectively integrating community prevention into health services delivery will be critical to health reform implementation and overall efforts to expand coverage, improve quality, and reduce costs. The Robert Wood Johnson Foundation aptly calls this focus on community a “new culture of health.” We think of this as a transition from a sick-care system to one the supports health in the first place. To realize this, we must shift what we prioritize and the ways we spend our money. Importantly, the CCHH model is serving as both a method and a metaphor for health care engagement in changing community environments and thereby improving health.

After 4 years of on-the-ground exploration of CCHHs nationwide, and related innovations emerging from across the country, we are beginning to see a shift. In health care circles, we hear conversations about the importance of community environments and social determinants, especially the elements that can diminish people’s need for medical care. More community clinics and health care organizations are fostering community initiatives to prevent disease and injury, and to help people who are sick and injured to heal. We see growing momentum for implementing activities based on health needs rather than health care needs alone, and for designing an approach for caring rather than simply treating.

Reinvigorating the Movement

It takes an independent spirit and ingenuity to break from the status quo. Luckily, independent spirit and ingenuity are core American values. Consolidating years of experience, we know what to do to save lives, reduce misery, and spend our resources more wisely. The time is right for the public health and prevention fields—including governmental public health and all the community, philanthropic, health care, and business colleagues who are engaged in and care about this area—to take a fresh look at what we do and how we do it.

To embrace a 21st-century approach to advancing health and equity, we must engage more deeply with health care and community institutions as well as leaders in sectors beyond public health; seek solutions that flow from the grassroots; engage businesses in promoting community health; and build a shared movement by broadcasting a new vision of opportunity that will save lives, preserve much-needed health care resources, and improve the quality of life of all. We must challenge industries that provide and market unhealthy products and who for too long have been allowed to profit by ignoring—or worsening—our health and safety. And we must chart a new path to health that is better than the one currently offered by large portions of the health care and pharmaceutical industries. For industry as a whole to thrive, health must become an ethical, prioritized enterprise for all.

We must never stop taking on what seems to be impossible. Major policy victories that required people to change unhealthy habits over time are now often remembered as easy victories—such as tobacco control, vehicle safety restraints, and reducing drunk driving. These were, in fact, hard-won battles that took many years of intense work. When Bob Sanders initiated the nation’s first car seat law, he arguably could not have chosen a more challenging state to begin with than Tennessee. But it was his home state, where he personally saw children injured and, in some cases, killed by preventable injuries. He too was told his efforts were impossible. And with perseverance, he prevailed.

We will need to develop new financial strategies to support prevention. This includes “closing the loop” (Cohen & Iton, 2014) to capture the taxes and fees related to health issues and applying these revenues to prevention, as well as capturing the money saved from reducing health care costs and the expenses saved in other sectors because of prevention (e.g., auto safety and violence prevention save money in policing and criminal justice; Fight Crime: Invest in Kids in Philadelphia, 2006; Institute of Medicine, 2011; RAND, 1998). We will need to ensure these substantial savings are indeed reinvested in prevention.

Profound change is never easy, but it is guaranteed when we engage together. We have a striking opportunity to reframe health in a way that builds on emerging practices and innovation. Each of us can contribute, and together we can build a powerful movement to hasten transformation in our nation’s health. The innovative sttif that communities and practitioners have already taken to advance health must be deliberately integrated into a comprehensive, 21st-century approach to health, equity, and safety. The health of our residents, and our nation itself, depends on it.