Many public health solutions to chronic diseases involve individual lifestyle choices: eating more healthfully, increasing physical activity, and quitting smoking. This approach neglects barriers in the community environment that make modifying unhealthy behaviors challenging. Addressing environmental barriers is an essential strategy to supporting behavioral changes. Changing community environments that contribute to unhealthy behaviors can improve community health.
Community indicator reports can be used to strengthen community environments for optimum health. The reports are comprehensive evaluations of community well-being that reflect community factors that influence health. Prevention Institute studied community indicator reports for The California Endowment and produced
Thinking about health as a function of environmental influences in our communities shifts the focus from individual behaviors to health needs and barriers that can be addressed through broad strategies such as policy change. Good health is a cornerstone of community members' quality of life and productivity and of the community's economy. Community indicator reports and report cards can be used to enhance the process of restoring good health in a community.
Most people understand prevention of chronic disease on an individual level. Accordingly, many public health solutions involve individual and lifestyle changes: eating more healthfully, increasing physical activity, and reducing or quitting smoking. Environmental barriers in the community can make modifying unhealthy behaviors challenging. Poor environmental quality; inadequate access to affordable, nutritious food; and safety issues often make healthy living impractical, particularly in low-income communities and communities of color. Although education can play a role in influencing individual behavioral choices, addressing environmental variables is an essential strategy to supporting behavioral change. Analyzing the underlying causes of inadequate diets and low levels of physical activity, for example, shows that community conditions play an important role in shaping health-related behaviors. To have an impact on rates of chronic disease, community environments must support and encourage healthy habits.
The Institute of Medicine affirmed the need to focus on changing the environment in order to foster behavior change, asserting:
To prevent disease, we increasingly ask people to do things that they have not done previously, to stop doing things they have been doing for years, and to do more of some things and less of other things. . . . 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 (
For example, environments supportive of reducing asthma, lung cancer, and cardiovascular disease would address the availability of tobacco, safe and affordable access to healthy food, safe access to physical activity, social cohesion and environmental design that encourage physical activity, and social and behavioral norms that encourage healthy habits and discourage unhealthy ones (Table). Understanding risk behaviors associated with chronic diseases and the elements of the community environment that contribute to those risk behaviors enables communities to develop strategies for addressing environmental factors. Indicators also serve as a tool for tracking progress in altering the community environment to support better health outcomes.
By paying attention to community environments that contribute to unhealthy behaviors, community indicator reports are an important tool for improving community health. Community indicator reports are comprehensive evaluations of community well-being that include multiple categories, reflecting various aspects of the ways people live and the living conditions in neighborhoods, cities, counties, states, or countries. They can be used to broaden the definition of health, develop local priorities, track progress, and bring disparate groups together in support of community health (
Prevention Institute reviewed 79 community indicator reports and 9 popular-culture report cards and interviewed 64 key informants. A review of literature also informed the study. As defined in
Community indicator reports use different naming conventions to categorize information. For example, the term
The reports reviewed for
Community indicator reports share many common features and criteria for development, even though they often differ in their approaches. The reports reviewed were categorized as quality of life, sustainability, health status, social well-being, and government performance. Many of the reports were not specifically referred to as community health reports, yet they offered valuable information about one or more elements in the community environment that contribute to the health of the community they describe.
Generally, community indicator reports are comprehensive summaries of community conditions, including health status, that include explanations about what each indicator means and why it is important. Occasionally, community report cards will feature highlights from larger reports and provide additional meaning to the information by adding grades, rankings, or comparisons as a way to track progress or performance over time in a way that readers recognize. They are, by definition, selective in what they report, but the use of grades and other types of judgments can be effective in improving community health outcomes. For example, providing incentives for change, especially when the grades identify key indicators and establish priorities, contributes to ownership and to action around potential solutions.
Although community indicator reports and report cards serve various purposes, a number of elements emerged that facilitate their use by advocates, community members, health departments, and other stakeholders (
Tracks progress and trends
Is actionable
Establishes accountability
Focuses on community assets
Captures what is important
Is grounded in a plausible theory of change
Uses credible and trustworthy data
Uses meaningful language
Is accessible and user-friendly
Is values-based
Community indicator reports facilitate community improvement in a number of different ways. They may foster community engagement and collaboration, improve health care quality, identify agendas for public resource distribution, set baselines for government performance, monitor progress in government performance or community health and well-being, inform public policy development and advocate for specific policies, or do a combination of these. Some reports focus on improving community health through a particular sector, whereas others suggest multisector collaborations to achieve the desired outcome.
Presents a vision for community health
Focuses goals based on key opportunities
Fosters collaboration based on relationships between sectors
Selects key indicators for maximum leverage in a given sector
Establishes accountability
Makes a commitment to data source development
Promotes and continues to seek ongoing community input
The process of developing community indicators is aimed at report creation, but several additional elements of the process are important for a successful outcome (
The following case studies illustrate many of the possible outcomes of community indicator reports. In West Oakland, California, a powerful coalition of local organizations worked together to rid the community of a source of air pollution. Their efforts educated and empowered the community, forming the foundation for further community action. In King County, Washington, the local public health department initiated a report that revealed county strengths and needs, enabling the community to identify its priorities, guide funding decisions, and suggest actions that strengthened the community environment. The example of Jacksonville, Florida, shows that long-term tracking of community indicators can influence public policy and planning in support of comprehensive social services.
Released in 2002,
In 2005, the Seattle-King County Public Health Department published
Now in its 22nd year, the
Developing a strategy for promoting community health requires understanding the places where people live, work, and play. Community indicator reports can be an important tool to assess and strengthen community environments for good health, enabling people to be productive, to learn, and to live healthy lives with dignity and self-determination.
Over the past 2 decades, community indicators and indicator reports have proliferated. Three broad themes are associated with the widespread use of indicator reports: the existence of many local initiatives aimed at improving general community well-being and quality of life; the evolution of a broadened definition of health, which has shaped the content of indicators; and the influence of the expanded availability and use of data.
The quality and accessibility of data have improved markedly over the past 25 years, which has strengthened the capacity to measure and monitor health. Information technology, combined with new and expanded sources of data, has transformed health assessment dramatically.
With these increases in data capacity, community indicator reports can facilitate community improvement by fostering community engagement and collaboration, framing accountability, informing policy, and gaining media attention.
This paper is an adaptation of a forthcoming document prepared for The California Endowment:
The authors acknowledge the many individuals and organizations who contributed to this work, in particular, Larry Cohen, MSW, Jeremy Cantor, MPH, and Michele Silver from Prevention Institute, Oakland, California. Ms Silver is now with the Partnership for the Public's Health in Oakland, California, a project of the Public Health Institute. We also thank Cheryl Wold, MPH, of Wold and Associates, Pasadena, California, for her contribution to this research.
The research described in this paper was funded through a contract with The California Endowment.
Community Environments, Mediating Indicators, and Chronic Disease, United States, 2006
What is sold and how it is promoted Look, feel, and safety Parks and open space Getting around Housing Air, water, and soil Arts and culture | Residents who eat 5 servings of fruits and vegetables per day. No. and types of supermarkets Alcohol outlet density Tree planting Abandoned buildings Life on the street (e.g., foot traffic) Places to play Perceived safety Safe, clean parks Bikeable and walkable streets Public transport availability Travel time to work Average weekday bus ridership per 1,000 people Housing affordability Owner-occupied housing Density/people per unit Local wild salmon runs Air quality Beach closures Water quality Pollution in neighborhoods Participation in arts and culture | These factors and sample indicators are associated with eating and nutrition, alcohol consumption, physical activity levels, and level of exposure to toxins, all of which can increase or reduce the risk of multiple forms of chronic disease, such as asthma, cancers, cardiovascular disease, and diabetes. |
Social networks and trust Participation and willingness to act for the common good Acceptable behaviors and attitudes | Neighborhood involvement Local and indigenous leadership Sense of community Commitment to community among its members Trust Voter activity Volunteerism Tendency to intervene or act to achieve community aims Availability of alcohol and cigarettes to minors | These factors and sample indicators are associated with social support for, and norms related to, multiple behaviors (e.g., eating, drinking, physical activity, sexual activity) as well as the capacity to make community-level changes that can improve health outcomes (e.g., reduce toxic exposure, obtain land for a new park, open a grocery store). Related chronic diseases include cancers, cardiovascular disease, diabetes, HIV/AIDS, and mental health problems. |
Racial justice Jobs and local ownership Education | Racially balanced schools Perceptions of racism Business ownership Percentage at or above living wage Unemployment and employment rates Local ownership of assets Reading level School success (dropout/graduation) Percentage of parents reading daily to their children | Access and equity affect health in fundamental ways over a lifetime, such as through stressors associated with poverty and racism. These factors are correlated with multiple chronic diseases. |
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