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Improving community health "from the ground up" entails a comprehensive ecological approach, deep involvement of community-based entities, and addressing social determinants of population health status. Although the Centers for Disease Control and Prevention, the Office of the Surgeon General, and other authorities have called for public health to be an "inter-sector" enterprise, few models have surfaced that feature local health departments as a key part of the collaborative model for effecting community-level change. This paper presents evaluation findings and lessons learned from the Partnership for the Public's Health (PPH), a comprehensive community initiative that featured a central role for local health departments with their community partners. Funded by The California Endowment, PPH provided technical and financial resources to 39 community partnerships in 14 local health department jurisdictions in California to promote community and health department capacity building and community-level policy and systems change designed to produce long-term improvements in population health. The evaluation used multiple data sources to create progress ratings for each partnership in five goal areas related to capacity building, community health improvement programs, and policy and systems change. Overall results were generally positive; in particular, of the 37 partnerships funded continuously throughout the 5 years of the initiative, between 25% and 40% were able to make a high level of progress in each of the Initiative's five goal areas. Factors associated with partnership success were also identified by local evaluators. These results showed that health departments able to work effectively with community groups had strong, committed leaders who used creative financing mechanisms, inclusive planning processes, organizational changes, and open communication to promote collaboration with the communities they served. [ABSTRACT FROM AUTHOR]

The research reported here evaluates outcomes of an intervention designed to reduce isolation and improve health and quality of life within a multiracial population of elders in Seattle. Carried out by a coalition of community groups, this intervention aimed at linking potentially isolated older people with individual peers, individuals outside their own age group, and social, volunteer, and community groups. A 3-year, longitudinal study was conducted on 87 elders. A statistically significant relationship was found between participation in the intervention and group attendance at least 1 year after the intervention; a near-significant relationship was found between participation in the intervention and contact with non- elders. No relationships were found between the intervention and health status or quality of life, although,, such relationships may be detectable in longer term follow-up studies. [ABSTRACT FROM AUTHOR]

We provide an overview of the Kaiser Permanente Community Health Initiative--created in 2003 to promote obesity-prevention policy and environmental change in communities served by Kaiser Permanente-and describe the design for evaluating the initiative. The Initiative focuses on 3 ethnically diverse northern California communities that range in size from 37,000 to 52,000 residents. The evaluation assesses impact by measuring intermediate outcomes and conducting pre- and posttracking of population-level measures of physical activity, nutrition, and overweight.

Despite growing support among public health researchers and practitioners for environmental approaches to obesity prevention, there is a lack of empirical evidence from intervention studies showing a favorable impact of either increased healthy food availability on healthy eating or changes in the built environment on physical activity. It is therefore critical that we carefully evaluate initiatives targeting the community environment to expand the evidence base for environmental interventions. We describe the approaches used to measure the extent and impact of environmental change in 3 community-level obesity-prevention initiatives in California. We focus on measuring changes in the community environment and assessing the impact of those changes on residents most directly exposed to the interventions.

Background: The Robert Wood Johnson Foundation requested this utilization-focused evaluation of its Active Living Research (ALR) program. This evaluation reports on the trajectory of influence of past and future ALR outcomes on field-building and policy contributions as well as on possible users of completed and disseminated ALR products., Methods: In 2006 and 2007, key-informant interviews were conducted with 136 representatives of first-line potential users of ALR research products, including state physical activity and nutrition program coordinators, policymakers, scientists, and funders. Literature reviews, bibliometric analyses, and document reviews served to describe the context for ALR's work and the ways it could enhance its utility for field building and policymaking., Results: The contributions of ALR to the emerging transdisciplinary field included leadership in the development of measurement tools, epidemiologic studies, implementation research, the translation of research to practice, and the communication of learned lessons to diverse audiences. ALR's contributions to policy discussions were found across a spectrum of policy-development phases that included describing the problem, raising awareness of alternative strategies for increasing physical activity, convening nontraditional partners, and evaluating policy implementation., Conclusions: Policy-relevant research can make contributions to policymakers' thinking but almost never causes a change by itself. Five years after the original authorization of ALR, there is ample evidence of its recognition as a resource by key players, its field-building influence, and its contributions to policy discussions. All these bear promise for a broader contribution to obesity prevention. Recommendations for increasing ALR's impact on policy and practice are offered.

This article examines behaviors and attitudes associated with the "Youth Development Model," widely cited as a means of promoting resistance among young people to adverse environmental influences. Focusing on tobacco use as an example of high-risk behavior, the research reported here (1) tests the statistical independence of individual Youth Development Model dimensions, and (2) assesses their relationships to tobacco-related attitudes and behavior. The "engagement" dimension, reflecting strong ties of youths with the broader community, most clearly distinguishes risk reduction interventions based on the Youth Development Model. Two exploratory studies indicate that, among dimensions associated with this model, engagement is the least readily measurable and the least consistent and robust as a predictor of tobacco-related attitudes and behavior. Editors' Strategic Implications: The authors present an important challenge to the increasingly prevalent Youth Development Model. The results of the two studies call for a better conceptual and operational understanding of engagement, which must precede its successful application in reducing risky behavior among young people.

Broad-based community partnerships are seen as an effective way of addressing many community health issues, but the partnership approach has had relatively limited success in producing measurable improvements in long-term health outcomes. One potential reason, among many, for this lack of success is a mismatch between the goals of the partnership and its structure/membership. This article reports on an exploratory empirical analysis relating the structure of partnerships to the types of issues they address. A qualitative analysis of 34 "successful" community health partnerships, produced two relatively clear patterns relating partnership goals to structure/membership: (1) "collaboration-oriented" partnerships that included substantial resident involvement and focused on broader determinants of health with interventions aimed at producing immediate, concrete community improvements; and (2) "issue-oriented" partnerships that focused on a single, typically health-related issue with multilevel interventions that included a focus on higher-level systems and policy change. Issue-oriented partnerships tended to have larger organizations governing the partnership with resident input obtained in other ways. The implication of these results, if confirmed by further research, is that funders and organizers of community health partnerships may need to pay closer attention to the alignment between the membership/structure of a community partnership and its goals, particularly with respect to the involvement of community residents.

Purpose: To evaluate the effect of the Health Improvement Initiative (HII), a 5-year grantmaking initiative funded by The California Wellness Foundation designed to identify the critical factors needed to bring about population health improvements through community-level systems change., Design: The evaluation of the HII used a case-study, logic-model approach to make inferences about the effect of each community coalition (Health Partnership) on its target community. The primary outcome measure was the creation of significant and sustainable community-level systems change., Setting: The HII included nine communities in California that received funding to create broad-based Health Partnerships., Subjects: Primary data were collected from a variety of Initiative stakeholders by key informant interviews, closed-ended surveys, and participant observation., Intervention: The HII provided funding over 5 years to nine Health Partnerships that were intended to be a driving force in implementing community-level systems change. The ultimate objective of the systems change process was to improve "population health, " broadly defined to include social economic, and cultural determinants of health, in addition to traditional health status indicators., Measures: Both qualitative and quantitative techniques were used to assess the effect of the HII on key community systems. The primary outcomes were qualitative descriptions of community-level changes., Results: At the end of the 5 years of HII funding, six of the nine Partnerships had played a critical role in implementing sustainable systems changes that would likely have a significant effect in their target communities., Conclusion: The HII was successful in promoting community-level systems change in the majority of funded communities, although the evidence was mixed regarding the role of the Partnerships in bringing about these changes.

The difficulties of conducting randomized trials to evaluate community-based initiatives have led some researchers to argue in favor of a case study "logic model" approach to evaluation. This article describes a case study logic approach adopted for the evaluation of one community initiative, the Health Improvement Initiative (HII) funded by the California Wellness Foundation (TCWF). The HII is a comprehensive, community-based initiative designed to improve population health by implementing and sustaining community-level systems changes. Nine communities received funding to create broad-based community coalitions (Health Partnerships) that were charged with developing and implementing action plans around systems change. The HII is being evaluated using a case-study logic-model approach that uses quantitative and qualitative data to construct indicators of coalition functioning, systems changes, and population health. By examining the relationship between these indicators over time, it should be possible to determine if any changes in intermediate or long-term outcomes are associated with Health Partnership activities.

Objectives: To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities., Methods: The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities., Results: With the exception of two intervention communities-a largely Hispanic community and a Native American reservation-we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse., Conclusions: Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions.

Staff at Group Health Cooperative of Puget Sound have undertaken numerous strategies and community alliances in an effort to decrease violence in their community. Beginning with pilot programs and interventions for their own providers and enrollees, programs now focus on strengthening the community, controlling firearms, and supporting youth.

Critics today charge that managed care organizations, intent on reducing costs to ensure survival and profitability, have forsaken public health. In fact, managed care and public health face common challenges and share common interests. Public health problems ultimately affect managed care enrollees and increase the cost of their care. Managed care organizations, then, must help reduce community-wide health risks. Public health agencies, traditionally responsible for population health, today face serious challenges due to budget reductions and public indifference. The article to follow proposes a model for mutually beneficial collaboration between managed care and public health. Programs linking managed care with public health in the Puget Sound area illustrate this model's feasibility and value.

Because of their comprehensive service capabilities and traditional focus on prevention, HMOs have an outstanding potential for contributing to health promotion and disease prevention among special populations. But HMOs must acknowledge the special needs of key groups and modify traditional offerings accordingly. This article describes the use of the health risk appraisal (HRA) in a program, A Healthy Future, aimed at promoting health and preventing disease among elders. Unlike ¿standard¿ HRAs, this program developed questions of special pertinence to elders and used face-to-face, human contact for communicating results. Most important, the program linked the HRA to primary care and to interventions particularly useful and acceptable to elders.

Service to the broader community is an important component of Group Health Cooperative's (GHC's) tradition, values, and mission. The role and potential of community services in a staff model HMO requires consensus, careful planning and communication, and attention to results. This paper describes GHC's efforts to define, implement, and sustain its community services initiative.

The Kaiser Family Foundation's Community Health Promotion Grant Program (CHPGP) provides funding and technical assistance in support of community-based efforts to prevent major health problems. The first phase of the program was implemented in 11 communities in the western United States. This paper describes the evaluation design of the CHPGP in the West, the methods of data collection, and the baseline comparability of intervention and control communities. Major features of the evaluation design include: (1) the randomization of qualified communities making application into funded and unfunded comparison groups; (2) a second set of matched control communities for some intervention sites; (3) data gathering through repeated surveys of community residents (probability samples of adults and adolescents) and institutions (health-related organizations and randomly sampled grocery stores and restaurants); and (4) the use of secondary data to monitor health events. Selected baseline data show that intervention and control communities differ in racial/ethnic composition, but relevant health behaviors and ratings of community activation for health promotion appear comparable.

Since its introduction some two decades ago, health risk appraisal (HRA) has become a standard offering in the health promotion repertoire. The technique's distinctive feature is its use of epidemiologic data to generate quantitative risk messages for the client. Yet despite the dedication and considerable investments that have gone into HRA's development, dissemination, and use, there is only limited empirical evidence that these quantitative risk messages have any effect on clients. There do not appear to be any formal studies of HRA's effect on participation in health promotion programs, although increasing recruitment is regarded as a major benefit of using HRA. There are few indications of HRA effects on health beliefs. Most positive reports of effects on behavior change come from uncontrolled studies; several randomized controlled trials have yielded ambiguous findings. Virtually no data exist concerning the impact of the quantitative risk messages that distinguish HRA from other assessment techniques and that have motivated the substantial efforts toward developing and refining HRA. HRA has evident appeal and is probably a useful health education device for middle-class, middle-aged, nonminority clients. It may well have desirable effects on health-related beliefs, attitudes, and behaviors when accompanied by counseling or education, but available evidence has not established its effectiveness. Given the difficulty of obtaining definitive evidence of the effectiveness of HRA and specifically of its use of quantitative risk projections, the need for such evidence is debatable. An adequately funded and reviewed research program to examine whether projections of absolute risk affect knowledge, beliefs, attitudes, and intention to change is recommended as the most fruitful next step. Epidemiologically based HRA procedures that provide feedback in terms of qualitative statements or relative risk may be a promising approach to prospective health assessment.

A community health education program has been established by the Department of Community Health Sciences of Duke University Medical Center in two target areas of Durham County, North Carolina. The program trains unpaid lay people, "health facilitators", to whom others already turn for help, to increase their competency for advising and referring community residents to appropriate community resources. Several methods for identifying potential health facilitators have been developed. Evaluation of the role of health facilitators hinges upon designing measures to demonstrate their existence in the community and the impact that they make. To be successful, the training of health facilitators should result in improving the quality of the advice they give their fellows. It is also important to assess the cultural acceptability of the facilitators' advice and to ensure that their helping role in the community is not disturbed by the possible professionalization of their role due to the training program.