doi: 10.1161/CIRCULATIONAHA.105.169179
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(Circulation. 2005;112:2538-2554.)
© 2005 American Heart Association, Inc.
AHA Scientific Statement |
Taking the Initiative
Implementing the American Heart Association Guide for Improving Cardiovascular Health at the Community Level: Healthy People 2010 Heart Disease and Stroke Partnership Community Guideline Implementation and Best Practices Workgroup
Key Words: AHA Scientific Statements • cardiovascular health • community-level guidelines • health promotion • prevention
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Introduction |
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In 1990, heart disease and stroke emerged as the leading causes of death worldwide and remain the first and third leading causes of death in the United States, respectively.1,2 Cardiovascular disease (CVD) in the United States is responsible for &40% of all deaths, more than the next 5 leading causes of death combined. CVD death rates have declined significantly over the past several decades as a result of decreased incidence of myocardial infarction and increased survival.3,4 Coronary heart disease is also a leading cause of premature and permanent disability in the US labor force.2 In addition, the economic consequences are grave. In 2004, total CVD costs in the United States were estimated to be $368.4 billion2; these costs are expected to increase 40% to 50% by the year 2010.5 Blacks, the poor, and residents of particular regions in the United States are examples of groups that shoulder a disproportionate burden of CVD.6
US health objectives, as presented in Healthy People 2010, have placed a national emphasis on the prevention of CVD and its risk factors.7 The Secretary of Health and Human Services recently released the Public Health Action Plan to Prevent Heart Disease and Stroke (Action Plan) to further the "Healthy People 2010 goal of improving cardiovascular health through the prevention, detection, and treatment of risk factors; early identification and treatment of heart attacks and strokes; and prevention of recurrent cardiovascular events."8 A recent American Heart Association publication focused on the optimal community approach to the prevention of CVD and its complications.9 This report, from the AHA Expert Panel on Population and Prevention Science, is entitled The American Heart Association Guide for Improving Cardiovascular Health at the Community Level: A Statement for Public Health Practitioners, Healthcare Providers, and Health Policy Makers (AHA Guide). On the basis of a review of the literature and the work of other national committees, the expert panel made 59 recommendations for community-based efforts to promote cardiovascular health. The Action Plan complements the local community focus of the AHA Guide by providing a national action framework and infrastructure recommendations needed to prevent heart disease and stroke more effectively.
The AHA Guide recommendations include such measures as providing healthy meals in schools, training emergency first responders in the use of automatic defibrillators, providing safe and convenient means for walking and bicycling, and increasing excise taxes on cigarettes. These recommendations were informed by the body of research on the successes and limitations of interventions in the following areas: (1) community-wide settings,10–28 (2) schools,29,30 (3) worksites,31–34 (4) faith communities,35–37 and (5) healthcare organizations.38,39
The recommendations were classified by 2 additional dimensions: (1) essential public health services (assessment, education, community organization and partnering, ensuring personal health services, environmental change, and policy change)40 and (2) type of risk factor or behavior (inadequate diet, sedentary lifestyle, tobacco use, hypertension or hyperlipidemia, early recognition of symptomatic disease).
Disseminating recommendations such as these into widespread practice remains a major challenge. Most community-based efforts do not have adequate resources and the capacity to implement all the interventions in a list of promising practices such as the AHA Guide. This issue must also be addressed in federally sponsored programs such as the State Heart Disease and Stroke Prevention Program, funded by the Centers for Disease Control and Prevention, and the Enhanced Dissemination and Utilization Centers of the National Heart, Lung, and Blood Institute, National Institutes of Health. With strong support from the community and policy makers, program planners can set priorities and implement and evaluate effective programs. For example, the New York State Heart Healthy Program implemented policy and environmental change initiatives at worksites and in faith communities, along with a successful educational campaign to encourage consumption of low-fat milk. The Montana program successfully translated and disseminated evidence-based science into practice to improve emergency-response systems and increase awareness of signs and symptoms of heart disease and stroke (Box 1). This article describes a model and strategies needed for a community-driven initiative with limited resources and shows how to prioritize and translate a list of promising practices into action with the AHA Guide as an example.
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Framework for Implementation |
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TopIntroductionFramework for ImplementationConclusionsWriting Group DisclosuresReferences |
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An important component of success in developing a community prevention program is early consideration of how to translate what is known about multiple and sometimes overlapping promising practices into effective and sustainable action at the community level. The Healthy People 2010 Heart Disease and Stroke Partnership proposes a framework for bridging the gap between research and action. This framework involves a cycle of assessment, community-based planning, and widespread and sustained implementation (Figure 1). Every step in this cycle is supported by community mobilization and evaluation.
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Community mobilization involves the development of partnerships, leadership, and community capacity. The mobilized community must first assess its cardiovascular health needs and assets. To start the planning process, community partners should decide which ideas will be implemented and how. Planning also entails decisions about how to adapt these ideas to the local community. With implementation, the goal is to reach the greatest number of at-risk individuals (reach) with the most effective combination of interventions (intensity) for the longest period of time (sustainability).41 Both ongoing community mobilization and evaluation are required to provide critical support throughout assessment, planning, and implementation. Strategies for each of the recommended steps in the framework are summarized in Figure 2. The case study in Box 2 describes how 1 community partnership in Arizona addressed the points in this framework.
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Community Mobilization
Definition
In this article, "community" may refer to a geographic area, a population group (eg, a racial/ethnic group, members of an association), a school, a workplace, a group of patients served by a clinic, or a faith community. It is a common assumption that effective and sustainable health promotion is about empowering people to gain control over the circumstances that affect their health and well-being.42,43 Thus, it is essential for the success of health promotion initiatives to develop partnerships with communities and mobilize them to take action. Community mobilization is the process by which community members, groups, or agencies come together and garner collective resources and capacity to develop a strategy, plan, or process to address a particular issue in the community. This step involves developing leaders and identifying, strengthening, and mobilizing the needed community and organizational capacity.
Strategies
Strategies for mobilizing the community involve 3 steps: (1) develop leadership, (2) create partnerships, and (3) identify assets and resources.
Develop Leadership
Community-based promotion of heart health involves identifying and developing community leaders who can engage in "collaborative leadership"44,45 to facilitate all stages of coalition development46 and lead policy change efforts.47 Leadership can be developed through formal training opportunities and "engagement strategies" such as on-the-job training.48 Developing and supporting leaders from the community such as community health workers can build a valuable bridge with the population.49 Planning, implementing, and evaluating programs with trained community health workers or lay health advisors who work through the community’s social networks with credibility and trust are powerful approaches that have been shown to make interventions more effective.50–53 Developing leadership teams or cadres can also be an effective approach.48
Create Partnerships
One goal of leadership in an initiative to promote heart health and prevent stroke is to form effective partnerships and constituencies. The first question is whether the partnership has the appropriate members around the table. The answer may depend on how the community is defined and whether advocacy (ie, political action) or broad-based consensus is the initial approach. However, a review of the advantages and disadvantages of these approaches and their combination over time is beyond the scope of this report. The AHA Guide describes various settings for engaging the community: religious organizations, workplaces, schools, healthcare organizations, and the community at large. Within each setting, the community that needs to be represented in a partnership can be defined as (1) all persons in the setting, including those with diverse and sometimes conflicting interests (eg, in a political jurisdiction); (2) persons with something in common (eg, nonsmokers)54; or (3) persons who share social ties and common perspectives and engage in joint action.55
When a partnership begins with a focus on advocating for a policy or program, a stakeholder analysis might be done to ensure involvement of a broad spectrum of influential supporters and community members. Influential persons or organizations who oppose a particular initiative might be targeted for efforts to neutralize their opposition. When a partnership begins with a focus on building consensus around how to address a particular problem, a broad range56 of stakeholders—especially community members and representatives of all interested parties in the for-profit, nonprofit, and public sectors—are invited to the table even when they bring opposing views. They participate and negotiate in the initial planning stages. Regardless of whether advocacy or broad-based consensus is the initial focus, community members and leaders exert great influence.
Research-based tools to improve the function and collaborative advantage of partnerships are now available and listed in Table 1 
. In addition, principles and practical steps of community-based participatory research are valuable guides for developing effective partnerships to promote heart health and prevent strokes. Developing trust and agreeing on ways to achieve community participation and control of the initiative are critical for effective community mobilization.57 Leadership from within particular communities may require unique approaches to organizing and implementing an initiative, for example, in working with American Indian and Alaska Native communities.58
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Identify Assets and Resources
In addition to developing leaders and partnerships, it is also important to identify and mobilize the capacity of the community to implement interventions and promote community change. This capacity extends beyond money and organizational resources (eg, information and program activities) and includes human and social capital.48,59,60 Knowledge of local cultures and how to engage in low-budget media advocacy are examples of human capital. Relationships among organizations,61 partnership members, and policy makers, as well as the trust in these relationships, are examples of social capital.62,63 Beyond the required understanding, sensitivity, and respect for local cultures, the shared beliefs, rituals, and values within a culture are critical and powerful resources on which to build an intervention.
It may be helpful to seek agreement among partnership members on a method to identify and mobilize the assets and resources within or available to a community. Because many communities may not have a wealth of local resources, this process should include identifying and leveraging additional resources available beyond the community, including regional and state health agencies, voluntary health organizations, healthcare systems, health plans, and universities. These organizations may also be valuable sources for training and technical assistance.
The Secretary’s Action Plan systematically identifies many of the optimal capacities, infrastructure, and resources needed for communities to take effective action,8 including population-wide data sources and surveillance systems, training, technical support, research efforts, programs, and cultural competency.
Although effective organization and mobilization of community capacity may be time and effort intensive, this step is vital and essential to ensure the sustainability and ultimate success of planned interventions.
Assessment
Definition
Assessment is an ongoing process to monitor health problems in a community, to identify the community’s capacity and effectiveness in dealing with these problems, and to communicate these findings to decision makers.64
Strategies
Assessment strategies can be broad, allowing for and requiring development of significant amounts of information on multiple health problems,65,66 or can be specific and focused on a health issue of great importance to the community such as CVD. The availability of community resources will determine the size and scope of the initial assessment. For broad assessment, a full CVD component would optimally be incorporated into the community health assessment. Important determinations include the information to be gathered, methods to be used, purposes of data analysis, and assignment of responsibility for assessment tasks.67 The numerous methods to gather data include seeking local expert consultation; collating existing research reports; analyzing existing data (eg, from hospital discharge records, mortality files, and surveys on behavioral risk factors); or collecting new data, usually through surveys of households, healthcare providers, or communities. Three assessments are critical: (1) obtain data on CVD burden, (2) identify CVD prevention indicators, and (3) conduct a needs and capacity assessment.
Obtain Data on CVD Burden
To document the magnitude of the problem, information can be gathered on the burden of CVD and disparities across racial and ethnic, socioeconomic, and geographic groups, as well as other groups of people within the community. Measures of disease burden can include the following: (1) the number of CVD cases and deaths in the community or locale, (2) years of potential or quality-adjusted life lost, (3) direct healthcare costs, (4) lost income and productivity, (5) social costs, and (6) measures of impairment, disability, disadvantage, and health-related quality of life.
Relating representative case studies or anecdotes about loss of a loved one to CVD or living with CVD can be a persuasive method to garner resources and support from decision makers.
Identify CVD Prevention Indicators
To provide guidance for setting CVD intervention priorities in a particular community, data can be collected on the full spectrum of causes and consequences of CVD. As shown in the literature,2,68–74 indicators can be developed for risk behaviors and biological risk factors, as well as their causes and CVD consequences (Table 2). Assessment options include the following: social and environmental conditions that are root causes of CVD; behavior patterns (eg, physical inactivity); biological risk factors (eg, obesity, diabetes, and elevated blood cholesterol concentration); first CVD events (eg, incidence of angina, myocardial infarction, congestive heart failure, stroke, and sudden death); recurrence of CVD events; CVD mortality; CVD complications; and quality of life with CVD.
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In both assessment and evaluation, it is possible to focus on the occurrence of these indicators in the population and/or their disparities across social groups defined, for example, by race and ethnicity or income. Gathering as much of this data as possible from different sources at the local level and breaking it down by age, sex, race and ethnicity, income, and geographic location can provide powerful information for the next step of community-based planning.
Conduct a Needs and Capacity Assessment
Although the development of statistical data on CVD is important in the initiation of successful prevention programs in a community, community concerns and priorities are often equally critical. They can be assessed directly through community meetings and through more formalized mechanisms such as semistructured needs assessment surveys or group interviews.75,76 As described here, assessment also involves determining the capacity of the community and organizations to address CVD prevention. This determination includes identifying and describing existing programs and policies affecting CVD77 (see Table 1
, PATCH, Community Programs/Policy Matrix and Community Resource Inventory) Instruments have been developed to assess the capacity to promote heart health,78,79 although more work needs to be done in this area.
Assessments of CVD burden in populations at the county or city level or in smaller jurisdictions can be difficult, especially when resources or time is not available to conduct data gathering and analyses for small areas. Existing data at the local level are likely to be limited in extent and quality. Some interactive maps or atlases of disease showing county-specific data are available at the federal level, as is the case for heart disease and stroke mortality (Table 1). Many state health departments produce county-specific rates of CVD mortality; some may produce prevalence estimates based on hospital discharge data (http://www.cdc.gov/cvh/maps/index.htm). Data on behavioral risk factors (eg, smoking, physical inactivity, and inadequate fruit and vegetable consumption) are also available for metropolitan/micropolitan statistical areas (www.cdc.gov/brfss). Communities may also be able to check with their local universities to identify relevant assessments that may have been done in the past.
If the community cannot recruit the resources and team to perform an assessment, existing data at the next higher level (eg, county or state) should be examined. To assess whether these data are meaningful in a particular small community, demographics of the local population and the larger population can be compared. State and county data are often not representative of local communities. With demographic information, it is also possible to estimate the rates of CVD that would be expected if the community had the same rates for variables such as age, sex, and race and ethnicity as the state or the United States. Documenting the perceptions of knowledgeable people about whether data from the larger population are representative of the local community is also useful. As noted in the Action Plan, there is a need to improve the data available to communities.
Assessments are supported by evaluation data as they become available (Figure 1). Tools that are particularly useful for conducting a community cardiovascular health assessment, and where to find them, are listed in Table 1. They include the Community Tool Box, the Planned Approach to Community Health (PATCH), Mobilization For Action Through Partnerships and Planning (MAPP), and Improving Health in the Community: A Role for Performance Monitoring.
Community-Based Planning
Definition
Community-based planning is the process of empowering community partners to reach a consensus on the combination of interventions to be implemented. Possible interventions include those aimed at reducing high-sugar, carbonated beverages sold in schools; working with neighborhood grocery stores to provide fresh and reasonably priced fruits and vegetables; posting "point-of-decision" signs to encourage workers to take the stairs; or engaging in media advocacy for improving walking trails. It is difficult to identify the most effective population-based interventions for a particular community because so few controlled community trials with adequate controls are conducted under a variety of circumstances. Factors that can influence health promotion include the following: (1) the presence of other interventions; (2) quality of implementation; (3) strength of community support and involvement; (4) leadership and trust surrounding the initiative; (5) cultural competence and relevance of the intervention; (6) social cohesion; and (7) political, social, and economic supports.
Each of these factors can have a positive or negative effect on the success of an intervention (eg, walking trails) in a community.80,81
Although the consensus on a "standard of evidence" in community-based health promotion is weaker than that for interventions in clinical settings,82 research demonstrating effectiveness in other populations is a useful starting point. It is also important to consider the community’s interests, needs, and support, in addition to theoretical support, cultural competence, and the feasibility of intervention options.
Strategies
A reasonable approach to assist communities in this process of developing and implementing successful CVD prevention programs entails the following steps: (1) identify behaviors or biological risk factors for modification, (2) select objectives and relevant program strategies, (3) tailor the program to local needs and circumstances, and (4) develop and refine the program plan.
Identify Behaviors or Biological Risk Factors for Modification
An effective approach requires the selection of the behaviors (eg, tobacco use, physical inactivity, unhealthy diet, and lack of provider adherence to screening guidelines) and biological risk factors (eg, hyperlipidemia, hypertension, obesity, and diabetes) to be targeted. The behaviors and risk factors should be chosen in partnership with community members and should reflect the concerns and priorities documented in the CVD assessment as previously described here. With findings from the assessment, it may be possible to determine the community’s greatest need. This approach allows a community to select important behavioral targets likely to have high impact on population health. It may be helpful to gauge the importance of a behavior or risk factor (eg, smoking, physical inactivity, obesity) by estimating the proportion of an outcome (eg, the number of new cases of CVD) that is attributable to that behavior or risk factor.83 In general, behaviors that are easier to modify and have a larger impact on CVD rates in a population are better and often simpler goals for health promotion.
Select Objectives and Relevant Program Strategies
The next step is to blend the wisdom of the local community with the literature on promising practices to select objectives for community change (eg, policies, environments, programs) and to program strategies to achieve them. Potential objectives for community change are listed in the AHA Guide under education, community organization and partnering, ensuring personal health services, environmental change, and policy change. Each recommendation targets 1 or more of the 5 community settings: community-wide settings, schools, worksites, faith communities, and healthcare organizations. Successful health promotion strategies usually require a multifaceted approach; rarely does a single change make a lasting difference in an entire community.84 Thus, the partnership can identify different combinations of community change objectives to consider. For example, to prevent smoking initiation in youth, the following combination could be considered: curriculum changes in schools, increased taxes on tobacco, and improved enforcement of laws prohibiting the sale of tobacco to minors.
For each combination of community change objectives chosen, a program strategy to achieve those objectives needs to be considered. The Community Tool Box, PATCH, and MAPP (Table 1) are excellent guides to planning. Working through a logic model also is useful. Logic models are used to graphically show the organization, associations, and actions that underlie a program and are expected to precede changes in CVD rates. For example, the logic model for the State Heart Disease and Stroke Prevention Program (Figure 3) is based on a socioecological model that links environmental and policy system changes with personal behavioral changes.68 The activities of capacity building, surveillance, and system changes are intended to support heart-healthy behavior, which leads to improved health status. Logic models are often cyclic rather than linear, in that 1 activity can modify another activity that precedes it in the logic model. For example, a policy to provide preventive follow-up services for persons with high blood pressure could lead to improved individual behavior change and could also influence surveillance and evaluation activities. Logic models not only serve to describe the program but also act as a tool to guide program evaluation. (See Table 1 for other logic models and guides for logic models, eg, Promising Practices in Chronic Disease Prevention and Control and Kellogg Logic Model Development Guide.)
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The answers to 4 questions can help to guide decision-making about selection of appropriate objectives for community change to promote cardiovascular health and the strategies relevant to achieving these objectives:
- Does pursuing this combination of objectives and strategies make sense to community partners?
- Is there evidence to support these objectives and strategies?
- Are the proposed strategies already being implemented?
- Is it feasible to implement the strategies?
Does pursuing this combination of objectives and strategies make sense to community partners?
Listening to the input of the community about the choice of objectives is critical to the planning process.42,43,84 This input includes the community’s perceptions about feasibility and likelihood of success, significant roadblocks, and community support for selected objectives and strategies.
Is there evidence to support these objectives and strategies?
"Evidence" in health promotion and disease prevention requires asking 2 questions: Is there a theoretical basis for expecting that this combination of objectives and strategies is effective, and have these objectives and strategies, alone or in combination, been shown to be effective in other populations?
Listening to the accumulated knowledge of the research community about theories of community change that predict behavior change is very useful in a community-based decision-making process.85 Efforts to combine multiple theories of behavior change into a single framework to assist communities in intervention design are only now emerging.86 However, communities can still select 1 or more theories that make the greatest sense to them. A simple integration of 2 theoretical perspectives is presented here.
First, Green and Kreuter87 have summarized the determinants of individual behavior change common to multiple theories in 3 concepts: factors that predispose (educate and motivate), enable, or reinforce a desired behavior change. Thus, any combination of interventions should ensure that efforts to educate and motivate individuals are accompanied by efforts to reinforce and make behavior change easier for people. For example, a mass media campaign to promote physical activity through walking can be enabled by upgrading existing trails or constructing new convenient and attractive walking trails or through worksite health promotion policies that allow extended lunch periods for exercise. These efforts can be reinforced by starting walking clubs that provide social support and incentives, as well as reduced health insurance premiums, copays, or deductibles. It is also important to consider how factors that predispose, enable, and reinforce behavior may vary over the course of one’s life88 and one’s readiness to change.89
The ecological approach is defined by a strategy that does not merely target the individual but also the individual’s environment, understood as systems (eg, families) nested within larger systems (eg, communities). An ecological approach seeks a combination of interventions at the following levels: individuals, families and networks of relationships, organizations, community and environment, and public policy.68,90 A comprehensive review of community-based health promotion strategies suggested that a potent multilevel combination may optimally involve (1) one-on-one interventions with high-risk individuals, (2) community-wide interventions to change social norms, and (3) policy-level changes.84 In general, a systemic, comprehensive approach to prevention that addresses individual lifestyles and behaviors in a multifaceted approach using economic, social, environmental, cultural, and policy supports affords the greatest assurance of success.68,91
In addition to ensuring that there is a theoretical basis for the proposed objectives, it is important to learn whether similar intervention strategies have worked in other populations. The AHA Guide is helpful in that regard. Also, the US Task Force for Community Preventive Services reviewed many of the AHA Guide recommendations in its Guide to Community Preventive Services (Community Guide) (Table 1). The Community Guide summarizes what is known about the effectiveness, economic efficiency, and feasibility of selected interventions to promote community health and prevent disease. It contains recommendations for the use of various interventions based on the evidence gathered in the rigorous and systematic scientific reviews of published studies conducted by the review teams. The Community Guide also summarizes the strength of each of its recommendations for widespread implementation. Members of a community should pay special attention to the number of studies reviewed, the strength of the results, and how consistent the results were for different settings and populations. The Community Guide also identifies major barriers to implementation and gaps in research. Communities may also have to review some pertinent studies independently. As the authors of the Community Guide affirm, prevention effectiveness demonstrated in a few study populations should not be the sole criterion for selecting interventions. Many other factors also must be considered such as "available resources, community priorities, perceived value, and culture."92
Are the proposed strategies already being implemented?
New initiatives should fill in the gaps in the current health promotion system. If 1 or more of the objectives or strategies are already being implemented, then strengthening or complementing the existing program might be considered.
Is it feasible to implement the strategies?
The primary driver of feasibility is the availability of resources. Subjective impressions by partnership members about how much a program would cost may suffice in the planning stage. However, studies that publish the cost of interventions are becoming more commonplace. The Community Guide (Table 1) summarizes information related to the cost of some interventions. Other determinants of feasibility that should be considered by partnership members are the presence of organizational, legal, ethical, cultural, and political constraints.
Tailor the Program to Local Needs and Circumstances
A program previously implemented in a different population, even if described as effective in the literature, will likely need to be tailored to fit the local circumstances of a new population.84 Excellent guides for this purpose are as follows: (1) the program adaptation guidelines for health education materials recommended within the Research-Tested Intervention Programs initiative at the National Cancer Institute, National Institutes of Health, and (2) Getting to Outcomes 2004 by the Rand Corporation (Table 1).
Develop and Refine the Program Plan
Health promotion program plans87,93 should include strategies for evaluation (see the Widespread and Sustained Implementation section) and sustainability. The evaluation component should optimally be integrated into the initial planning steps. A key aspect of implementation is ensuring sustainability. Implementers should define the type and duration of sustainability needed.94,95 Beyond continual grant writing, the process of institutionalization in which a program becomes an integral part of an established organization affords the greatest prospects of sustainability.96,97
Widespread and Sustained Implementation
Definition
Implementation is the process of carrying out a community plan in a widespread and sustained manner for sufficient time to produce change. It can take 2 forms: advocacy and programs. Implementation takes the form of advocacy when it involves an effort to change policy. Implementation takes the form of a program when it involves education, social marketing, delivering health care, altering the environment, or carrying out a changed policy. The tasks within advocacy can be organized like a traditional public health intervention47 and effectively adopted as part of an expanded role for a community health coalition,98 as long as the reality and complexity of the policy-making process is considered.99 Implementation optimally involves both advocacy and programs. An advocacy effort is usually implemented by a coalition of people, but a single organization or service-delivery network can also implement programs.
Implementation Strategies
Two strategies for implementation should be considered. First, the approach of continuous improvement through performance monitoring (see the Evaluation section) can improve effectiveness in the face of changing circumstances.65,100 Without the ability to monitor, adapt, and change policy or program interventions, approaches proven effective in other populations may fail if they are implemented as fixed protocols in a world in which the circumstances are changing. Second, during implementation, it may be important to continually build community support for participation, especially among underserved or high-risk populations (see Community Mobilization above).
Additional resources to guide program implementation are briefly described and referenced in Table 1 (eg, Community Tool Box, and PATCH).
Evaluation
Definition
Evaluation is "a process of measuring components critical to the success of [a prevention program or initiative], including surveillance, program monitoring,"101 as well as impact and outcome evaluation. An evaluation plan should be developed before the program is implemented. The evaluation of community-based health promotion initiatives is not limited to the logic of clinical or community trials. Instead, meaningful evaluation expands to answer a broad spectrum of questions from stakeholders. Funding agencies, policy makers, program staff, and community stakeholders often have 2 key questions. First, what impact has the program had on behavior, health status, or health-related quality of life in the population? Second, how can the performance of the program be improved as it unfolds? Answering the first question on health impact enhances understanding of what works and justifies continuing support for the program. Answering the second question through ongoing feedback on performance and relevant circumstances can help program stakeholders adapt and fine-tune an intervention shown to work elsewhere, so that it is effective in their community. This type of evaluation (process evaluation or performance monitoring) is critical to translate evidence-based recommendations into practice.
The emphasis stakeholders place on different evaluation questions may depend partly on whether the program is in the initial evaluation phase or is being disseminated and sustained in communities after the early evaluation has indicated effectiveness.
Evaluation Strategies
Practical and flexible guidelines for evaluating public health programs have been developed through national consensus.67 The recommended process of engaging stakeholders, describing the program, focusing the evaluation, gathering credible evidence, and justifying conclusions is based on 7 concepts that are particularly useful for evaluation in the complex world of community health promotion.
- Make sure the evaluation is useful to all who have a stake in the program, including funders, policy makers, program staff, clients, and community members. Thus, stakeholders are engaged to reach consensus about what the evaluation will accomplish given limited resources, to participate in the evaluation, and to interpret its findings.
- Develop a meaningful evaluation based on a clear understanding of how the program will achieve its goals step by step. As discussed previously, developing a logic model from the beginning of program planning can be very useful.
- Focus on asking and answering evaluation questions to meet the needs of identified users for specific uses. For example, a funding organization may want to know how many lives were saved by the program to determine whether to continue funding it. A grassroots community leader may also want to know whether the program fostered increased dependence on outside experts and support or whether it built the internal capacity of the community.
- Engage diverse stakeholders in interpreting evaluation findings in light of their values and standards.
- Use performance monitoring in organizational100 and community-wide settings65 when implementing and adapting interventions already shown to be effective in other populations. A small strategic selection of quantitative indicators can be used to monitor the following: structure (eg, whether staff have been trained and funds transferred), process (eg, number of patients in underserved communities participating and number and quality of contacts with legislators), and outcome (eg, percentage of schools or workplaces that offer healthy foods and beverages in vending machines).65,102
Table 2 provides examples of indicators of short-and long-term outcomes of cardiovascular health promotion.
In performance monitoring, the purpose of outcome indicators is to inform the program staff whether the anticipated changes are actually occurring. As noted by Durch and associates,65 a number of characteristics describe indicators that are useful; these include validity, reliability, sensitivity, and robustness.
- Use qualitative methods and quantitative indicators to identify and address barriers, problems, and opportunities to improve.103 For example, "dialog boxes" can be used to confidentially report the messages of stakeholders (eg, program clients) to other stakeholders (eg, program staff).104
- Evaluate short- and long-term program outcomes to justify program change or sustainability and to identify effective programs. The traditional and costly approach of comparing intervention communities with control communities over time105 may be important for some programs such as programs in their original evaluation phase and those implemented in relatively controlled settings (schools, worksites, and clinics or interactions between community health worker and patients). Instead of determining which programs work, controlling for differences between communities, a recent evaluation perspective can be used in efforts to identify "what works for whom under what circumstances."16,80,81 The Action Plan, for example, calls for research on the effectiveness of prevention to determine "what combination of effective interventions (eg, policy, environment, individual) at what doses, in what settings (eg, family, school, worksite, healthcare, community), at what life stages, and among which priority populations are most effective...."8 From a community perspective, especially when evidence-based interventions are being disseminated to other communities, it might be sufficient merely to monitor changes in outcome indicators and to interview well-selected informants to interpret the causes of those changes.106
Evaluation is often perceived as a burden by organizations and community partnerships. Sufficient staff time and expertise must be allocated, but evaluations can be made more easily and more efficiently by using existing data sources or collecting data by means requiring the least time and resources. Unobtrusive environmental measures like miles of walking trail per capita or the percentage of restaurants that prohibit smoking may be appropriate indicators.73,74
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Conclusions |
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TopIntroductionFramework for ImplementationConclusionsWriting Group DisclosuresReferences |
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Substantial advances in the secondary prevention of adverse CVD outcomes have been made by bridging the gap between guidelines and practice through programs and tools such as Get With the Guidelines, an AHA quality improvement process that helps to ensure that patients hospitalized for acute coronary syndrome are effectively treated and discharged with life-saving medications and the benefits of preventive services such as smoking cessation counseling. This program has enabled hospitals to easily integrate individual preventive efforts into a comprehensive hospital discharge system to maximize benefits.107 In communities, schools, faith-based organizations, worksites, and healthcare organizations, research on preventing and controlling CVD risk factors (primordial and primary prevention) has led to the recommendations in the AHA Guide. Similarly, translating these recommendations into community-based practice requires a workable framework for implementation. Such a framework begins and ends with mobilizing the community through organizations, partnerships, leadership, trust, and a shared understanding of community participation and control. Organizations and partnerships need to assess the cardiovascular health of their community, to identify and plan for a combination of interventions, and to implement them in a far-reaching and sustained manner. Evaluation that begins with a clear picture of how the interventions are thought to produce change can help to nurture assessment, planning, and implementation into success and lessons learned.
To assess the needs for CVD interventions in a particular community, the recommendation is to blend the insights of community members with available data on CVD risk factors in the community, their underlying causes, and their consequences (eg, heart attacks, stroke, mortality, and impaired quality of life). Identifying both the burden of CVD in the community and its own interest in cardiovascular health is useful in the planning step. Selecting and developing plans for the right mix of prevention strategies in a community setting is a unique challenge. Unlike research on therapeutic interventions, research on the effectiveness of community-based prevention strategies is difficult to generalize to other communities. Effectiveness is likely to vary by the quality and duration of an intervention and numerous community circumstances.
Evidence of effectiveness in other populations is an ideal starting point for selecting the appropriate mix of CVD interventions for a particular community. Partners must also consider the needs of the community, whether the interventions make sense to community members and are theoretically sound, and whether the strategy is feasible and sustainable. Implementation of CVD interventions such as messages through mass media and efforts for policy change must be accomplished with an eye toward quality, reach, and sustainability.
Even if the selected interventions have been shown to be effective in another population under different circumstances, evaluation is still crucial. Ongoing feedback on the performance of the interventions is particularly useful to allow continuous learning and adaptation and fine-tuning of the program to different and changing circumstances. The effectiveness of some interventions may depend as much on the leadership and resources that support them as on their intrinsic design. Thus, in the framework presented here, an effort to mobilize the capacity of the organization and community around assessment, planning, implementation, and evaluation is central to success. Community mobilization also involves developing and maintaining trust among the partners, as well as a practice of community participation and control that is supported by all the stakeholders.
Recommendations to improve cardiovascular health at the community level, such as those offered in the AHA Guide, are most effectively incorporated into a process that respects community rights, wisdom, and complexity, combined with the knowledge gained from scientific research—a process that learns from and adapts to changing circumstances. Optimally, initiatives to promote heart health and to prevent stroke should be integrated as much as possible into diverse community settings (eg, schools, communities, healthcare facilities, and worksites) with the support of policy, public health practice, and infrastructure. A comprehensive approach that addresses the environmental, social, and cultural aspects of health, as well as individual lifestyles and behaviors, offers the greatest prospect for success. The cardiovascular health of whole populations may depend on it.
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We wish to thank David C. Goff, Jr, MD, PhD, Carolyn Jenkins, DrPH, and Debra Wigand, MEd, CHES (Certified Health Education Specialist), for sharing their review of this article in a panel presentation at the Second CDC Prevention Conference on Heart Disease and Stroke. We would like to acknowledge Stephen Fortmann, MD, Director of the Stanford Prevention Research Center, for his helpful review of this manuscript. We also wish to thank Crystelle Fogle, Program Coordinator of the State Heart Disease and Stroke Prevention Program, Montana Department of Public Health and Human Services, for providing the case studies. The US Department of Health and Human Services does not endorse organizations or organizational products.
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The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 8, 2005. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0331. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or e-mail kgray@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.
These Guidelines also appear in Prevention and Control.
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier=3023366.
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