Promoting Healthy Living and Preventing Chronic Disease An Action Planning Guide for Communities A publication of the KU Work Group for Community Health and Development The University of Kansas http://communityhealth.ku.edu/ Stephen B. Fawcett, Ph.D. Valorie Carson, M.S. Jamie Lloyd Vicki L. Collie-Akers, M.P.H. Jerry A. Schultz, Ph.D. Daniel J. Schober, M.A. Zora Pace, M.A. A World Health Organization Collaborating Centre for Community Health and Development at the University of Kansas, the mission of the KU Work Group is to promote community health and development through collaborative research, teaching, and service. All rights reserved. No part of this publication may be reproduced, stored in retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the KU Work Group for Community Health and Development. © 2005, 2008 The University of Kansas KU Work Group for Community Health and Development 1000 Sunnyside Avenue, Room 4082 The University of Kansas Lawrence, Kansas 66045-7555 (785) 864-0533 http://communityhealth.ku.edu/ A Preface ur common purpose: to assure that all people live under conditions that promote healthy living. To achieve this broad aim, we must create environments that encourage healthy behaviors—in particular, those that promote physical activity, healthy diets, tobacco-free surroundings, and access to health care and preventive services. Healthy People 2010, the health objectives for the nation, calls for creating environments that make these behaviors easier and more rewarding. Public agencies, such as the U.S. Centers for Disease Control and Prevention, and private foundations have launched an array of efforts to promote physical activity, reduce tobacco use, encourage healthy diets, and increase access to health services. “Promoting healthy living for all” is a worthy and challenging aim. This work is bigger than any one of us. It demands new levels of collaboration. It requires us to make multiple and interrelated changes in many different aspects of our communities and broader systems. Social justice requires a commitment to eliminating disparities in health outcomes among different ethnic, racial, and income groups. The purpose of this guide is to help support community efforts to promote healthy living and prevent chronic diseases by increasing those behaviors that we know protect individuals from chronic diseases, such as physical activity and fruit and vegetable consumption. It also aims to reduce disparities in related health outcomes, such as diabetes and cardiovascular diseases, associated with race, ethnicity, or social inequalities. It outlines a process for involving those most affected by negative health outcomes, and those who can bring about the most change, in planning for a common purpose. The focus is on identifying those community and system changes—the new or modified programs, policies, and practices—that could make a difference in health outcomes. This guide is informed by what we know about “what works” (evidence based practices), and the conditions under which they work. It draws on both scientific assessments and experiential knowledge about what might work in our communities. It captures working knowledge about what we can do in communities to promote healthy living and prevent chronic diseases and enhances co-learning among those doing the work. Creating conditions to support healthy living requires broad- based efforts involving many different sectors or parts of the community. Often referred to as state and community partnerships, these initiatives involve key community leaders, experts, and representatives of grassroots organizations who value healthy living in our communities. They bring together representatives from health organizations, faith communities, schools, businesses, and other sectors of the community that share a concern about the problem of chronic disease or have a stake in their prevention. The aim of such initiatives is to foster changes in communities that promote healthy living for all. This planning guide offers many potentially valuable ideas for creating conditions that promote healthy living. It outlines community and system changes that community members, service providers, and broader agents and allies can make to prevent the health-related problems of diabetes, cardiovascular disease, and some cancers. These include new or modified: ƒ programs, such as screening or peer support programs, ƒ policies, such as “health opportunity” zones that allow tax credits to support health improvement efforts in neighborhoods of concentrated poverty, and ƒ practices, such as increased after-hours care or enforcement of tobacco restrictions. The community’s action plan outlines what will happen to achieve its vision of healthy living for all. How could health organizations be changed to help promote healthy living and prevent chronic disease? What changes in faith communities would help fulfill the mission? How can the business community do its part? What about schools? How about local government? How could community residents assist? The process of action planning consists of several major sets of activities, including: ƒ Convening a planning group in your community that consists of: ƒ Key officials ƒ Grassroots leaders from the community ƒ Representatives of key sectors ƒ Representatives of ethnic and cultural groups ƒ Listening to the community ƒ Documenting the levels of healthy behavior and chronic disease ƒ Identifying risk and protective factors ƒ Developing a framework for action ƒ Becoming aware of local resources and efforts ƒ Defining your group’s vision, mission, objectives, and strategies ƒ Defining your group’s choice of targets and agents of change ƒ Determining what community sectors should be involved in the solution ƒ Developing tentative lists of changes to be sought in each sector ƒ Building consensus on proposed changes and finally, ƒ Outlining action steps for proposed changes Taken together, the proposed changes in all relevant sectors of the community provide a blueprint for action. Each community has different assets and needs for promoting healthy living and preventing chronic disease. A particular community’s intervention for promoting healthy living—the combination of programs, policies, and practices it seeks—will be unique. To work, chosen approaches must be adapted to fit the culture and context. Together, we have a lot to discover about how people can work together to create the “dose” of environmental (community and system) change sufficient to improve population-level outcomes and reduce disparities. Activities for developing an action plan are explained in detail in this guide. Chapter 1 provides background information on key issues and concepts in community planning. Chapter 2 offers an overview of the planning process, with particular emphasis on how the community can clarify its vision, mission, objectives, and strategies for change. Chapter 3 provides help in considering which sectors of the community should be involved in the initiative. Chapter 4, the heart of this guide, assists in identifying particular community or system changes that local communities will seek to promote healthy living and prevent chronic disease. Appendix 1 provides an inventory or menu of hundreds of different community and system changes that your community might use and adapt to fit your context. Chapter 5 outlines a process for building consensus on those changes to be sought. Chapter 6 offers guidance in listing action steps to finalize the community’s unique action plan. Finally, Chapter 7 outlines a strategy for documenting progress in bringing about community and system change and promoting celebration and renewal within the initiative. The conditions that promote healthy living, such as environmental and policy changes that promote physical activity and healthy diets, should be widespread. Our hope is that each community’s planning efforts will help bring about the conditions that support healthy living for all. Table of Contents Preface Chapter 1 Community Planning for Healthy Living 8 Table 1: Some Personal and Environmental Factors Related to 17 Healthy Living Your Planning Page: Listening to the Community 19 Your Planning Page: Identifying Personal and Environmental Factors 21 and Developing a Framework Action Your Planning Page: Becoming Aware of Local Resources and Efforts 23 Your Planning Page: Involving Key Officials and Grassroots Leaders 24 Your Planning Page: Creating a Supportive Context for Planning 25 Chapter 2 Planning Overview: Vision, Mission, Objectives, Strategies and 27 Action Plans Your Planning Page: Refining Your Group's Vision, Mission, 32 Objectives, and Strategies Your Planning Page: Refining Your Group's Choice of Targets and 34 Agents of Change Action Planning Workshop(s): An Example Outline 35 Chapter 3 Working Together to Promote Healthy Living and Prevent 37 Chronic Diseases: Involving Key Sectors in the Community's Framework for Action Working Together to Promote Healthy Living: Identifying Key 39 Community Sectors in an Example Coalition Your Planning Page: Choosing Community Sectors to be Involved in 40 the Effort Envisioning a Community Working Together to Promote Healthy 41 Living: An Example of Community and System Changes to be Brought About in Health Organizations Envisioning a Community Working Together to Promote Healthy 42 Living: An Example of Community and System Changes to be Brought About in Faith Communities Envisioning a Community Working Together to Promote Healthy 43 Living: An Example of Community and System Changes to be Brought About in Businesses Envisioning a Community Working Together to Promote Healthy 44 Living: An Example of Community and System Changes to be Brought About in Schools Envisioning a Community Working Together to Promote Healthy 45 Living: An Example of Community and System Changes to be Brought About in Community and Cultural Organizations Chapter 4 Preparing Your Action Plan: Using an Inventory to Identify 46 Community and System Changes to be Sought "Changes to be Sought" Worksheet 49 Example Community/System Changes for Better Nutrition 51 Example Community/System Changes for Promoting Physical 52 Activity Example Community/System Changes for Reducing Tobacco Use 53 Example Community/System Changes for Assuring Access To 54 Health Care and Preventive Health Services Example Community/System Changes for _____________ 55 Chapter 5 Refining Your Action Plan: Building Consensus on Proposed 56 Changes Chapter 6 Finalizing Your Action Plan: Listing Action Steps for 59 Proposed Changes Action Steps for an Identified Change in Community 60 Organizations (An Example) Action Steps for an Identified Change in Workplaces (An Example) 61 Your Planning Page: Action Steps for Identified Changes 62 Chapter 7 Documenting Progress and Promoting Celebration and 65 Renewal Some Potential Community-Level Indicators of Healthy Living and 71 Chronic Disease Outcomes Selected References and Sources 73 An Epilogue 75 A Glossary of Terms 76 Appendix A1 Acknowledgments Credits Chapter 1 Community Planning for Healthy Living With clarity of purpose, it is possible to address even a very complex issue like promoting healthy living and preventing chronic disease. This guide uses a process of action planning to help build consensus on what can and should be done within the unique needs and assets of local communities. The primary aim is to help communities specify the concrete ways in which they can take action, such as to promote physical activity and healthy diets and reduce tobacco use, in order to prevent chronic diseases such as diabetes, cardiovascular diseases, and some cancers. This chapter explores key background issues and concepts of the planning process. At the end of this chapter, we provide planning pages that can be used to help: ƒ Listen to the community about issues and options ƒ Document the problem ƒ Understand personal and environmental factors affecting health outcomes ƒ Develop a framework for action ƒ Raise awareness of local resources and efforts ƒ Involve key officials and grassroots leaders ƒ Create a supportive context for planning and action. Listening to the Community about Issues and Options Related to Healthy Living for All Listening contributes to a better understanding of what the issues are and what can and should be done. It helps ground the planning in the lives of local people. Perhaps the most important preliminary step in action planning is to become familiar with the issues and context of the community. Leaders of local healthy living initiatives begin by talking with people actually experiencing difficulties in maintaining health promoting behaviors such as regular physical activity, including those from communities that are disproportionately affected by chronic diseases. As with any community organization effort, it is critical to listen before taking action. Connect with and listen to a variety of people. These should include those most at risk for chronic diseases, such as diabetes and cardiovascular disease, and those interested in doing something about the goal of promoting healthy living and preventing chronic diseases for the whole community. 8 Copyright © 2005, 2008 University of Kansas Work Group for Community Health and Development In addition to talking one-on-one, group leaders can listen by conducting public forums or focus groups in which people express their views about the issues and what can be done about them. Such public meetings should be convened by and with people from different ethnic and cultural groups. People from multiple income groups and social classes, and from those places or locations most affected in the community, should be represented. This will expand available perspectives on issues and options for promoting greater physical activity and better food choices and eliminating tobacco use and poor access to health care. Conducting listening sessions. One method of becoming familiar with the issues uses structured opportunities to listen to a variety of members of the community. These listening sessions go by different names including focus groups, public forums, social reconnaissance, or community meetings. Group listening sessions are a straightforward and effective tool for gaining local knowledge about the issues and context. We recommend sing public forums to learn about the community’s perspectives on local issues and options. Listening sessions provide information regarding: ƒ The problem or issue (e.g., assuring physical activity and healthy diets, preventing tobacco use, assuring access to health services) ƒ Barriers and resistance to addressing the problem or issue ƒ Resources for change ƒ Recommended solutions and alternatives ƒ Current and past initiatives Discussion leaders set a limited time for brainstorming about each factor, using newsprint or poster paper to record the product of discussions. Brief reports based on the findings can be used to publicize the issue in the media, thereby enhancing the credibility of the early developing initiative. Documenting the Level of Health-Related Behaviors and Related Chronic Diseases In addition to hearing the community’s perspective on the issue of healthy living and chronic disease, it is important to document relevant aspects of the problem or goal using existing information sources. Health organizations, such as local public health departments or clinics, may have data that can be used to document the level of healthy behaviors (i.e., reported levels of regular physical activity, fruit and vegetable intake, tobacco use) and the prevalence of chronic diseases such as diabetes, Promoting Healthy Living and Preventing Chronic Disease 9 cardiovascular disease, obesity, and emphysema in your community. For Chapter 1: example, data may be available on the percentage of local community Community Planning members who engage in physical activity regularly. Perhaps public records for Healthy Living can be used to create a scorecard for priority community health outcomes such as the number of people who have diabetes. Such information can be used to help document the level of the problem (social attainment) and to consider whether further action is necessary. Later, these data can be used to determine how effective your group was in addressing the problem. (A caution: Increased community awareness and activity may also bring changes in reporting or other activities that may make it difficult to conclude that there was an effect or that observed effects were solely due to the initiative.) Some Personal and Environmental Factors Associated with Physical Activity, Healthy Diets, and Tobacco Use Those most affected by conditions related to healthy living include: ƒ Community members, ƒ Service providers, and ƒ broader agents of change (and their allies) in this effort. A number of factors contribute substantially to risk. Addressing these factors can help protect against negative health outcomes. Although our knowledge is incomplete, research and experience suggest that somefactors may contribute to access to opportunities for healthy behaviors, such as engaging in physical activity, eating fresh fruits and vegetables, and working in smoke-free environments. Table 1 (near the end of this chapter) provides a list of personal factors and environmental factors that may affect healthy living. Personal factors may include: ƒ Knowledge, skills, and history, such as knowledge of healthy food choices and skills to incorporate physical activity into daily living ƒ Biological/genetic influences such as the type and degree of one’s current health or the presence of a physical or mental disability. Aspects of the social and physical environment may also affect healthy living. Environmental factors may include: 10 Copyright © 2005, 2008 University of Kansas Work Group for Community Health and Development