Treating patients can be complex, but have you ever thought about what it might take to treat a sick population? In this module, we'll describe the key ways to improve a population's health through community level interventions. There are basically four different ways in which we can intervene on communities. We can change the health policies, so that's things like taxation or, for instance, smoking bans. Another whole category is health promotion and disease prevention campaigns. We see them all over the place, whether or not it's in a local clinic, a neighborhood community center, or a local bathroom. We can also look at implementing community-wide interventions that are much more specific to somebody's location or their interest groups. So for instance, beach-side communities have to pay special attention to whether or not there are E.Coli in the water in which they themselves, their neighbors, or visitors are at risk of getting if they go to the beach. We also would need to think about creating new infrastructure. So these are working alliances, often across government, business, and community organizations. Because across communities sectors, we can build a web that creates basically the healthy choices that make a difference within our communities. How do we do it? Well, the two things that we're going to be proponents of in this course are evidence-based priority setting and decision-making. So that's really counting on the evidence that is basically developed by researchers, and academia, and business, and other sectors to figure out which of the interventions are going to be the best for our situation, and are going to be the most cost-effective? The other thing that's essential to community interventions is multi-stakeholder collaborations. Trying to do anything at the population level that doesn't involve many different sectors is not likely to have the same staying power as just a couple of organizations or agencies trying to do something. Digging in a little deeper to what does it mean to change health policy, let's look first at the definition because policy can be everything from a law and a regulation to change in process or procedure or an incentive, something that actually within a business, or an organization, or even local governments put the boundaries on what people can or cannot do. In order to get policies enacted, there's a whole process. It has to start with the problem identification, move to an analysis of where the policies are and are not there to support improvement in that area. So once you figure out what's not working, you need to think about, well, what is the strategy for developing the policy? Who needs to be involved and who needs to pull it into the next phase, which is policy enactment? So once a policy is passed or it's approved, now you actually have to roll it out. Then, of course, that last step, which is the wider implementation, and there's a whole science of policy implementation that's been arising because of the way in which if you wanted to improve population health, you have to find a way to propagate it out to everybody. Inside of the core of the health policy landscape is a real focus on stakeholder engagement in education, it's its own part of this process, as well as evaluation, which is always key to figuring out, "Well, what part of our process worked well and didn't work well, and how can we do it better next time?" Another major way in which we do community intervention is through health promotion and disease prevention campaigns. What I have listed here is the current set of CDC featured campaigns. So these are campaigns that the CDC is rolling up, but their materials are freely available. So I just want to make people aware that the CDC is going to be a regular resource for really good materials that they can use in their own communities. What they're focusing on right now are things like, knowing hepatitis B or prescription awareness campaigns. Things that pull people's attention to, what should they do with their leftover prescriptions? They have a nice campaign also around diabetes awareness because we still have a fair number of people that are walking around with type 2 diabetes, who don't know that they even have the disease. One of their other main focuses is on medication safety, so making sure that medication doesn't get into the wrong hands, and that the medication itself is safe. So is it past due and you really should get rid of it? Or are there ways in which other safety aspects of medications aren't being addressed within the home? Clearly, we've got campaigns out there around clean hands count. This has always been a big part of community health because we spread diseases easily by the things that we touch. Another major campaign that there's a lot of investment in by a number of different organizations is making health easy because we realized that people want to do the right thing, but they don't have the easy stepping stones or bridges to get there. A lot of other emphasis has been placed on self-management of disease and the education on how do you actually self-manage your chronic disease? Whether or not it's asthma, diabetes, obesity. Then, of course, one of the foundational ways in which we stay healthy is physical activity, and I bet you didn't know that it was also related to being an arthritis pain reliever. So these are just some of the prevention campaigns that the CDC has got going on right now, but they form a portfolio that most of us need to be aware of if we're really invested in population health improvement. So finding good sources for evidence-based interventions has always been a major pursuit of people interested in population health. Two of the best sources are presented by the CDC and the Department of Health and Human Services, what is called the Community Guide. This is a set of recommendations from the Community Services Preventative Task Force. But we also have the US Preventative Services Task Force, which is much more focused on clinical guidelines. The thing is that, if we understand the clinical guidelines, we can actually pull those in to create targets or what we actually want to avoid and use that prevention information to formulate campaigns at the community level. Recently, the CDC also started a new program that it's calling HI-5, just like the high five, to help communities prioritize. The HI-5 campaign is highlighting 14 non-clinical community wide approaches, that they think has strong evidence for positive impacts, results in five years, and something that is either cost-effective or actually saves people money. These 14 strategies fall into two categories; improving social determinants of health and making the healthy choice easy. The social determinants of health interventions that they're focused on right now are things like, early childhood education and clean diesel bus fleets, improving public transportation, and even doing things like home improvement loans and grants, or earned income tax credits, and, of course, water fluoridation. So these are systematic changes that can be done underneath of a community that basically benefit everyone. They shift the curve for everyone towards a lower risk status. But then also, there's a whole set of interventions that change the context and make the healthy choice easy. Like, school-based programs to increase physical activity, or to reduce violence, or making the route to school safe. Motorcycle injury prevention, which has been a longstanding concern of people at the CDC and for many people within their communities. Tobacco control interventions, access to clean syringes, pricing strategies for alcohol products, and then multi-component worksite obesity prevention, which is a whole big mouthful. But basically means not just one approach to obesity prevention in a worksite, but many different approaches all working together to hit people where they are in their own process. From those 14 interventions, over two dozen health outcomes are being addressed. They range for everything from anxiety, and depression and asthma, to youth violence and type 2 diabetes. I think what you can see from this list is that 14 different interventions can actually have this multi-fold improvement for a community or a population. The HI-5 initiative is just one example of how agencies like the CDC are working to help local communities make a difference. There also whole groups of people that have come together to create new fields, like the field of Healthy Community Design. This helps to make the healthy choice an easy choice, and often uses the multi-sector approaches that we've been talking about. For example, when we think about our own use of land in our communities, how are homes and shops and work put together? Are they separate? Or are they integrated? Because from a design point of view, if they're integrated, it's a better chance for people to run into each other and get social support, or for instance, to walk to work, or to walk to a local shop rather than getting in their car. So it has this, I'll call it multi-beneficial impact. Another is public transport. It can make walking easier, it can also make reducing air pollution easier. Then things like making safe walkways. Do you have sidewalks in your neighborhood? Or ride a bike. Is it a bicycle friendly town? Then what about housing in your town for people that are low income? Are there opportunities for that? Are they in one section of the town that is run-down or on the outskirts and they have a much more difficult time getting to work? Then, of course, there are things that we all enjoy, like green spaces and parks. Is it easy to get to? Are they in good shape? Are they safe? Do we ultimately have access to the things like healthy foods and vegetables that allow us to thrive and be healthy? This kind of work takes multi-sector partnerships because there's so many different offices and agencies that are going to have to work together. The National Association of County and City Health officials have put together a great road-map for creating those partnerships, and how to put plans together for these types of interventions. They literally call it the MAPP, standing for Mobilizing for Action through Planning and Partnership. It's a step-by-step guide that's available on the web for local communities everywhere to actually just pick up and walk through the workbook so they can get started and make a difference in their local communities. Here I have represented their signature MAPP. It walks through the different stages in the process, and it features the main four assessments that really allow a community to look at its resources and where it needs to go. Those four assessments are community themes, and strengths assessments. What's the local public health system landscape like? Then looking deeply into the community health status assessments, so where are the pain points? Where is the community actually doing well? Then lastly, the forces of change assessment. These forces of change assessment actually lets a community think for a moment or reflect, "So where do we actually have a wave that we can build on? Where are those basic supports that are not there are, or have been dwindling and we can't really count on them for our own change process? Then the steps that take you through all of these assessments and move it through visioning, and identification of strategic plans, and then finally to the goals and the strategies for implementation. It's an incredible process that they've laid out for everyday people within their communities to actually bend together in these multi-sector partnerships and make a difference. As you can see, there are a lot of different ways that we can propose community interventions and walk them out into population health improvements. Just so that you know, there are a lot of people working on a lot of different resources that would make it easy for anybody to pick up and actually improve health in their communities.
