A model memorandum of collaboration: a proposal.

The authors propose a model memorandum of collaboration for use by state and community partnerships, support organizations, and grantmakers in working together to build healthier communities. Described as an idealized social contract, the model memorandum lays out interrelated responsibilities for the key parties.

Effects of a replication of a multicomponent model for preventing adolescent pregnancy in three Kansas communities.

CONTEXT: A significant amount of attention has been devoted to the complex issue of teenage pregnancy and to programs for reducing pregnancy among adolescents. Careful evaluations of such programs are needed to ascertain what strategies will be most effective at reducing teenage pregnancy. METHODS: A pretest-posttest comparison group design was used to analyze the effects of a comprehensive multicomponent school and community intervention on estimated pregnancy rates and birthrates among young people in three Kansas communities: Geary County, Franklin County and selected neighborhoods of Wichita. RESULTS: There were high levels of program activity in all three communities during the intervention period, including teacher training and sexuality education for students. Survey respondents rated highly such project interventions as the extension of school-linked clinic hours to accommodate student schedules and support groups established in middle schools. Between 1994 and 1997, the proportions of adolescents reporting that they had ever had sex decreased significantly among all ninth and 10th graders in Geary County, from 51% to 38% among females and from 63% to 43% among males. In Franklin County, more males in grades 11 and 12 reported using condoms in 1996 (55%) than had done so in 1994 (39%). Age at first intercourse remained relatively stable in Franklin and Geary counties during the intervention period. The estimated pregnancy rate among adolescents aged 14-17 decreased between 1994 and 1997 in Geary Country, while it increased in comparison areas. The estimated pregnancy rates among 14-17-year-olds decreased in both Franklin County and its comparison communities. The birthrate declined both in one target area of Wichita and in its comparison area from 1991-1993 to 1994-1996. Over the same time period, the birthrate increased in a second target area of Wichita, while it decreased in the comparison community. CONCLUSIONS: This evaluation of a comprehensive multicomponent program for adolescent pregnancy prevention contributes to our understanding of this model and its replicability in diverse communities. Ongoing program evaluation is important for developing initiatives and for refining strategies so they respond to local conditions.

PIP: This paper evaluates a multi-component program for reducing pregnancy among adolescents in the US. The study employed a pretest-posttest comparison group design to analyze the effects of a comprehensive multi-component school and community intervention on estimated pregnancy rates and birthrates among young people in three Kansas communities: Geary County, Franklin County and selected neighborhoods of Wichita. Results revealed high levels of program activity in all three communities during the intervention period, including teacher training and sexuality education for students. From 1994-97, the proportion of adolescents who reported that they had experienced sex decreased significantly among all 9th and 10th graders in Geary County. Condom use among males in grades 11 and 12 in Franklin County increased from 39% in 1994 to 55% in 1996. In Franklin County and its comparison areas, the estimated pregnancy rates decreased among adolescents aged 14-17 years. The birthrate declined both in one target area of Wichita and in its comparison area from 1991-93 and 1994-96. In general, this research contributed to an understanding on the impact of multi-component school- and community-based interventions on adolescent pregnancy rates.

Evaluating community coalitions for prevention of substance abuse: the case of Project Freedom.

In the United States alone, there are more than 2,000 community coalitions to address local concerns about abuse of alcohol, tobacco, and other drugs. This article describes an evaluation system used to examine the process, outcome, and impact of coalitions for the prevention of substance abuse. The evaluation addresses five key questions: (a) Was the community mobilized to address substance abuse (Process)? (b) What changes in the community resulted from the coalition (Outcome)? (c) Is there a change in reported use of alcohol and other substances by youths (Outcome)? (d) Does the coalition have a community-level impact on substance abuse (Impact)? and (e) Is community-level impact related to changes facilitated by the coalition (Impact)? To address these and other questions, using eight core measurement instruments, the evaluation system collects 15 distinct measures. This evaluation system is illustrated with a multiyear study of Project Freedom, a substance abuse coalition in a large midwestern city.

Evaluating a statewide partnership for reducing risks for chronic diseases.

We describe a case study evaluation of Kansas LEAN, a statewide partnership with the mission of reducing risks for chronic diseases through dietary and exercise modification. We used a case study design to examine five primary questions related to process and outcome: (a) were the goals of the partnership important to constituents? (process), (b) were constituents satisfied with the partnership (process), (c) were community or systems changes (new or modified programs, policies, or practices) facilitated by partnership efforts (outcome)?, (d) were these changes important to the partnership's mission (outcome)?, and (e) what critical events helped facilitate community changes (outcome)? several measurement instruments--a monitoring and feedback system, constituent surveys, and semistructured interviews--were used to address key evaluation questions. Kansas LEAN is a strong statewide partnership with involvement from key representatives throughout Kansas. It is an ongoing, comprehensive health promotion program that plans and implements multiple components, in a variety of settings, to create awareness, behavior change, and a supportive environment. Kansas LEAN has facilitated several important community or systems changes related to its mission. We conclude with a discussion of the challenges of evaluating partnerships that seek to reduce risks for chronic diseases.

Developing capacities of youth as lay health advisors: a case study with high school students.

Youth lay health advising, a form of support or helping, is an important potential resource for preventive intervention. This article describes a case study of a youth lay health advising program designed to provide high school students with support and guidance to handle challenges and concerns related to their health and quality of life. First, the planning, program development, and implementation of the approach are described. Second, a rapid formative evaluation presents quantitative and qualitative information on adolescent issues faced, the types and content of interactions, and peer helper satisfaction with the program. Third, the strengths and challenges of the peer helping program and the role of youth as lay health advisors are discussed. The article concludes with a discussion of the implications for practitioners on this approach to building the capacity of adolescents as lay advisors for community health.

Evaluating the effects of a community coalition's efforts to reduce illegal sales of alcohol and tobacco products to minors.

Minors' access to alcohol and tobacco is a major public health concern because of the many deaths and disabilities associated with use and the ease with which minors purchase these products. We evaluated the effects of a community-based substance abuse coalition's efforts to reduce alcohol and tobacco products to minors. The intervention--implemented entirely by coalition members--consisted of adults and minors issuing citations to clerks in supermarkets, convenience stores and liquor stores, who were willing to sell alcohol and tobacco products to minors and issuing commendations to clerks who refused to sell. For those liquor stores receiving the citizen's surveillance, there was a marked decrease in alcohol sales to minors, from 83% to 33%; and in those liquor stores not experiencing the intervention, there was a smaller decrease in alcohol sales, from 45% to 36%. This study's findings suggest that citizen surveillance and feedback may be effective in reducing alcohol sales to minors when the intervention is fully implemented, but may be ineffective, at least in these doses, with tobacco sales.

Improving employee health and wellness: a pilot study of the employee-driven Perfect Health Program.

These preliminary findings suggest that participation in the account may have modified participant behaviors associated with risk for death from heart attack and lung cancer. Although further research and development is needed before stronger conclusions about the impact of the program can be made, these findings suggest positive effects of participation in an innovative employee-driven health and wellness program.

Health marketing in the supermarket: using prompting, product sampling, and price reduction to increase customer purchases of lower-fat items.

Reducing purchase and consumption of higher-fat foods is an important health objective for the nation since these behaviors are associated with cardiovascular disease and some cancers. Public health agents attempt to promote health-related behaviors, such as purchases of lower-fat foods, by changing key features of relevant environments. This study examined the effects of a marketing intervention in a supermarket on customer purchases of lower-fat products. Customers of one store of a major supermarket chain participated in this study. Direct observations of customer purchases of lower-fat milk, salad dressings, and frozen desserts were conducted. The supermarket intervention consisted of prompting, product sampling, and price reduction (store coupons). Using an interrupted time series design with switching replications, we found low to moderate increases for the lower-fat counterparts of milk, frozen desserts, and salad dressing. The greatest increase in purchases was found with frozen desserts. Findings from this study suggest that prompting, product sampling, and price reduction can increase customer purchases of some lower-fat products. Implications of these findings for the development and evaluation of health marketing interventions are discussed.

Using empowerment theory in collaborative partnerships for community health and development.

Models of community empowerment help us understand the process of gaining influence over conditions that matter to people who share neighborhoods, workplaces, experiences, or concerns. Such frameworks can help improve collaborative partnerships for community health and development. First, we outline an interactive model of community empowerment that describes reciprocal influences between personal or group factors and environmental factors in an empowerment process. Second, we describe an iterative framework for the process of empowerment in community partnerships that includes collaborative planning, community action, community change, capacity building, and outcomes, and adaptation, renewal, and institutionalization. Third, we outline activities that are used by community leadership and support organizations to facilitate the process of community empowerment. Fourth, we present case stories of collaborative partnerships for prevention of substance abuse among adolescents to illustrate selected enabling activities. We conclude with a discussion of the challenges and opportunities of facilitating empowerment with collaborative partnerships for community health and development.

Promoting the use of advance directives. An empirical study.

OBJECTIVE: To examine the effects of a practical method to increase patient completion and filing of advance directives. METHODS: Randomized controlled trial to examine the effects of structured discussions, information, and mailed reminders on completion of advance directives by internal medicine outpatients. MAIN OUTCOME MEASURE: Presence of advance directives in patients' medical files. Secondary analyses include (1) participant satisfaction with procedures, (2) data on delayed effects of discussion, and (3) data on discrepancies in patients' completion of forms. RESULTS: Six months following the intervention, 23% of patients in the experimental group and 3% of patients in the control group had directives on file. The findings were statistically significant. Patients, nurses, and physicians were satisfied with intervention procedures. Chart reviews at 6 weeks and 6 months indicated that intervention effects were delayed. CONCLUSIONS: Structured discussions and follow-up mailings substantially increased use of advance directives and were time effective and cost-effective.

Home access modifications: effects on community visits by people with physical disabilities.

We examined the effects of access modifications to home entrances of people with physical disabilities on their reported community outings. An interrupted time-series design was used, in which the introduction of ramps was staggered across the homes of 6 people with moderate to severe mobility impairments. Four participants reported increases in weekly outings following installation of ramps at their entrances, and 2 reported a small decrease. These findings suggest that reducing the response requirements of access to and from the residence of people with mobility impairments may increase community visits, but may be insufficient given other environmental barriers in the community.

A contextual-behavioral model of empowerment: case studies involving people with physical disabilities.

When people with disabilities, ethnic minorities, older adults, women, and others lack power, they usually experience adverse conditions disproportionate to other members of society. Empowerment--the process by which people gain some control over valued events, outcomes, and resources--is an important construct for understanding and improving the lives of people of marginal status. This manuscript presents a contextual-behavioral model of empowerment and its application in collaborative research with people with physical disabilities. The eight case studies illustrate 18 tactics for promoting empowerment that flow from the model. The case studies show the use of different combinations of empowerment tactics in a variety of contexts: (a) setting improvement agendas from the perspective of people with disabilities, (b) enforcing ordinances that preserve access to parking spaces designated for people with disabilities, (c) enabling access to homes through housing modifications, (d) enhancing support available through mutual-aid groups, (e) developing skills for recruiting mentors, (f) promoting self-directed behavior change with personal and health concerns, (g) enhancing skills for personal self-advocacy, and (h) building the capacities of groups of people with disabilities for systems advocacy. Finally, we discuss issues that may contribute to research and action related to empowerment.