STRENGTHENING COMMUNITIES:
A PREVENTION FRAMEWORK FOR ELIMINATING HEALTH DISPARITIES (DRAFT)

Appendix 1: Prevention Charts for California's Priority Medical Issues

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
Asthma		1. Tobacco (MF, CC) 2. Microbial agents (MF) 3. Toxic agents (MF)		Built Environment Housing (2, 3) Transportation (3) Environmental Quality (2, 3) Product Availability (1) Social Capital Collective Efficacy (1, 3) Civic Participation /Engagement (1, 3) Social/Behavioral Norms (1) Gender Norms (1) Services and Institutions Public Health, Health, and Human Services (1, 2, 3) Education and Literacy (1, 3) Community-Based Organizations (1, 3) Structural Factors Economic Capital (3) Media/Marketing (1)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
Breast cancer		1. Tobacco (MF) 2. Diet and Activity Patterns (MF) 3. Toxic Agents (MF) 4. Alcohol		Built Environment Activity-promoting Environment (2) Nutrition-promoting Environment (2) Transportation (2, 3) Environmental Quality (2, 3) Product Availability (1, 4) Aesthetics/Ambiance (2) Social Capital Social Cohesion and Trust (1, 4) Collective Efficacy (1, 2, 3, 4) Civic Participation/Engagement (1, 2, 3, 4) Social/Behavior Norms (1, 2, 4) Services and Institutions Public Health, Health, and Human Services (1, 2, 3, 4) Public Safety (2, 4) Community-Based Organizations (1, 2, 3, 4) Structural Factors Media/Marketing (1, 2, 4)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
Cervical cancer		1. Sexual behavior (MF, CC) 2. Alcohol (MF) 3. Tobacco (CC)		Built Environment Product Availability (2, 3) Social Capital Social Cohesion and Trust (1, 2, 3) Collective Efficacy (1, 2, 3) Social/Behavior Norms (1, 2, 3) Civic Participation/Engagement (1 2, 3) Gender Norms (1, 2, 3) Services and Institutions Public Health, Health, and Human Services (1, 2, 3) Public Safety (2) Community-Based Organizations (1, 2, 3) Structural Factors Media/Marketing (1, 2, 3)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
Diabetes		1. Diet and Activity Patterns (MF, CC) 2. Tobacco (CC)		Built Environment Activity-promoting Environment (1) Nutrition-promoting Environment (1) Transportation (1) Product Availability (2) Aesthetics/Ambiance (1) Social Capital Collective Efficacy (1, 2) Civic Participation/Engagement (1, 2) Social/Behavior Norms (1, 2) Gender Norms (1, 2) Services and Institutions Public Health, Health, and Human Services (1, 2) Public Safety (1) Community-Based Organizations (1, 2) Cultural/Artistic Opportunities (1) Structural Factors Media/Marketing (1, 2)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
HIV/AIDS		1. Alcohol (MF, CC) 2. Microbial agents (MF) 3. Sexual behavior (MF, CC) 4. Illicit drugs (MF, CC)		Built Environment Product Availability (1) Aesthetic/Ambiance (4) Social Capital Social Cohesion and Trust (1, 3, 4) Collective Efficacy (1, 4) Civic Participation/Engagement (1, 3, 4) Social/Behavior Norms (1, 3, 4) Gender Norms (1, 3) Services and Institutions Public Health, Health, and Human Services (1, 2, 3, 4) Community-Based Organizations (1, 3, 4) Public Safety (1, 4) Structural Factors Media/Marketing (1, 3, 4)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
Infant mortality		1. Tobacco (MF, CC) 2. Alcohol (CC) 3. Sexual behavior (MF, CC) 4. Illicit drugs (MF, CC) 5. Diet and Activity Patterns (CC)		Built Environment Nutrition-promoting Environment (5) Product Availability (1, 2) Aesthetic/Ambiance (4) Social Capital Social Cohesion and Trust (1, 2, 3, 4) Collective Efficacy (1, 2, 4, 5) Civic Participation/Engagement (1, 2, 3, 4, 5) Social/Behavior Norms (1, 2, 3, 4, 5) Gender Norms (1, 2, 3) Services and Institutions Public Health, Health, and Human Services (1, 2, 3, 4, 5) Public Safety (2, 4, 5) Community-Based Organizations (1, 2, 3, 4, 5) Structural Factors Media/Marketing (1, 2, 3, 5)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
Mental health		1. Alcohol (CC) 2. Illicit drugs (CC)		Built Environment Product Availability (1) Aesthetic/Ambiance (2 and directly) Social Capital Social Cohesion and Trust (1, 2, and directly) Collective Efficacy (1, 2) Civic Participation/Engagement (1, 2, and directly) Social/Behavior Norms (1, 2) Gender Norms (1, 2) Services and Institutions Public Health, Health, and Human Services (1, 2) Public Safety (1, 2) Community-Based Organizations (1, 2) Cultural/Artistic Opportunities (linked directly to mental health) Structural Factors Media/Marketing (1)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Priority Medical Issue		Actual Causes & California Campaign Major Factors		Key Community Clusters and Factors
Trauma		1. Firearms (MF) 2. Motor vehicles (MF) 3. Illicit Drugs (MF, CC) 4. Alcohol (MF, CC) 5. Tobacco (MF)		Built Environment Transportation (2) Product Availability (1, 4, 5) Aesthetic/Ambiance (3) Social Capital Social Cohesion and Trust (1, 2, 3, 4, 5) Collective Efficacy (1, 2, 3, 4, 5) Civic Participation/Engagement (1, 3, 4, 5) Social/Behavior Norms (1, 2, 3, 4, 5) Gender Norms (2, 3, 4, 5) Services and Institutions Public Health, Health, and Human Services (1, 2, 3, 4, 5) Public Safety (1, 3, 4) Community-Based Organizations (1, 3, 4, 5) Cultural/Artistic Opportunities (1) Structural Factors Media/Marketing (1, 3, 4, 5)

CC: These relationships are based on the analysis of the California Campaign.
MF: These relationships are based on McGinnis' and Foege's analysis of the actual causes of death.

Appendix 2: Continuation of explanation of the web of health benefits starting with a focus on Cardiovascular Disease

Health outcomes associated with social cohesion and economic capital

Social cohesion and economic capital are associated with other health outcomes as well. For example, social cohesion and trust is linked not only with improved mental health but also lower suicide rates, including from firearms. Economic capital is indirectly linked to multiple health factors by influencing income levels and quality of work environment, including exposure to toxic agents. These relationships are depicted in green in the following chart.

Expanding the web of community factors

The analysis can be taken further depending on the circumstances within a community. For example, economic capital promotes stability that in turn fosters social cohesion. Likewise, social networks may also contribute to economic capital by opening up opportunities for employment or increasing chances of bringing capital to an area. Strong social networks also produce and enforce social sanctions and controls to diminish negative behavior and reduce the incidence of crime, juvenile delinquency, and access to firearms within communities.^{115, 116} Such constraints can influence behavior norms around a number of behaviors including use of tobacco, alcohol and illicit drugs or sexual behavior. Changes in sexual behavior alone can contribute to reductions in infant mortality, cervical cancer, and HIV/AIDS. Social cohesion and trust is also predictive of a willingness to take action on behalf of the community good. This form of collective efficacy has contributed to multiple outcomes at a community level including reducing violence levels (trauma) and increasing access to nutritious food (diet and activity patterns). These potential relationships are indicated in dotted lines in the following chart.

Additional benefits of a focus on transportation

Finally, efforts to strengthen the transportation factor can go beyond an emphasis on transit systems. Such efforts within a community may include modifying street design, parking options, and traffic flow. A well-designed effort can contribute to an activity-promoting environment by developing safe places for walking and bike riding,¹¹⁷ reduced motor vehicle crashes by decreasing speeds and improving road design, and improved economic capital¹¹⁸ outcomes by promoting increased foot traffic in specific areas. The relationships are designated in the following chart in lime green.

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