Lead Risk in BayView Hunters Point, San Francisco, California Students, staff, and parents were concerned about lead in the water at a BayView Hunters Point elementary school (45% African American, 35% Latino, 10% Samoan, 7% Asian, 3% other). The district had shut off water lines to the playground and some into the school building and instructed staff and students to run the remaining faucets before usage. The district would not release the lead readings to the site administrator but confirmed that they exceeded safety levels. The school-site safety team took the lead in mobilizing the school community to address the problem. They initiated classroom lessons about the effects of lead in the blood and how to limit lead exposure in neighborhood playgrounds, homes, and in school water. The team also hosted an informational session for parents and community members about the hazards of lead in the school and community, preventing children's exposure, and testing for lead in their homes. After hearing about the lead in their school and community, students wrote to city council members encouraging them to take action. School staff and parents testified to the city council about the presence of lead at the school site. On the same day, a local television station covered the school's lead problem on the evening news. Within a few days of the testimony and the local media coverage, the district changed the school fixtures throughout the building and playground. The major health outcome of this school effort was 1) Reduced risk of children's exposure to lead (environmental quality). In addition to the reduced risk at school, parents reported stories of their children intervening with younger siblings at home had the water in their homes tested through the health department. Another outcome was the 2) Knowledge that in coming together, the members of the school community had the capacity to make positive changes (collective efficacy).

Services and Institutions

The availability of and access to high quality, culturally competent, appropriately coordinated public and private services and institutions is a critical element of good health. The range and quality of these services within a community represent an opportunity to overcome barriers to health and safety and to foster strengths. The availability of public and community-based services may be particularly important in low-income communities, as residents may not have access to or be able to afford paying for services. Further, it is critical that community services be connected to broader systems and policy bodies, including those at the city, state, and federal levels in order to ensure that decisions that are made will have a positive impact on the community. Services and institutions factors are:

13. Public Health, Health, and Human Services: Prevention, intervention, and treatment

14. Public Safety: Law enforcement and fire protection

15. Education and Literacy: Education and literacy services across the life span

16. Community-Based Organizations: Non-profit, grassroots, faith-based, and coalitions

17. Cultural/Artistic Opportunities: Opportunities cultural and artistic expression/reflection

Public health plays a valuable role in promoting population health and advocating for or ensuring needed services within a particular community. Health and human services can promote health, foster community violence prevention efforts, and ensure that those in need have access to needed medical services, substance abuse treatment programs, and mental health services. Communities can strengthen services or the level of services by working with these entities to make sure that they are addressing the priority needs of the community. Effective public safety services contribute to lower injury and violence rates within communities. In addition law enforcement may contribute to substance abuse prevention efforts. Law enforcement efforts to address violence and crime, as well as pedestrian safety, can foster perceptions of safety that may translate to increased levels of physical activity.⁸⁴ Quality education is also important. Lower education levels are associated with a higher prevalence of health risk behaviors such as smoking, being overweight, and low physical activity levels.⁸⁵ While some of the relationship can be explained through income levels, education shapes opportunities in relation to income and occupation. Related to education, literacy levels impact health outcomes in a number of ways. One study shows "75% of American adults who report having a physical or mental health condition scored in the two lowest literacy levels of the National Adult Literacy Survey."⁸⁶

Healthy Youth Lifestyles, Selma, California Residents of the predominantly Latino community of Selma, California were concerned about the lack of activities for young people and the risk of their becoming involved in illicit activities. Through a community wide strategic planning process, they prioritized youth services and opportunities and developed the Healthy Youth Lifestyles program. These efforts were supported through the city's partnership with California Healthy Cities and Communities. Under the guidance of the City of Selma, they established a visual and performing arts program for youth, art classes, and a volunteer service-learning program for middle school children. The outcomes of this project include: 1) Reduced the risk of violence and other illicit activities by establishing a summer arts program (cultural/artistic opportunities) and 2) Increased youth participation in the community through a service learning program which connects middle school youth to local businesses and organizations (civic participation/engagement).

The presence of art and other cultural institutions contributes to an environment that is conducive to health and safety. Artistic outlets, such as gardens, murals, and music, promote a healing environment. This has been demonstrated in hospitals and other health care facilities, where the incorporation of arts into the building's spaces has reduced patient recovery time and assisted in relief for the disabled, infirm, or their caregivers.⁸⁷ The visual and creative arts enable people at all developmental stages to appropriately express their emotions and to experience risk taking in a safe environment. For those who have witnessed violence, art can serve as a healing mechanism. More broadly, art can mobilize a community while reflecting and validating its cultural values and beliefs, including those about violence. Also, artistic expression can encourage physical activity, as in the case of dance. A report commissioned by the Ottawa City Hall states that culture "provides benefits in terms of... social cohesion, community empowerment... health and well being and economic benefit."⁸⁸

Although many people involved in prevention have begun relying less on government and more on foundations and grassroots efforts to promote health and safety, government is still a major source of economic support through the allocation of tax funds. Tax money far exceeds the amount of money contributed to serve the public good by charitable donations, foundations, and businesses. In fact, the combination of government funding with individual commitment and volunteerism is probably the most important resource in creating change for the common good. It is therefore incumbent on government to provide a range of quality services for people. In some cases, this means that different governmental agencies must work together.

Services for community members should be easily accessible and integrated when appropriate. Too often, people in need end up navigating a complicated and ambiguous web of services and being shuffled from one place to another without receiving the services they need. Integrating appropriate services may require sharing or coordinating data, cross-disciplinary training, and shared strategy planning.

Finally, community services and institutions may serve as the focal point from which community change can be planned and implemented. These places may have resources, including mandates and funding, staffing, facilities, connections beyond the community, and community support and credibility, to foster and engage the necessary momentum and participation. The capacity of such organizations to lead or catalyze such change is an important element in the community.

Vietnamese Health Promotion Project, San Francisco, California The Vietnamese Health Promotion Project was concerned about extremely high cervical cancer rates among Vietnamese immigrant women in San Francisco. Sponsored by the University of California, San Francisco, the project brings together university medical researchers and community residents to promote screening and early detection. In addition to getting the word out through Vietnamese radio, television and newspaper outlets, the project also employs lay health workers to bridge cultural and language gaps and encourage women to get Pap tests on a regular basis. Program data suggests that radio, television and newspaper ads are effective at getting the general word out about what cervical cancer is, why to be concerned about it, and about the Pap test. Further, the lay health worker component seems to be effective at giving women specific information about causes of cervical cancer and may be more effective than media alone at encouraging women who have never had a Pap test to get one. Outcomes include 1) Earlier detection of cervical cancer among Vietnamese women in San Francisco (public health, health, and social services), 2) Increased awareness about the problem of cervical cancer via the use of media (media/marketing), and 3) Increased knowledge and awareness of other health issues, such as smoking, asthma, and health insurance (public health, health, and social services).

Structural Factors

Generally speaking, structural factors are overarching in nature, influencing all other factors and rooted in broader systems or structures. There are a number of structural factors that impact communities directly and indirectly. These include 1) technology and product design, 2) global trade and business, 3) national and international politics, 4) socioeconomic structure and distribution of wealth, 5) media, and 6) racism, oppression, and discrimination. While the first three ultimately impact health and well-being at a community level, they are not considered here because they are largely beyond the scope of community level action. The final three are considered here to the extent that each has community elements that can benefit from community attention. Structural factors are:

18. Economic Capital: Local ownership of assets or access to capital and investment

19. Media/Marketing: Supports health outcomes through positive messages and role models.

20. Ethnic, Racial, and Intergroup Dynamics: Relations between groups of people

Because economic conditions relate more generally to the availability of appropriate services, stress, and the effectiveness of a community to change its circumstances or environment, this factor links multiple health and safety issues and supports the development of other factors. Economic capital, including adequate living wage employment opportunities, job training, local ownership of businesses, homeownership, access to loans and investment capital can be encouraged and promoted at a local level. It results in local access to resources, the opportunity to increase local capital that can be reinvested into the community, and stability among residents. Increases in local business are associated with reduced crime and achieving living wages may be correlated with reduced stress levels and better housing. Economic capital is also directly tied to the effectiveness of community coalitions. In particular, in a community without economic capital, resources are too limited to make change.⁸⁹

Pico Union/MacArthur Park Economic Development Zone, Los Angeles, California The Pico Union/MacArthur Park area of Los Angeles has a diverse Latino population, which comprises seventy-seven percent of the community. As part of Los Angeles' Economic Development Zone, the area has a program for its under-employed and unemployed residents. With city and county redevelopment funds, it provides educational training, employment services, and training that enables participants to become licensed to prepare, handle, and sell food products, and to establish self-employment and micro-business enterprises. Further, they have created a licensed vending program and opened a restaurant. These food outlets offer healthy tamales and other foods that reflect the culture of the people in the program and in the community. There are plans to replicate this program in a Korean neighborhood with Korean food. Outcomes include: 1) Job training and preparation for people with limited income opportunities and job skills (economic capital), 2) Increased availability of culturally appropriate, affordable prepared foods in the community (nutrition-promoting environment).

Media is omnipresent in U.S. society and includes television, film, music, print news and magazines, the Internet, video games, and numerous other industries. Media can influence sexual behavior,⁹⁰ violence,^{91, 92} obesity,⁹³ mental health stigma, substance abuse, and other health threats. Media can also play a positive role in promoting health. "[M]edia approaches should focus on increasing the reservoir of social capital by engaging people and increasing their involvement and participation in community life... mass media strategies should also provide citizens with the skills to better participate in the policy process to create these conditions [for people to be healthy]."⁹⁴ According to John Kingdon's model, policy-making is not simply a rational process of defining a problem and designing solutions; rather, problems and solutions are mediated by public attention and opinion.⁹⁵ To a large extent, media cycles can set health agendas through their news selection -- for example, guns in schools were a problem in inner city districts long before Columbine made it a national concern. And, since policymakers are often affected by elections, public opinion must always be taken into account -- for example, AIDS was, for a long time, seen as a disease of drug users and homosexuals, making it politically dangerous for a politician to champion AIDS relief efforts.

Efforts to promote healthy behaviors in low-income communities and improve the environment are often rendered ineffective because racism, bias, and discrimination can foster conflicts that leave the residents feeling powerless, divided, and alienated. Divisions among residents in these neighborhoods impede efforts to build trust and the sense of community required to effectively advocate for needed change. The impact of such conflict is manifested in a number of ways. Public institutions such as health clinics, schools, law enforcement, and parks tend to be perceived as serving one group of residents to the detriment of the other, and they are viewed with mistrust by one or more segments of the population in a community. Human service and community-based programs may serve only one racial or ethnic group in a community, and they are rightly or wrongly perceived as favoring one group. Additionally, outside perceptions of community groups or coalitions can limit the effectiveness of their work.⁹⁶ Without a sense of community based on place rather than race or ethnicity, neighborhood efforts to address health related goals can be fractionalized. In Understanding and reducing socioeconomic and racial/ethnic disparities in health, House and Williams summarize the wide impact of racial/ethnic dynamics: "...racial/ethnic status shape[s] and operate[s] through a very broad range of pathways or mechanisms, including almost all known major psychosocial and behavioral risk factors for health."⁹⁷

While racial discrimination, which can impact health in a number of ways, certainly can be traced beyond community boundaries, it is critical that communities address discrimination within their boundaries and foster positive ethnic and racial relations. To the extent that there are positive dynamics, people within diverse communities can work together to achieve change that will impact the overall well being of the community.

Cultivating Communities, Seattle, Washington Cultivating Communities is a neighborhood gardening program for low-income communities in Seattle, Washington. The program was developed when Seattle Housing Authority (SHA) recognized that residents were planting gardens outside their homes, where the soil was potentially contaminated with lead. To address the problem, SHA partnered with the Department of Neighborhoods' P-Patch program, which helps Seattle residents develop unused plots of land in the city. Together they formed Cultivating Communities in 1995, adopting a proactive approach to working with low-income communities and immigrant populations. Seattle now has 17 community gardens in 4 SHA sites in different communities, providing lead-free organic gardening space for more than 120 families to grow food for family and friends. Two of the four participating communities, Rainer Vista and Yessler Terrace, have populations in which 50% of the residents are of Southeast Asian origin, many with agricultural backgrounds. Cultivating Communities has leveraged local resources to support the community gardens, such as the Neighborhood Matching Fund (NMF) administered through Seattle city government. Applications to the Cultivating Communities program are available to any community group, which can form for the purpose of getting a community garden. Cultivating Communities also assists residents with grant management if needed. Currently, Cultivating Communities is transferring the management of existing gardens to community residents and establishing new gardens in recently redeveloped communities. Cultivating Communities also has two community-supported agriculture (CSA) enterprises that provide supplemental income for some families. Subscribers pay a set fee and receive a bag of fresh organic produce for 24 weeks. The interaction between customers and gardeners enables the gardeners practice their English skills and links them to the broader Seattle community, helping them adjust to life in the United States. Since most of the gardeners had little contact with each other when the project began, the enterprise is also helping to build community among the gardeners themselves. Cultivating Communities addressed a potentially harmful problem by building on the capacity and skills of residents and leveraging local resources. The program has resulted in multiple health-promoting outcomes. Most directly, these include 1) Decreased exposure to lead by providing lead-free gardening plots (environmental quality); 2) Decreased risk of chronic disease as a result of increased availability of healthy food (nutrition-promoting environment); and 3) Decreased risk of mental health problems and violence by promoting social connections and trust between community members (social cohesion and trust). In fact, residents have noted that relationships among neighbors have contributed to community building and crime prevention. Additionally, the program has achieved outcomes that indirectly promote health including 4) Increased economic opportunity through supplemental income development and increasing participant skills (economic capital); 5) Opportunities to learn English (education and literacy); and 6) Improved relations between different racial and ethnic groups (racial, ethnic and intergroup dynamics).

Characteristics of Community Factors and Clusters

The community clusters and factors are intended for people who want to improve the environment within a community to promote better health outcomes. While their influence may be direct or indirect, each of the factors influences health and/or safety. For example, modifying transportation design can directly impact rates of asthma and pedestrian injury while also shifting physical activity levels, and thereby indirectly affecting diabetes and cardiovascular disease. The framework is designed to delineate an overall set of factors that foster health and safety but allows for flexibility based on local priorities and solutions. In developing this framework a number of important conclusions emerged which should be taken into account when using the framework to develop community health strategies.

a) Each of the factors and clusters affects more than one of California's Priority Medical Issues. Factors and clusters are generally not related to only one disease or actual cause; virtually all of them are linked to a number of behavioral/environmental factors and diseases. For these reasons, intervening in a set of community factors will start to produce multiple changes that improve overall health. For example, improving housing conditions may impact mental health, asthma, and trauma as well as physical activity levels which is associated with reduced rates of diabetes and cardiovascular disease.

b) Strengthening one factor may strengthen other factors, thereby having a cumulative effect. Multiple factors build on each other and the cumulative sum of the whole is greater than the sum of individual factors. For example, as neighbors gain more trust of each other, they are more likely to join collectively to take action, which can in turn result in achieving positive outcomes in the community. This was the case for a gun buy-back program in Boston which both raised awareness about firearm safety and fostered positive relationships between different ethnic/racial groups with a history of significant conflict.⁹⁸ Such positive relationships reduce the likelihood of violence and are the foundation for collective action on other issues. The converse of this characteristic is that generally none of the factors works in isolation. They have an interactive and synergistic relationship with each other, which must be considered as strategies are developed and implemented.

c) Factors have a cultural component. Values, customs, and priorities vary from one culture to another and these differences must be accounted for in designing health strategies. For example, social services, food, and artistic opportunities all have cultural aspects that should reflect those living in the community. While the preponderance of research that links health to these factors is focused generally, it is postulated here that the research is still relevant to health disparity approaches because the diseases are the same. What is needed is additional research about variations given different cultures and values.

d) Factors have a developmental component. When designing strategies based on the framework, developmental needs should be taken into account. Young children, teens, adults, and seniors have different needs in relation to all of the factors. For example, in fostering an activity-promoting environment, young children benefit from safe and interesting playgrounds, teens may value athletic courts and fields, and seniors may look for safe walking paths. The relative importance of some factors may vary across the life span.

e) Community factors strengthen individual resiliency factors. Individual resiliency is associated with a number of positive outcomes including academic achievement, reduced substance abuse, and decreases in teen pregnancy. The most common indicators of individual resiliency are caring and supportive relationships, high expectations, and opportunities for meaningful participation.⁹⁹ These are fostered through stronger community factors. For example, the presence of social cohesion and trust enhances opportunities for mentorship and role models, increasing the chances that children will have relationships with caring adults.

f) Community approaches that strengthen community factors support healthy behaviors and individual responsibility. Individual responsibility is a strongly held U.S. value that influences public policy and devalues efforts to support people with disadvantages or living in disadvantaged environments. However, the ability to take individual responsibility is influenced by environmental conditions. For example, greater availability of healthy, affordable food has been linked to better diets in African American communities.¹⁰⁰ In fact, community factors are critical in protecting and promoting individual health. Individuals still must take responsibility for their own health, but communities can help to create environments in which making healthy choices is easier.

g) Some results may take a long time. The Institute of Medicine suggests taking a "long view" of health outcomes.¹⁰¹ Seeing improvements in some of the factors may take a long time, and once established, it may take years to see improvements in health outcomes. However, because of the research basis of the factors, progress on each of them can be seen as benchmarks for better health and safety outcomes. For example, bringing a supermarket to a neighborhood can be a slow process. However, having such an outlet is a marker for improved nutrition levels within that community.

h) The four clusters link to broader statewide and national policies, conditions, and trends. Health disparities are affected by broader societal influences such as environmental, communications, and welfare policy, industry practices and regulations, technology and product design, and state, national, and international politics. Their relative role should be considered when implementing community change. Fostering improvements related to the community factors can address gaps in state or national policies or strengthen the impact of existing policies. For example, government programs like the Women, Infants and Children (WIC) program improve the nutrition levels of low-income children and mothers.

Communities can make the WIC program more effective by encouraging grocery stores, farmers' markets, and other local vendors to accept WIC vouchers, display WIC information, and educate their employees about the program. Also, bolstering community factors in one place can catalyze change on a broader scale. Effective community interventions serve as models for county, state, or national policies aimed at reducing health disparities. In addition to local solutions, interventions that target broader policies -- for instance, working towards a specific statewide environmental regulation -- can be beneficial to multiple communities because of the broad-based impact of these policies, conditions, and trends.

i) The factors are not always parallel. Some of the factors have a direct and specific effect on medical conditions and health outcomes. For example, activity-promoting environments and nutrition-promoting environments are directly linked to cardiovascular disease and diabetes. Other factors may have a more indirect link to health outcomes or a general link to improved health outcomes more broadly. For example, education and literacy levels are associated with improved health outcomes in a number of areas.

j) Most factors fall along a risk and resilience continuum. The community factors tend to represent risk and resilience continuums. That is to say, the presence or absence of something may represent a community risk and the opposite a resilience factor. For example, a lack of economic opportunity is a risk factor, whereas the presence of economic capital, such as living wage jobs and availability of loans represents a resilience factor. Similarly, the proliferation of fast food and junk food is a significant risk factor for poor nutrition while the availability of safe, healthy, affordable and culturally appropriate food in a community promotes healthy eating. The effects of risk and resilience factors on health and safety are interactive and cumulative. Not everyone exposed to risk factors will be impacted but those who are exposed to multiple risk factors are at greater risk. The combination, frequency, and severity of risks influence whether or not problems develop. Further, poor health and safety outcomes within a community are generally accounted for by an overwhelming accumulation of risk without a compensatory accumulation of resilience factors. On an individual level, resilience factors can counteract the negative impact of risk factors^{102, 103} and the protection effects reducing problem behaviors become stronger as levels of risk exposure increase.¹⁰⁴

Similar effects may be seen on a community level. For instance, while a high availability of firearms and alcohol within a community is a risk factor for violence, positive social norms can provide social controls that are protective against the use of weapons or excessive drinking. Further, approaching a community with an emphasis on its strengths and assets rather than simply its problems will be better received as it shows respect for effectiveness in the face of difficult environmental conditions. The set of 20 community factors are delineated on a risk-resilience continuum in Chart 2: Evolution to Effective Prevention -- From Health Disparities to Health Promoting Community Environments.

Chart 2: Evolution to Effective Prevention
From Health Disparities to Health Promoting Community Environments

	Community Factors	From		To
	Activity-promoting Environment	Absence of places for physical activity or unsafe or uninspiring places		Places in which people can safely participate in walking, biking and other forms of incidental or recreational activity105 and such activity is promoted
	Nutrition-promoting Environment	Absence of nutritious food and proliferation and promotion of fast food and junk food		Availability and promotion of safe, healthy, affordable, culturally appropriate food106
	Housing	Unsafe and inadequate levels of housing		Availability of safe, affordable housing in the community
	Transportation	Unsafe, inadequate, and/or overly auto-oriented at the expense of alternative or transit-oriented		Availability of safe, reliable, and affordable methods for moving people around
	Environmental Quality	Range from polluted, toxic water, soil, air, and building materials		Safe and clean water, soil, indoor and outdoor air, and building materials
	Product Availability	Availability of potentially harmful products such as tobacco, firearms, alcohol, and other drugs		Availability of beneficial products, such as books and school supplies, and sports equipment, arts and crafts, and other recreational items
	Aesthetic and Ambiance	Uninviting, inappropriate, culturally irrelevant settings		Well maintained, appealing, clean, and culturally relevant environment
	Social Cohesion and Trust	Mistrust and absence of social networks		Strong social ties among persons and positions, built upon mutual obligations, opportunities to exchange information, shared norms, and the ability to enforce standards and administer sanctions107
	Collective Efficacy	Apathy, a sense of helplessness, and unwillingness to take action for the good of the community		Social cohesion coupled with a willingness to intervene on behalf of the common good108
	Civic Engagement and Participation	Lack of involvement by community members in the community and decisions that affect the community		Involvement in community or social organizations and/or participation in the political process
	Social/Behavior Norms	Expectations and social reinforcers that shape and promote unhealthy and unsafe behaviors		Shared beliefs and standards of behavior that encourage positive choices and support healthy environments
	Gender Norms	Socialization and inflexible gender roles that limit opportunity or promulgate disrespect and reckless behavior		Socioculturally determined standards of behavior, specific to males or specific to females, that encourage positive choices, create safe and supportive relationships between and within gender groups, and generally support healthy environments
	Public Health, Health, and Human Services	Inadequate, unresponsive, incompetent, or absence of appropriate services		Available, accessible, high quality healthcare, health promotion and wellness services, health-related services such as mental health and substance abuse prevention and intervention, public health, and social services
	Public Safety	Inadequate, corrupt, unresponsive, or absence of appropriate services		High quality law enforcement and fire protection that responds rapidly and has gained the trust of the community
	Education and Literacy	Poor performing schools and inadequate early childhood education and literacy programs		High-quality and available education and literacy services across the life span that meet the needs of all people within the community
	Community-based Organizations	Ineffective or non-existent community-based services		Non-profit, grassroots, and faith-based organizations and coalitions within a community that fill service gaps, advocate for community needs, and promote health and safety for the community
	Cultural/Artistic Opportunities	Absence of artistic and cultural opportunities including theaters, museums, festivals, community centers, arts programs, etc.		Proliferation of opportunities within the community for cultural and artistic expression and participation and for cultural values to be expressed through the arts
	Economic Capital	Low levels of local ownership of homes and businesses, inability to access capital for local investment, and absence of opportunities to make a living wage		Local ownership of assets or access to capital and investment and abundant opportunities to make a living wage
	Media and Marketing	Promotion of unhealthy products and behaviors		Presence of responsible marketing and media that support healthy behaviors and environments through positive messages and role models
	Ethnic, Racial, and Intergroup Dynamics	Strained, negative interactions and relations or mistrust between people of different races and ethnic backgrounds, people with different characteristics (e.g. sexual orientation), or status (e.g. employer/employee or police/youth)		Positive interactions, relations, and trust between people of different races and ethnic backgrounds, people with different characteristics, or status

The Relationship between Community Factors and California's Priority Medical Issues

A community's efforts to make improvements along the continuum of four clusters and twenty community factors will strengthen health overall and will specifically reduce the incidence of California's Priority Medical Issues. All four clusters are of importance in virtually every community and for virtually every disease. The weighting of specific factors will depend on the community's priorities in terms of the disease or health issues that most concerns it, as well as other criteria (e.g. achievability, local buy-in and interest, etc.) Irrespective of which particular priority is selected, a focus on community factors ensures that a number of health issues should be positively affected as the following example -- cardiovascular disease -- reflects. (Additional charts for other priority medical issues are in the appendices.)

Cardiovascular Disease: Key Community Factors

The California Campaign to Eliminate Racial and Ethnic Disparities has identified cardiovascular disease as a priority issue for the state, citing the fact that African Americans in California had the highest heart disease death rate over a five-year period from 1991-1995.¹⁰⁹ According to the McGinnis and Foege analysis, cardiovascular disease causes include tobacco, and diet and activity patterns. There are a number of community factors associated with these causes. For example, tobacco use is directly influenced by product availability and diet patterns by nutrition-promoting environments that limit junk food and provide access to healthy and affordable food; activity patterns are influenced by activity-promoting environments in which physical activity is fostered through incidental** and recreational opportunities; transportation can both contribute to accessing food and improve patterns of physical activity; and social/behavior norms and media/marketing can encourage (or, too frequently, discourage) healthy choices. Other factors have a less obvious effect. Aesthetics/ambiance can foster increased levels of physical activity by promoting comfort levels going to parks or shopping in the community, collective efficacy can enable a community group to secure a supermarket in the neighborhood or eliminate billboards touting unhealthy products. Public health and community-based organizations should play a role addressing cardiovascular disease and health facilities must play a role in screening and treatment. Effective public safety programs will reduce fear of crime and thereby promote increased activity levels in the community. All of these factors are depicted in the following chart. ** By incidental physical activity we are referring to the activity that can occur in the course of daily activity -- walking, biking, taking the stairs, carrying groceries, etc.

Key Community Clusters and Factors		Actual Causes		Priority Issue
Built Environment Activity-Promoting Environment (1) Nutrition-Promoting Environment (1) Transportation (1) Product Availability (2) Aesthetics/Ambiance (1) Social Capital Collective Efficacy (1,2) Social/Behavior Norms (1, 2) Services and Institutions Public Health, Health and Human Services (1,2) Public safety (1) Community-based organizations (1,2) Structural Factors Media/Marketing (1,2)		1. Diet and Activity Patterns 2. Tobacco		Cardiovascular disease

Factors can contribute not only to cardiovascular disease but also to other priority medical issues

One key community factor listed in the above example is transportation. As noted, transportation can both increase access to healthy food and promote short walking trips. Efforts to bolster this factor will not only contribute to reductions in cardiovascular disease, but will also result in improvements in other priority issues as well. For example, in regards to transportation, Trevor Hancock, a leader in prevention strategy in Canada, has identified several health benefits associated with a good public transit system.¹¹⁰ Direct benefits include not only lower rates of cardiovascular disease, including heart disease, but of respiratory diseases including asthma and lower trauma rates due to reduced motor vehicle crashes, and lower diabetes and cancer rates due to increased physical activity from walking and biking. These relationships are depicted in blue in the following chart.

Less Direct Benefits

Indirect benefits of improved transportation include less stress and increased social cohesion. Hancock also noted the opportunities for increased economic capital associated with effective transit. This is particularly true for low-income communities of color that tend to be more isolated from jobs and other forms of social capital as well as other resources, including healthy food outlets. These relationships are depicted in red in the following chart.

Communities may start from very different places -- by focusing on different medical conditions or they may start by focusing on positive factors such as enhancing education and literacy or cultural and artistic opportunities. What is critical in applying the community factor framework is that a community understand the potential of upstream approaches, decide on its own priority issues, determine its strengths and weaknesses in terms of the factors, and select an approach that will strengthen the community factors most likely to improve its health outcomes and reduce the medical issues that are its greatest concern. Because many of these factors, causes, and diseases interrelate, a well-designed solution can solve multiple problems. The above example continues (see appendix 2) to create a web of health enhancing efforts.

In fact, the overall framework promotes multiple health and safety outcomes at a community level. Such an approach makes sense in addressing health disparities because people who live in low-income communities of color are disproportionately sick and generally face a variety of health problems. They experience the cumulative effect of the environment on their health and this approach provides an opportunity to strengthen the overall environment. This has the potential to affect the community population and results in a bigger effect on health outcomes than efforts that are focused on preventing one disease at a time.

Improving Individual Outcomes

While the approach is necessarily designed to improve health outcomes for a community population, progress can be assessed not only in terms of population health, but also for individuals. Given the profound affect of the environment on health, it can be anticipated that health strategies that promote progress along the community factors will not only change the conditions in which people live, but also the behaviors that people choose. These individual behaviors and conditions that promote healthy outcomes provide indicators for evaluation of this approach. Examples are delineated in the following chart.

Chart 3: Individual Health-Promoting Behaviors and Conditions Eat safe, healthy food Walk 60 minutes/day or equivalent Have living wage job/be in school Read at 8th grade level Breathe clean air Drink clean water Be smoke-free Practice safe sex Drink moderately Have social supports Have wellness care Have safe housing Have safe transportation Be safe from violence

Conclusion: A Good Solution is Overdue

"In 1968 and again in 1969 and 1974, [Henrik Blum] vigorously promoted an enlargement and clarification of the concept of forces that affect health so that health planners could see more clearly how to intervene effectively to reduce the risks that presaged ill health."¹¹¹ However, he recounts with frustration, "For a number of reasons, this idea did not catch on."¹¹² Now we have far more information about the community environment -- the specific clusters and factors that will enable communities to intervene in reducing illness. This idea must catch on if California is to reduce the level of health disparities.

Low-income people of color are disproportionately exposed to hazardous conditions in their homes, workplaces, and communities. Further, many of their poor health decisions must be seen not only as a cause of poor health, but also as an indicator of an environment encouraging poor health. Recognizing the context in which behavior takes place creates opportunities to change social and behavior norms, which have immense power over the ways in which individuals behave. Altering the environmental conditions alters the pathways between oppression and poverty and multiple health problems. Focusing on the pathways and trajectory from root factors to poor health outcomes provides the basis for action that can make a difference in communities. In addition to improving health outcomes in low-income, communities of color, this framework may also have applicability in reducing other disparities in health. Further, it can inform policy decisions at local, state, and even national levels. "Policy cannot be intelligently conducted without mechanisms; correlations are not enough."¹¹³

Some have calculated that nearly 70% of all medical care spending is used for chronic and preventable diseases and injuries.¹¹⁴ Too many people, and especially low-income people of color, are needlessly getting sick, injured, dying prematurely, and are living with conditions that detract from quality of life. There is now a research basis that supports approaches that alter the conditions in which people live and work. In conjunction with medical approaches that treat the already sick, a preventive strategy to reduce the number of those getting sick in the first place, is critical.

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

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

End Notes

¹ A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000:3.

² House JS, Williams DR. Understanding and reducing socioeconomic and racial/ethnic disparities in health. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000:81.

³ Adler NE, Newman, K. Socioeconomic Disparities In Health, Pathways And Policies. Health Affairs. 2002:21(2):60-76.

⁴ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

⁵ Chung M. Campaign to Eliminate Racial and Ethnic Disparities in Health. California Strategic Approach. American Public Health Association. Draft 12.16.02.

⁶ Blum HL. Social perspective on risk reduction. Family and Community Health. 1981;3(1):41-50.

⁷ McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2213.

⁸ Adler NE, Newman, K. Socioeconomic Disparities In Health, Pathways And Policies. Health Affairs. 2002:21(2):60-76.

⁹ Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000.

¹⁰ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

¹¹ National Institutes of Health, Addressing Health Disparities: The NIH Program of Action. What are health disparities? Available at: http://healthdisparities.nih.gov/whatare.html. Accessed January 14, 2002.

¹² Chung M. Campaign to Eliminate Racial and Ethnic Disparities in Health. California Strategic Approach. American Public Health Association. Draft 12.16.02.

¹³ Chung M. Campaign to Eliminate Racial and Ethnic Disparities in Health. California Strategic Approach. American Public Health Association. Draft 12.16.02.

¹⁴ Chung M. Campaign to Eliminate Racial and Ethnic Disparities in Health. California Strategic Approach. American Public Health Association. Draft 12.16.02.

¹⁵ A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000:3.

¹⁶ Mikkelsen L, Cohen L, Bhattacharyya K, Valenzuela I, Davis R, Gantz, T. Eliminating Health Disparities: The Role of Primary Prevention, Prevention Institute report prepared for The California Endowment:2002.

¹⁷ Bird ME. Personal communication at American Public Health Association: Campaign to Eliminate Racial and Ethnic Disparities in Health. Executive Board Meeting. July 30, 2002. Berkeley, Calif.

¹⁸ Mikkelsen L, Cohen L, Bhattacharyya K, Valenzuela I, Davis R, Gantz, T. Eliminating Health Disparities: The Role of Primary Prevention, Prevention Institute report prepared for The California Endowment:2002. pg. 3.

¹⁹ Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, D.C.: National Academy Press; 2003.

²⁰ Blum HL. Social perspective on risk reduction. Family and Community Health. 1981;3(1):41-50.

²¹ Adler NE, Newman, K. Socioeconomic Disparities In Health, Pathways And Policies. Health Affairs. 2002:21(2):60-76.

²² Interview, Dr. Laura Hill-Sakurai, December 4, 2002.

²³ Blum HL. Social perspective on risk reduction. Family and Community Health. 1981;3(1):41-50.

²⁴ McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993:270:2207-2213.

²⁵ McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993:270:2207-2213.

²⁶ Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs. 2002:21(2):60-76.

²⁷ McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993:270:2207-2213.

²⁸ Adler NE, Newman, K. Socioeconomic disparities in health, pathways and policies. Health Affairs. 2002;21(2):60-76.

²⁹ Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs. 2002:21(2):69.

³⁰ Personal interview, January 2003.

³¹ Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs. 2002:21(2):60-76.

³² Geronimus A. Understanding and eliminating racial inequalities in women's health in the United States: the role of the weathering conceptual framework. JAMWA. 2001;56(4):133-136.

³³ Norton A. Low-income childhood linked to later heart risks. British Medical Journal. 2002;325:805-807.

³⁴ Schultz A, Parker E, Israel B, Fisher T. Social context, stressors, and disparities in women's health. JAMWA. 2001;56(4):143-149.

³⁵ Jackson SA, Anderson RT, Johnson NJ, Sorlie PD. The relations of residential segregation to all-cause mortality: a study in black and white. AJPH. 2000; 90(4):615-617.

³⁶ Schultz A, Parker E, Israel B, Fisher T. Social context, stressors, and disparities in women's health. JAMWA. 2001;56(4):143-149.

³⁷ Blum HL. Social perspective on risk reduction. Family and Community Health. 1981;3(1):41-50.

³⁸ Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington D.C.: National Academy Press; 2000:337-365.

³⁹ A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC. National Academy of Sciences; 2000:3.

⁴⁰ Blum HL. Social perspective on risk reduction. Family and Community Health. 1981;3(1):41-50, p. 43.

⁴¹ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

⁴² Husain, A. "Psychosocial Stressors of Asthma in Inner-City School Children." APHA poster presentation, November 2002.

⁴³ Geronimus A. Understanding and eliminating racial inequalities in women's health in the United States: the role of the weathering conceptual framework. JAMWA. 2001;56(4):135.

⁴⁴ McGinnis, M, Williams-Russo, P, and Knickman, JR. The case for more policy attention to health promotion. Health Affairs. 2002; 21(2): 78-93.

⁴⁵ Blum HL. Social perspective on risk reduction. Family and Community Health. 1981;3(1):41-50.

⁴⁶ Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs. 2002:21(2):69.

⁴⁷ A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000.

⁴⁸ Mitka M. Economist takes aim at "big fat" US lifestyle. JAMA [serial online]. January 1, 2003;289:33-34. Available at: http://jama.ama-assn.org/issues/v289n1/fpdf/jmn0101.pdf. Accessed January 16, 2003.

⁴⁹ Morland K, Wing S, Roux AD. The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. AJPH. 2002;92(11):1761-1768.

⁵⁰ Duhl L. In Kurland J ed., Public Health Reports. v 115(2-3): Cary, NC: Oxford University Press; 2000.

⁵¹ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

⁵² Satcher D. Eliminating racial and ethnic disparities in health: the role of the ten leading health indicators. Journal of the National Medical Association. 2000;92(6):315-318.

⁵³ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

⁵⁴ Jackson RJ, Kochtitzky C. Creating a Healthy Environment: The Impact of the Build Environment on Public Health. Sprawl Watch Clearinghouse Monograph Series. Washington D.C.. p. 1-19.

⁵⁵ Jackson, Richard J. "Creating a Healthy Environment: The Impact of the Built Environment on Public Health." Centers for Disease Control and Prevention. Available at: http://www.sprawlwatch.org, accessed December 19, 2002.

⁵⁶ Active Community Environments (factsheet). Centers for Disease Control and Prevention. June 2000.

⁵⁷ Hancock, Trevor. "Healthy Communities must also be Sustainability Communities." Public Health Reports. Volume 115, March/April & May/June 2000.

⁵⁸ Hancock, Trevor. "Healthy Communities must also be Sustainability Communities." Public Health Reports. Volume 115, March/April & May/June 2000.

⁵⁹ Helfer, B, Federal Transit Administration. Personal communication. March 11, 2003

⁶⁰ Cotterill RW, Franklin AW. The Urban Grocery Store Gap. Storrs: Food Marketing Policy Center, University of Connecticut; 1995. Food Marketing Policy Issue Paper No. 8.

⁶¹ Morland K, Wing S, Roux AD. The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. AJPH. 2002;92(11):1761-1768.

⁶² Laveist TA, Wallace JM. Health risk and inequitable distribution of liquor stores in African American neighborhood. Social Science & Medicine. 2000;51: 613-617.

⁶³ Schultz A, Parker E, Israel B, Fisher T. Social context, stressors, and disparities in women's health. JAMWA. 2001;56(4):143-149.

⁶⁴ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

⁶⁵ Geronimus A. Understanding and eliminating racial inequalities in women's health in the United States: the role of the weathering conceptual framework. JAMWA. 2001;56(4):133-136

⁶⁶ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

⁶⁷ Calhoun J. National Crime Prevention Council. New Partners for Smart Growth: Building Safe, healthy, and Livable Communities 2nd annual conference flyer. 2002.

⁶⁸ Jackson RJ, Kochtitzky C. Creating a Healthy Environment: The Impact of the Build Environment on Public Health. Sprawl Watch Clearinghouse Monograph Series. Washington D.C.. p. 1-19.

⁶⁹ Land Use Planning for Safe, Crime Free Neighborhoods. Local Government Commission Center for Livable Communities. Available at: http://www.lgc.org/freepub/PDF/Land_Use/focus/plan_safe_neighborhoods.pdf.

⁷⁰ Putnam, Robert. Bowling Alone: The Collapse and Revival of American Community. New York, NY: Simon & Schuster, 2000.

⁷¹ A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000:11.

⁷² A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000:10.

⁷³ Wandersman A, Nation M. Urban neighborhoods and mental health: psychological contributions to understanding toxicity, resilience, and interventions. American Psychologist. 1998;43:647-656.

⁷⁴ Buka S. Results from the project on human development in Chicago neighborhoods. Presented at: 13th Annual California Conference on Childhood Injury Control; October 25-27, 1999; San Diego, CA.

⁷⁵ Wilkenson R. Income inequality, social cohesion, and health: clarifying the theory -- a reply to Muntaner and Lynch. International J of Health Services. 1999;29:525-545.

⁷⁶ PolicyLink. Reducing health disparities through a focus on communities. A PolicyLink Report. Oakland, CA: 2002.

⁷⁷ Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel study of collective efficacy. The Am Assoc for the Advancement of Science. 1997;277(5328:15)918-924.

⁷⁸ Pothukuchi K. Attracting grocery retail investment to inner-city neighborhoods: Planning outside the box, Wayne State University, Detroit, MI.

⁷⁹ "Principles of Community Engagement." Centers for Disease Control and Prevention Public Health Practice Program Office. Atlanta, GA, 1997.

⁸⁰ Emmons KM. Health behaviors in a social context. In: Berkman LF, Kawachi I. eds. Social Epidemiology. New York: Oxford University Press; 2000:pg. 251.

⁸¹ Eisler RM. The relationship between masculine gender role stress and men's health risk: the validation of construct. In: Levant RF, Pollack WS, eds. A New Psychology of Men. New York: Basic Books; 1995:207-225.

⁸² Courtenay W, Men's Health: Behavioral, Psychological, and Social Influences, personal communication, June 21, 2000.

⁸³ Peacock D. Building on a Legacy of Social Justice Activism: Enlisting Men as Gender Justice Activists in South Africa. J of Men and Masculinities, Sage Publications 2003:327-330.

⁸⁴ Active Community Environments (factsheet). Centers for Disease Control and Prevention. June 2000.

⁸⁵ Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality. JAMA. 1998;279(21):1703-1708.

⁸⁶ Greenberg D. Health literacy statistics. [Health Literacy Toolbox 2000 website]. Available at: http://www.prenataled.com/healthlit/hlt2k/script/ht2_a_2.asp, Accessed November 26, 2002.

⁸⁷ http://www.ncartsforhealth.org/Scope_of_Arts_for_Health.pdf; accessed 12/20/02.

⁸⁸ Key Points in Support of the V.P.I. Available at http://www.them-art.com/VPL-keypoints.rtf. Accessed December 20, 2002.

⁸⁹ Personal communication, Elizabeth Baker, Feb. 13, 2003

⁹⁰ Brown JD. Mass media influences on sexuality. J of Sex Research. 2002:39(1):42-45.

⁹¹ Zuckerman DM. Media violence, gun control, and public policy. Am J of Orthopsychiatry. 1996:66(3):378-89.

⁹² Brown JD, Witherspoon EM. The Mass Media and American Adolescents' Health. [UNC Chapel Hill website]. November 1998. Available at: http://www.unc.edu/courses/jomc145/witherspoon.html. Accessed December 13, 2002.

⁹³ Kotz, K. & Story, M. (1994). Food Advertisements during children's Saturday morning television programming: Are they consistent with dietary recommendations? Journal of the American Dietetic Association, Volume 94, Number 11: 1296-1300.

⁹⁴ Wallack L. The role of mass media in creating social capital: a new direction for public health. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington D.C.: National Academy Press; 2000:337-365.

⁹⁵ Dievler A, Pappas, G. "Implications of social class and race for urban public health policy making: a case study of HIV/AIDS and TB policy in Washington, DC." Social Science & Medicine. 48 (1999) 1095-1102.

⁹⁶ Personal communication, Elizabeth Baker, Feb. 13, 2003.

⁹⁷ House JS, Williams DR. Understanding and reducing socioeconomic and racial/ethnic disparities in health. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington D.C.: National Academy Press; 2000:81-124.

⁹⁸ Spivak, H. Keynote address. Youth Crime and Violence in California: From Evidence to Policy. March 6, 2002. Pasadena, California.

⁹⁹ Bernard B. Resilience Research: A Foundation for Youth Development. New Designs for Youth Development. 1996.

¹⁰⁰ Morland K, Wing S, Roux AD. The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. AJPH. 2002;92(11):1761-1768.

¹⁰¹ A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington D.C.: National Academy Press; 2000:6.

¹⁰² Bradley RH, Whiteside L, Mundfrom DJ, Casey PH, Kelleher KJ, Pope SK. Early indications of resilience and their relation to experiences in the home environments of low birthweight, premature children living in poverty. Child Development. 1994;65;346-360.

¹⁰³ Smith C, Lizotte AJ, Thornberry TP, Krohn MD. Resilient youth: identifying factors that prevent high-risk youth from engaging in delinquency and drug use. In Hagan J ed. Delinquency in the Life Course: Contextual and Dynamic Analyses. Greenwich, CT: JAI Press; 1995:217-247.

¹⁰⁴ Pollard JA, Hawkins JD, Arthur MW. Risk and protection: are both necessary to understand diverse behavioral outcomes in adolescence? Social Work Research. 1999;23(3):145-158.

¹⁰⁵ Active Community Environments (factsheet). Centers for Disease Control and Prevention. June 2000.

¹⁰⁶ Household Food Security in the United States in 1995, Summary Report of the Food Security Measurement Project. Office of Analysis and Evaluation, Food and Consumer Service, US Department of Agriculture; 1997.

¹⁰⁷ Sabol WJ, Coulton CH, Korbin JE. Building Community Capacity for Violence Prevention. Presented at: National Network for Applied Research on Violence Prevention Workshop; January 17-18, 2002; San Diego, CA.

¹⁰⁸ Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel study of collective efficacy. The Am Assoc for the Advancement of Science. 1997;277(5328:15)918-924.

¹⁰⁹ Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Facts About Heart Disease - California. http://www.cdc.gov/nccdphp/cvd/combinedatlas/factsheets/01fs-ca.htm, accessed on 6/21/02.

¹¹⁰ Hancock, Trevor. "Healthy Communities must also be Sustainability Communities." Public Health Reports. Volume 115, March/April & May/June 2000.

¹¹¹ Blum H. Social Perspective on Risk Reduction. Family and Community Health. May 1981 p38.

¹¹² Blum H. Social Perspective on Risk Reduction. Family and Community Health. May 1981 p38.

¹¹³ Deaton A. Policy implications of the gradient of health and wealth. Health Affairs. March/April 2002. Available at http://www.healthaffairs.org/freecontent/s6.htm. Accessed May 13, 2002.

¹¹⁴ A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academy Press; 2000.

¹¹⁵ Putnam R. Bowling alone: America's declining social capital. J of Democracy. 1995;6:65-78.

¹¹⁶ Veenstra G. Social capital and health. ISUMA [serial online]. 2001;2:72-81. Available at: http://isuma.net/v02n01/veenstra/veenstra_e.shtml. Accessed March 18, 2002.

¹¹⁷ Active Community Environments (factsheet). Centers for Disease Control and Prevention. June 2000.

¹¹⁸ Local Government Commission, Center for Livable Communities. Designing safe streets and neighborhoods. Fact Sheet.

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