There are many preventable factors that contribute to the leading causes of death and disability: economic and educational disparities; public policy; environments that do not promote health; poor delivery of clinical and community preventive services; and unhealthy behaviors and other lifestyle risk factors. When assessing preventive strategies, it is useful to consider the “socio-ecologic framework” that posits that behaviors and health are influenced over the life span at “multiple levels from the individual to families to larger systems and groups and then more broadly to populations and the ecosystem” (Stokols, 1996).
Levels of Intervention
This socio-ecologic framework allows one to map out effective prevention strategies for a particular health issue targeted to one or more level (e.g., clinical, community, or public health level). As discussed earlier, individual-level interventions like screening, counseling, and immunizations occur in a clinical setting between the clinician and the patient. Social, family, and community network interventions, often aimed at behavior change and social support systems, include: exercise programs at places of worship, weight loss competitions between employee teams in a workplace, or nutrition education programs for school children. Community-level interventions that influence working and living conditions may target specific communities (e.g., racial, geographic, or ethnic) and include environmental interventions such as providing recreational facilities in neighborhoods or implementing water fluoridation. Large geographic area or population interventions may involve policies and programs within or outside the health sector (e.g., expanding health insurance access, revising minimum sentences for drug possession, passing ordinances restricting public tobacco smoking, implementing vehicle emission regulations, or enforcing intimate partner violence laws).
Community Task Force (CTF)
Similar to the USPSTF role as an expert panel on individuals, the Community Task Force (CTF) assesses and makes evidence-based recommendations for effective prevention strategies at the community or population level. Convened by the Centers for Disease Control and Prevention, the CTF considers interventions including environmental improvements, health policy, education, service delivery, and system improvements. The recommendations can be implemented in schools, work places, or an entire community. The CTF is often used by the Institute of Medicine or public health programs to shape national initiatives to achieve and maintain health promotion goals.
The CTF recommendations can be found in the “Community Guide” online.
Integration of Clinical Preventive Services and Community Level Interventions
Integrating preventive interventions determined to be effective by the USPSTF and the CTF fits nicely with the socio-ecologic model. Using multiple strategies at inter-related levels yields optimal individual and community health outcomes.
A good example of integrated initiatives is tobacco control. The USPSTF recommends screening all adults in clinical settings for tobacco use and providing cessation interventions. Clinicians should screen all pregnant women and provide pregnancy-tailored counseling and interventions. The CTF recommends several community preventive services, including banning or restricting smoking in public or work places, increasing tobacco prices, launching media campaigns, reducing patient costs for smoking cessation regimens, and deploying telephone quitter support. “Optimal success in reducing tobacco-use prevalence has occurred when, in addition to clinical services, community-level interventions…have been made accessible and available” (Ockene, 2007).
Although difficult to measure, direct evidence is emerging around the superiority of combined clinical and community interventions. One study compared approaches to juvenile offenders with substance use disorders. Compared to traditional family court, combined implementation of a dedicated juvenile drug court, group support, and intensive individual counseling reduced alcohol, marijuana, and polydrug use more than implementation of drug court alone (Henggeler et al, 2006).
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