The Kaiser Family Foundation Community Health Promotion Grants Program: Findings from an Outcome Evaluation

Health Services Research, August, 2000 by Edward H. Wagner, Thomas M. Wickizer, Allen Cheadle, Bruce M. Psaty, Thomas D. Koepsell, Paula Diehr, Susan J. Curry, Michael Von Korff, Carolyn Anderman, William L. Beery, David C. Pearson, Edward B. Perrin

Objectives. To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities.

Methods. The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities.

Results. With the exception of two intervention communities--a largely Hispanic community and a Native American reservation--we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse.

Conclusions. Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions.

Key Words. Health promotion, community health services, consumer participation Community-based health promotion interventions make great sense. They target the increased risk found in large proportions of the population (Kottke, Puska, Salonen, et al. 1985); use low-cost treatment methods, such as media presentations or legislative action; and mobilize the community around an issue of public health importance. Early evidence of success in Finland (Puska, Nissinen, Tuomilehto, et al. 1985) and by the Stanford Group (Farquhar, Maccoby, Wood, et al. 1977; Farquhar, Fortmann, Maccoby, et al. 1985) spurred further activity. The dramatic declines in the prevalence of risk factors such as smoking, inactivity, and dietary fat consumption over the past few decades offered further evidence that changes in social norms and the environment, not individual risk reduction treatments, were influencing Americans to change their behaviors. Social learning theory (Bandura 1977) provided strong intellectual support for the role of social norms and the environment in behavior and behavior change. Their int uitive appeal, basis in theory, and low cost have made community-based programs a popular public health strategy.

But the popularity of the approach stands in contrast to evidence that has shown little effect on targeted risk factors. Four well-tested programs, the Stanford Five City Study (Farquhar, Fortmann, Flora, et al. 1990), the Minnesota Heart Health Program (Luepker, Murray, Jacobs, et al. 1994; Mittelmark, Luepker, Jacobs, et al. 1986), COMMIT (Community Intervention Trial for Smoking Cessation) (COMMIT Research Group 1995a,b) and the Pawtucket Heart Health Program (Carleton, Lasater, Assaf, et al. 1995) recently reported their final results. The Minnesota and Pawtucket programs reported essentially no differences in risk factors between intervention and control communities. The Stanford study reported limited effects for selected subgroups. The COMMIT program achieved no higher rates of cessation among heavy smokers, their primary targets, in the intervention communities than in control sites, but they did find a modest increase in cessation among lighter smokers in the intervention communities. These generall y discouraging new findings have stimulated thoughtful reappraisals of the state of the art (Fisher 1995; Susser 1995; Green and Kreuter 1993).

Most published community health promotion programs have targeted a single disease and have been initiated "top-down," often with a university-based group in charge. The Kaiser Family Foundation's Community Health Promotion Grants Program in the western United States (CHPGP) followed a different approach. The CHPGP provided financial support and technical assistance to local coalitions and staff in grantee communities for the development of programs to reduce several health problems: substance abuse, adolescent pregnancy, cardiovascular disease, cancer, and injury. A Health Promotion Resource Center at Stanford University provided technical support, but program development and design was generally under local control (Tarlov, Kehrer, Hall, et al. 1987). Therefore, this was not a formal experiment in which communities were expected to adhere rigidly to guidelines. The Foundation gave grantees substantial flexibility to develop program targets and activities tailored to meet local needs and priorities. The inte rvention model (Tarlov, Kehrer, Hall, et al. 1987; Syme 1976; Green and Raeburn 1988) gave emphasis to activating communities by developing consensus and coordinated action among key organizations and groups in each community through involvement in a coalition.