APPLYING SYSTEMS SCIENCE TO COMMUNITY-BASED PREVENTION

Systems science methods can be used to explore the various pathways leading from community-based prevention interventions to improvements in population behavioral and health outcomes, such as the influence of a sugar-sweetened beverage tax on the purchase and consumption of foods and beverages. Such methods can also capture the variation in these pathways associated with contextual factors (such as population characteristics, concentration of fast food restaurants, employment opportunities, and living wages) and detect changes in the overall system as new interventions surface.

Systems science methods can address both detail and dynamic complexity. With respect to detail complexity, these methods can clarify assumptions about public health problems, local community context, and change strategies and processes by identifying the variables and the underlying causal relationships among the variables. At the same time these methods are designed to examine how causal structures change over time, including the effect of changes in the type or number of interventions implemented, changes in social norms and community practices, changes in leadership or staff, and so on. Examining these causal structures can help identify the system leverage points that have the greatest potential for affecting behavioral and health outcomes, can increase understanding about intended effects and unintended consequences of the interventions implemented, and can identify facilitating factors and challenges influencing community change processes (Meadows, 1999; Sterman, 2000; Ulrich, 2000).

For examples of systems science approaches to valuing community-based prevention interventions, see Appendix B.

VALUING COMMUNITY-BASED PREVENTION: DOMAINS AND ELEMENTS

Policy makers, funders, and relevant stakeholders make decisions about the value of community-based interventions. Traditional approaches to assess value tend to focus solely on health impacts, to value interventions in isolation, to overlook community processes, and to fail to monitor pathways toward progress. The committee was asked to develop a framework for assessing the value of community-based prevention. Because of the way in which community-based prevention is designed and developed (e.g., often to address the social and environmental determinants of health), the committee concluded that impacts of these interventions go beyond health effects. Therefore, a framework for valuing community-based prevention needs to take into account not only the outcomes in the domain of health, but also the outcomes in areas other than health. A framework that does not take into account and value non-health outcomes would be counting all the costs but not all the benefits, thereby providing an inaccurate and inadequate picture of the value of community-based prevention. To assess the true value of community-based prevention, therefore, decision makers, funders, and stakeholders would benefit from an approach that looks not just at health impacts, but at other impacts as well.

A major task facing the committee, then, was determining what domains should be included in a framework to value community-based prevention interventions. As a first step, each committee member was asked to list the outcomes he or she thought could result from community-based prevention interventions. The list generated included more than 100 items and all acknowledged that not everything that could be valued appeared on the list. As a next step, the committee decided to group the items into major categories. Clearly, a major outcome of community-based prevention is its impact on health. Therefore, health was identified as a major domain of interest.

However, there were a number of other items on the list that did not fall neatly into a health domain, for example, education, income, green space, crime, social support, and workplace safety. Initially, the committee identified six major categories under which these other items could be grouped: social environment, physical environment, economics, equity, employment, and education. Yet, as the committee discussed these items and reviewed the literature, it became clear that these elements were all elements related to well-being. Therefore, the committee identified a second major domain as the domain of community well-being.

There were a number of items that did not fit readily into either the health category or the well-being category but which the committee identified as important items of value, including such things as leadership, skill building, and civic participation. An examination of the history of community health efforts demonstrates that various process elements (such as skill building, leadership, and participation) are features that account for the relative success of community-based programs. Early efforts in the first half of the 20th century involved engaging stakeholder organizations and affected populations in first, the support of planned programs, then in actually planning programs, then in evaluating programs, and finally in community-based participatory research (CBPR) (Green, 1986).

Based on the literature of CBPR (e.g., Minkler and Wallerstein, 2008) the committee deliberately decided to identify community process as a specific area of valued outcomes for community-based prevention.

Elements in the community process domain inherently affect outcomes upstream (e.g., civic participation) that, in turn, affect outcomes downstream (e.g., policy adoption and implementation), further downstream (e.g., equitable access to environments or resources to support health), further downstream (e.g., healthy behaviors of citizens in these environments or use of these resources), further downstream (e.g., healthy lifestyle choices of citizens), and, ultimately, health (although health feeds back to greater capacity for civic participation). Therefore, the committee concludes community process should be identified as a separate domain because in many cases, community empowerment and community capacity have been shown to be valued by communities in their own right (Sandoval et al., 2011). Also, because process elements are intermediary outcomes that increase well-being and health interventions (Minkler et al., 2008; Viswanathan et al., 2004), failing to recognize the increase of such potential as a valued outcome will further disadvantage those communities whose structural and population characteristics put them at increased risk of health and well-being deficit. It is important to note that without a solid grounding in science, community process, as is the case with any democratic process, could lead to worse outcomes with respect to health and well-being.

This section of Chapter 3 describes in more detail the wide array of effects that community-based prevention can have, grouping them under the three distinct but interrelated categories of outcomes, or domains of value: health, community well-being, and community process. The committee is aware that health is a component of well-being but for purposes of this report the health component is separated from other elements of community well-being because health is a particular outcome of interest. The goal in valuing these domains is to account for all of the potential harms and benefits of community-based interventions as well as the possible savings and costs associated with the interventions. This section introduces the domains of value as well as associated elements.

It is important to note that the list of elements included in each domain below is meant to be illustrative. The actual elements selected for valuing will depend on the particular intervention and its implementation. It is unlikely that any given intervention will have value in all elements listed, and there may well be other elements not listed here that should be included. The committee has identified one element, equity, that crosses all domains.

VALUING RESOURCES AND COSTS FOR COMMUNITY-BASED PREVENTION

Community-based prevention is a collaborative effort among three sets of actors: funders, community partners, and participants. Typically all of these actors contribute resources to the implementation of community-based interventions. As a result of an implementation, various effects are experienced by the actors as benefits, harms, savings, or costs (Drummond et al., 2005; Luce et al., 1996; Parasuraman et al., 2006). To ensure that the full range of resources used by the intervention is identified and counted, a broad net should be cast.

The funders of an intervention are those government agencies (international, federal, state, or local), private foundations, corporations, and individual philanthropists and donors that provide financial resources to the community partners to implement interventions. These funds are typically used to pay for salaries, wages, and benefits of staff, the cost of outside professionals and consultants, facilities costs (e.g., overhead, space, and equipment), program materials (e.g., devices and printed materials) and supplies. Funders provide other resources as well, such as professional expertise, consultants, training, and program materials to support community partners.

Community partners, such as local government agencies, nonprofit agencies like the YMCA or United Way, local employers, schools, churches, and physicians, are typically responsible for implementing the intervention. They provide staff, facilities, supplies, equipment, and program-related materials. Some of these resources are paid for by grants from funders. However, community partners themselves may donate additional staff time, facilities, equipment, and materials. The community partners may also use volunteer time. Volunteer time includes the unpaid services of individuals who are not employed by the community partners but who participate in the development, production, and delivery of the intervention. Community partners sometimes also incur intangible costs, such as costs associated with building coalitions and collaborations among community organizations. It is not unusual for community partners to have different organizational cultures, missions, and values. Each community partner may have to change or compromise its brand, reputation, and goals in order to participate in the community-based prevention program with a broader coalition of community partners.

Community-based prevention also requires the time and resources of participants. Participating in an intervention may reduce the time that participants can spend on work or leisure. These time costs need to be considered lest the intervention appear less costly than it really is compared to interventions that rely on participants purchasing goods or services. Some interventions may require participants to make various purchases items, such as of devices, equipment, transportation, and childcare expenses. Also, a participant’s family members may have to use their time and resources to accommodate his or her participating in the intervention. Participation may also have intangible costs. The intervention may require participants to do things that they feel are unpleasant or to stop doing things that they enjoy. Sometimes these opinions about the intervention are temporary and after participants adopt the lifestyle change they prefer the new behaviors to the old ones. However, feelings about the intervention sometimes do not change.

Nonparticipants can also be impacted by the implementation of community-based prevention. The committee prefers to treat these impacts as benefits and harms rather than as savings and costs.

To determine the cost of a community-based prevention program one must first decide from whose perspective the determination is being made. Funders may consider only their program costs, while community partners may want to consider only the costs that they bear. However, a comprehensive perspective considers the costs of all of the resources expended, including those of the participants. This perspective eliminates the possibility of double counting because it looks at the resources used to provide the intervention. This perspective assumes that resources have alternative uses and therefore opportunity costs. If a resource is traded in a market place, then its opportunity costs can be estimated as its market prices, i.e., wages and salaries for personnel, rental rates for facilities, and purchase prices for equipment, services, and material. Sometimes, however, market prices may not represent the true resource costs—for example, if those prices are too high because they include excess profits or too low because of government subsidies.

The opportunity costs of non-market items such as volunteer and participant time can be estimated at an appropriate wage rate (Luce et al., 1996). The choice of a wage is left to the judgment of the analysts. Examples are actual, average, or overtime wage rates of volunteers and participants. In the case of non-working participants, the disabled, and children, using wage data is an imperfect solution, but there are no good alternatives in economic evaluation literature. Some analysts use zero in these cases, implying that there is no alternative use for volunteers’ and participants’ time. This assumption is unreasonable, however, given that volunteers and participants do have other uses for their time, uses that they value. Not counting volunteer and participant time misleads decision makers on the true costs of an intervention, much in the same way as overlooking the community wellness and community process aspects of community-based prevention misleads decision makers on the true benefits and harms.

As another example, the occupation of a building by a program means that the building cannot be used in another activity—the intervention has eliminated this alternative use. From an economic perspective, the cost of using the building is the value of the services that the building would have generated in this alternative use. Even if the program pays no rent, there is still a cost, and that cost can be approximated by the rents paid for similar buildings.

The valuation of an intervention is based on the changes in outcomes and in resources used that were caused by an intervention, as compared to an alternative. The alternative can be the existing situation (sometimes called the status quo) or another intervention. If an intervention uses less of some resources than the alternative, it yields savings for those items of cost. Sometimes the total costs of an intervention may be less than those of the alternative, yielding an overall saving. The crucial point is that savings become apparent only when two alternatives are compared and that the savings depend on the specific comparison. An intervention that yields savings, i.e., uses fewer resources, compared to one alternative may not yield savings when compared to a different alternative.

For example, in addition to the costs of implementing an intervention, community-based prevention may reduce costs in health care and other social service sectors of the community. For example, a community health workers program that helps residents with chronic health conditions improve their self-care and medication use could result in lower emergency room use and rates of preventable hospitalizations. This lowers the residents’ hospital care costs, thus generating savings for them and their health plans. Another example is community-based prevention targeting at-risk youth who have a dual diagnosis of mental illness and substance abuse. In addition to helping youth maintain their mental health and staying drug free, such a program could reduce costs in the juvenile justice system through lower arrest and incarceration rates. These types of cost offsets should be considered when computing the costs of community-based prevention. The cost offsets should not be confused with the benefits of the programs, which are improvements in health, community well-being, and community process.

Table 3-1 provides a hypothetical example of a total costs computation for an illustrative community-based renovation of a derelict park undertaken to promote physical activity among the town’s citizens. Donated resources are valued according to the closest market rates for time, space, and other goods and services. The total net costs are $10,000.

TABLE 3-1

Hypothetical Community-Based Renovation of a Park: Cost Computation.

Resource use and benefits occur over a period of time that may extend many years into the future. If that period is greater than 1 year, it is appropriate to discount, in order to capture two realities: people prefer benefits sooner rather than later; and resources are productive—if they are not consumed now but are invested instead, they will produce even more resources in the future. (It is important to note that the concept of a discount rate is net of and different from that of inflation.) In cost–benefit and cost-effectiveness analysis, the practice is to discount both costs and benefits and to discount them at the same rate (Lipscomb et al., 1996; OMB, 2003). When the time horizon is very long, it can lead to difficult questions regarding discounting. This is particularly true of prevention interventions where the costs accrue immediately but the benefits accrue much later. In theory this could lead to an undervaluation of the long-term benefits relative to the short-term costs. In this case it is important to value the long-term benefits adequately rather than attempt to adjust the discount rate (IOM, 2006b; Lipscomb et al., 1996).

Various governmental and nongovernmental groups recommend—or require—specific discount rates, but there is no general agreement among them on what the discount rate should be (Jawad and Ozbay, 2006). For example, the Office of Management and Budget recommends a real (adjusted for inflation) discount rate of 7 percent per year, with 3 percent as an alternative to test the sensitivity of an evaluation’s results to the discount rate (OMB, 2003). The Panel on Cost-Effectiveness in Health and Medicine recommends a real rate of 3 percent for cost-effectiveness analyses and the National Institute of Health and Clinical Excellence in the United Kingdom requires a real rate of 3.5 percent.

DATA SOURCES AND INDICATORS FOR VALUING COMMUNITY-BASED PREVENTION

There are a variety of sources of data on health, including surveys (e.g., the National Health Interview Survey and the Behavioral Risk Factor Surveillance System), cohort studies (e.g., the Framingham Heart Study), registries, health services data, vital statistics, and data collected by state public health agencies. Unfortunately, there are several limitations on using these data for local, community-based measurement (IOM, 2011b). For example, national surveys are unable to provide the detailed data needed for local estimates without specifically designing local data collection. Registries and health services data provide information only about those who seek and receive health services, cohort studies are resource intensive, and vital statistics are subject to coding errors (IOM, 2011b). To collect information to measure baseline health and changes in health at the local level may require developing and implementing local surveys aimed at the specific health issues of interest.

Identifying measures and sources of information for community well-being and community process elements is even more challenging than collecting such information about health. Table 3-2 lists elements and indicators that could be used in the three domains of interest: health, community well-being, and community process. As stated before, these are examples only. The actual elements and indicators chosen will depend on the community-based prevention intervention being considered.

TABLE 3-2

Domains and Examples of Elements and Indicators for Valuing Community-Based Prevention Interventions.

Applying methods from systems science to community-based prevention efforts can help increase our understanding of the complex interrelationships among factors important to building healthy populations and healthy communities. The following chapter discusses how a framework for valuing resides within a decision-making context, reviews eight frameworks currently used to assess community-based prevention, and discusses the strengths and limitations of each for addressing the special characteristics of community-based prevention.

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Footnotes

1

As defined by the Office of Behavioral and Social Sciences Research at the National Institutes of Health: http://obssr​.od.nih.gov​/scientific_areas​/methodology/systems_science/index. aspx (accessed July 5, 2012).