Notes from the Field
Editor's Note: Submissions to Notes from the Field (500-1 000 words) should be senttoHugh H. Tilson, MD, DrPH, Medical Division, Burroughs Wellcome Company, 3030 Comwallis Road, Research Tnangle Parl4 NC 27709. This column presents information regarding newsworthy public health programs and project experience at the community level. Further information should be sought from the person(s) listed in the footnote to each article.
Healthy Cities Indiana: Mainstreaming Community Health in the United States Healthy Cities Indiana is a collaboration effort between the Indiana University School of Nursing Department of Community Health Nursing, the Indiana Public Health Association, and six Indiana cities: Fort Wayne, Gary, Indianapolis, Jeffersonville, New Castle, and Seymour. Fort Wayne, Gary, and Indianapolis are large urban areas with populations ranging from 152,000 to 701,000. The remaining cities are small with populations ranging from 15,000 to 21,000. This program began in 1988 with a three-year grant of $464,200 from the W. K Kellogg Foundation and contributed costs from Indiana University of
$250,918. There are over 300 healthy city initiatives in the world and the Indiana program is modeled after the European and Canadian healthy cities programs. Healthy Cities Indiana is adapting the European and Canadian models to, and evaluating the program within, the sociopolitical context of Indiana and the United States.
510 American Journal of Public Health
In Indiana, healthy cities is a process of enabling people to have a unified voice for health in order to bring about planned change to improve community life, services and other resources. A healthy city is a combined effort of government, business, the arts, science-the community as a whole. Employment, good housing, adequate education, good transportation, a clean environment, friendly people, and safe streets and parks all help to promote a healthy city. A significant and unique part of the Indiana program is community leadership development that supports local problem solving and action in health. Community leaders exist in any city but they may not know their potential in health promotion. Healthy Cities Indiana prepares community leaders to take an active role in promoting healthy public policy. In community leadership development the program staff provide technical assistance and emphasize self-help and consensus building. Healthy Cities Indiana, through a process of preparing local leaders in community health is one approach that addresses many of the issues, including constituency building in public health, raised in the Institute of Medicine's report on The Future of Public Health.1 There are several phases to the Healthy Cities Indiana process. * The first phase is city commitment; after the program was explained the city leaders determined there was enough local support for participating in Healthy Cities Indiana. Then the mayor and local health officer signed a commitment for broad-based participation in the placement of health as a priority of the city's political agenda and in the adoption of policies that promote health. * The second phase is the formation of a healthy city committee, which involves a community-wide public-private
partnership of people willing to be actively involved in the healthy city process. * The third phase is community leadership development, where the project staff assist community leaders in developing their skills in the healthy cities process. The methods being used include a compilation and explanation of city data; consultation by leaders in the field; statewide workshops; national and international conferences of relevance to healthy cities; network sessions for shared learning among the six cities; and sharing of books, articles, and audiovisual materials. * The next phase is city action where each of the healthy city committees is involved in identifying their city's strengths and health problems. In this process, the committees have reviewed existing data and conducted additional surveys to obtain further information from others in their communities. While the committees are conducting their longer term community assessments they have undertaken several short-term projects including the formation of a community walking club, a mouth guard campaign for children in contact sports, "Healthy Moments" radio messages, a family drug education event, healthy city speakers' bureau, city street clean-up, health fairs with health screening. "Visions of a Healthy City" poster competition for school children, vision workshops for adults and youths in neighborhoods, and a "Walk against Drugs" for children and youth 6 to 14 years old. These projects have been accomplished with little cost, mainly through volunteer efforts of committee members. In addition these short-term projects have generated considerable city interest and have encouraged the committees to take further action. * The next phase is provision of database information topolicymakers where the committees promote the development
Aprd 1991, Vol. 81, No. 4
Notes frm the FIield
of healthy public policy through their long range city efforts. Examples of these are: curbside recycling, a comprehensive teenparent highschool education program, a comprehensive program for affordable housing, and a healthy babies program aimed at preventing infant mortality. In addition, all the committees have initiated and supported the introduction and passage of a resolution "Promoting Healthy Cities in Indiana" by the state legislature in 1990. This phase of the healthy cities process is critical to sustaining these cities as healthy cities. It is in this phase that local and other resources can be committed to the healthy cities' long term future. Interactions with policymakers can help promote the allocation of resources to these important efforts. The city councils and/or mayors are being asked to allocate funds to continue healthy city activities beyond the Kellogg Foundation funding. Also, three of the cities have obtained or requested state or local money to sustain programs initiated by the healthy city committees. All ofthe city committees are interested in developing skills in proposal writing and developing a community fund which can help support their committees' plans. Many of the major concerns of the Healthy City Committees are consistent with the recently announced Health Objectives for the Year 2000,2 Physical Activity, Fitness, Tobacco, Alcohol and other Drugs, Family Planning, Violent and Abusive Behavior, Educational and Community-based Programs, Environmental Health, Oral Health, Maternal and Infant Health, and Mental Health are objectives categories that match directly with the committees' priority issues. Also, the National Health Objectives indicate major health concerns for different age groups. These national objectives should be helpful to the committees in further planning of objectives at the local level and monitoring their progress in reaching them. 0 The last phase, action research and evaluation, has only recently been initiated. A self-administered questionnaireThe Healthy City Indiana Committee Effectiveness Inventory-has been developed as one measure of community leadership development. Other areas of research are more complex and involve interdisciplinary efforts, using quantitative and qualitative approaches to measure issues including policy change, health status change, health care change, environmental change, and the sustainability of the six healthy cities programs following program funding. Action research is
April 1991, Vol. 81, No. 4
integral to community development as it encourages community accountability for health. Based on experiences to date, the healthy cities process seems to be facilitated by a number of factors. The official political support of mayors and health officers, especially when they take an active role on the healthy city committee, has been a driving force in committee action. Smaller cities have been able to move at a faster pace than the larger cities. The committees that have been more successful in obtaining broad-based representation of the city have been able to identify citywide problems and generate comprehensive solutions to problems. Successful projects have encouraged the committee to take further action. Technical support provided not only by the project staff, but by the Indiana Public Health Association, local health departments, and other universities surrounding the cities, has been invaluable. The news media, by being part of the committee itself, has facilitated a positive image of the committee's work in the cities. In these times of budget constraints, local communities need to explore alternate ways to address local health problems and needs. Based on experiences with the Healthy Cities Indiana Program, it is estimated that a city will need approximately $50,000 over a two-year period to establish the healthy city process. This funding would cover consultation, workshops, conferences, and network sessions which will assist community leaders to develop their skills in the healthy city process. The Healthy Cities Indiana Resource Center has on file introductory information on healthy cities including videotapes, audiotapes, bibliography, resources for on site consultation, and is a distributor for Healthy City Papers published by FADL, Copenhagen, Denmark. Specific descriptions and prices can be obtained from Jean Good, Secretary, Healthy Cities Indiana, Indiana University School of Nursing, Room NU 237, 1111 Middle Drive, Indianapolis, IN 46202. S
References 1. Institute of Medicine: The Future of Public Health. Washington, DC: National Academy Press, 1988. 2. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: USDHHS, Public Health Service, 1990.
Prepared by: Beverl C. Flynn, PhD, RN, FAAN, Professorand Director, InstituteofAction Research for Commwruny Health, and Di-
rector, Healthy Cities Indiana, and Melinda S. Rider, M4, Associate Director, Healthy Cities Indiana, Indiana UniversiiySchoolofNursing Departnment of Community Health Nursing, NU 237, 1111 Middle Dnive, Indianapolis, IN 46202 TeL (317) 274-3319.
The Role of the Local Health Department in Traffic Safety In general, local public health departments have not taken an active role in promoting traffic safety. Vehicular crashes have been regarded as unavoidable accidents, behavioral problems, or a law enforcement problem rather than a public health problem. However, the impact of traffic crashes on the public is difficult to overlook. They are the leading cause of death for those under age 44; a major cause of disability, including the loss of more workingyears of life than cancer and heart disease combined; and one of the most expensive health problems.1 Despite their neglect of traffic crashes as a public health problem, health departments have much to contribute in the area of traffic safety. Within the public health mission of assessing, developing policy, and assuring the health of the population, goals of traffic safety should be included. In Ohio, funding has been provided to local communities by the Ohio Department of Highway Safety (ODHS) and the National Highway Traffic Safety Administration (NHTSA) to conduct comprehensive county-wide traffic safety programs; 19 of the 36 programs are currently based in local health departments. These health departments work cooperatively with other community agencies to provide comprehensive programs which generally emphasize safety belt use, not drinking and driving, and maintaining the speed limit. The health departments design activities to meet the needs of their own particular community. This is extremely important in Ohio since the population is very diverse; programs must be designed for large urban areas, very rural areas, small towns, and Amish communities. Traffic safety activities through local health departments occur in many different ways. * Face to face education provides programs for schools or community
groups. * Use of incentives rewards drivers
for safety belt use or encourages competitions between schools.
American Journal of Public Health 511
Notes from the Field * Public information provides traffic safety messages through news articles, radio spots, posters, or marquees. * Use requirements encourage the implementation of safety belt policies at the worksite and encourage the enforcement of safety belt laws. One requirement of all the comprehensive community traffic safety programs is to organize a community task force. The health departments identify community members who may be interested in traffic safety and conduct regular meetings. The task force serves as an advisory group, participates in many of the activities, distributes materials, and coordinates traffic safety activities among various community agencies and groups. Since the response from the health departments involved in the community programs has been so positive, the Ohio Department of Highway Safety has been interested in ways to involve additional health departments. A survey was conducted to determine traffic safety activities in the county health departrnents without comprehensive community programs. With 81 percent of these health departments responding, the following information was gained. * Twenty-four percent of Ohio health departments have a child safety seat distribution program. * Traffic safety activities or materials provided most often by the local health department include: Brochures (56.9%) Posters (40.2%) Message during a clinic visit (32.4%) Displays (16.7%)
512 American Journal of Public Health
Topics most often included were child safety seats (53.9 percent), safety belts (43.1 percent), drinking and driving prevention (30.4 percent), and bicycle safety (25.5 percent). * When asked about using materials provided by ODHS/NHTSA, the health departments indicated a willingness to use resources similar to those already being used, including: Pamphlets or posters (43.1%) Materials for children (24.5%) Stickers (20.6%) Materials for programs (18.6%) Videotapes (17.6%) News releases (15.7%) * The barriers to providing traffic safety activities reflected a lack of staff time rather than a lack of interest by the staff. The perceived problems which may be encountered in providing traffic safety programs included: Not enough staff time (68.6%) Lack of funding (50.0%) Other agencies already providing traffic safety activities (23.5%) Lack of information regarding funding available (19.6%) Lack of interest among clients or community members (17.6%) Lack of interest by staff (9.8%) Findings from this survey revealed an interest on the part of local health departments to provide information on traffic safety for their clients. Currently, a pilot study is being conducted using three health departments which do not have a comprehensive community traffic safety program. Each month for six months, materials are provided by the Ohio Depart-
ment of Highway Safety, including posters and pamphlets, messages to staff and stickers for children, a videotape, news articles, coloring books, and other materials to conduct programs. The health department contact person (a health educator, nurse, or clerk) uses the materials in conjunction with health department clinics, thus the direct costs of this program enhancement are negligible. Preliminary response suggests that the materials are very well received by health department staff and clients. They are not only providing materials for clinic clients but have asked for additional materials for schools, hospitals, pediatric centers, Head Start programs, and Girl Scout troops. Information from this pilot study of three health departments will be used to develop and distribute materials to interested health departments throughout Ohio. Such materials will serve to initiate traffic safety activities through health departments, thus encouraging a more active role in this public health issue. Copies ofthe materials used in this statewide project are available on request from the authors. El
Reference 1. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press, 1985.
Prepared by: Jan Jurs, PhD, Assistant Professor, SchoolofHeakth, Physical Education, and Recreation, Bowling Green State University, Bowlng Green, OH 43403-0248, and Jill Berington, Contract Officer, Ohio Department of Highway Safety, 240 ParsonsAvenue, Colwnbus, OH 43215. Telephone: (614) 466.3250.
April 1991, Vol. 81, No. 4
Editor's Note: Submissions to Notes from the Field (500-1 000 words) should be senttoHugh H. Tilson, MD, DrPH, Medical Division, Burroughs Wellcome Company, 3030 Comwallis Road, Research Tnangle Parl4 NC 27709. This column presents information regarding newsworthy public health programs and project experience at the community level. Further information should be sought from the person(s) listed in the footnote to each article.
Healthy Cities Indiana: Mainstreaming Community Health in the United States Healthy Cities Indiana is a collaboration effort between the Indiana University School of Nursing Department of Community Health Nursing, the Indiana Public Health Association, and six Indiana cities: Fort Wayne, Gary, Indianapolis, Jeffersonville, New Castle, and Seymour. Fort Wayne, Gary, and Indianapolis are large urban areas with populations ranging from 152,000 to 701,000. The remaining cities are small with populations ranging from 15,000 to 21,000. This program began in 1988 with a three-year grant of $464,200 from the W. K Kellogg Foundation and contributed costs from Indiana University of
$250,918. There are over 300 healthy city initiatives in the world and the Indiana program is modeled after the European and Canadian healthy cities programs. Healthy Cities Indiana is adapting the European and Canadian models to, and evaluating the program within, the sociopolitical context of Indiana and the United States.
510 American Journal of Public Health
In Indiana, healthy cities is a process of enabling people to have a unified voice for health in order to bring about planned change to improve community life, services and other resources. A healthy city is a combined effort of government, business, the arts, science-the community as a whole. Employment, good housing, adequate education, good transportation, a clean environment, friendly people, and safe streets and parks all help to promote a healthy city. A significant and unique part of the Indiana program is community leadership development that supports local problem solving and action in health. Community leaders exist in any city but they may not know their potential in health promotion. Healthy Cities Indiana prepares community leaders to take an active role in promoting healthy public policy. In community leadership development the program staff provide technical assistance and emphasize self-help and consensus building. Healthy Cities Indiana, through a process of preparing local leaders in community health is one approach that addresses many of the issues, including constituency building in public health, raised in the Institute of Medicine's report on The Future of Public Health.1 There are several phases to the Healthy Cities Indiana process. * The first phase is city commitment; after the program was explained the city leaders determined there was enough local support for participating in Healthy Cities Indiana. Then the mayor and local health officer signed a commitment for broad-based participation in the placement of health as a priority of the city's political agenda and in the adoption of policies that promote health. * The second phase is the formation of a healthy city committee, which involves a community-wide public-private
partnership of people willing to be actively involved in the healthy city process. * The third phase is community leadership development, where the project staff assist community leaders in developing their skills in the healthy cities process. The methods being used include a compilation and explanation of city data; consultation by leaders in the field; statewide workshops; national and international conferences of relevance to healthy cities; network sessions for shared learning among the six cities; and sharing of books, articles, and audiovisual materials. * The next phase is city action where each of the healthy city committees is involved in identifying their city's strengths and health problems. In this process, the committees have reviewed existing data and conducted additional surveys to obtain further information from others in their communities. While the committees are conducting their longer term community assessments they have undertaken several short-term projects including the formation of a community walking club, a mouth guard campaign for children in contact sports, "Healthy Moments" radio messages, a family drug education event, healthy city speakers' bureau, city street clean-up, health fairs with health screening. "Visions of a Healthy City" poster competition for school children, vision workshops for adults and youths in neighborhoods, and a "Walk against Drugs" for children and youth 6 to 14 years old. These projects have been accomplished with little cost, mainly through volunteer efforts of committee members. In addition these short-term projects have generated considerable city interest and have encouraged the committees to take further action. * The next phase is provision of database information topolicymakers where the committees promote the development
Aprd 1991, Vol. 81, No. 4
Notes frm the FIield
of healthy public policy through their long range city efforts. Examples of these are: curbside recycling, a comprehensive teenparent highschool education program, a comprehensive program for affordable housing, and a healthy babies program aimed at preventing infant mortality. In addition, all the committees have initiated and supported the introduction and passage of a resolution "Promoting Healthy Cities in Indiana" by the state legislature in 1990. This phase of the healthy cities process is critical to sustaining these cities as healthy cities. It is in this phase that local and other resources can be committed to the healthy cities' long term future. Interactions with policymakers can help promote the allocation of resources to these important efforts. The city councils and/or mayors are being asked to allocate funds to continue healthy city activities beyond the Kellogg Foundation funding. Also, three of the cities have obtained or requested state or local money to sustain programs initiated by the healthy city committees. All ofthe city committees are interested in developing skills in proposal writing and developing a community fund which can help support their committees' plans. Many of the major concerns of the Healthy City Committees are consistent with the recently announced Health Objectives for the Year 2000,2 Physical Activity, Fitness, Tobacco, Alcohol and other Drugs, Family Planning, Violent and Abusive Behavior, Educational and Community-based Programs, Environmental Health, Oral Health, Maternal and Infant Health, and Mental Health are objectives categories that match directly with the committees' priority issues. Also, the National Health Objectives indicate major health concerns for different age groups. These national objectives should be helpful to the committees in further planning of objectives at the local level and monitoring their progress in reaching them. 0 The last phase, action research and evaluation, has only recently been initiated. A self-administered questionnaireThe Healthy City Indiana Committee Effectiveness Inventory-has been developed as one measure of community leadership development. Other areas of research are more complex and involve interdisciplinary efforts, using quantitative and qualitative approaches to measure issues including policy change, health status change, health care change, environmental change, and the sustainability of the six healthy cities programs following program funding. Action research is
April 1991, Vol. 81, No. 4
integral to community development as it encourages community accountability for health. Based on experiences to date, the healthy cities process seems to be facilitated by a number of factors. The official political support of mayors and health officers, especially when they take an active role on the healthy city committee, has been a driving force in committee action. Smaller cities have been able to move at a faster pace than the larger cities. The committees that have been more successful in obtaining broad-based representation of the city have been able to identify citywide problems and generate comprehensive solutions to problems. Successful projects have encouraged the committee to take further action. Technical support provided not only by the project staff, but by the Indiana Public Health Association, local health departments, and other universities surrounding the cities, has been invaluable. The news media, by being part of the committee itself, has facilitated a positive image of the committee's work in the cities. In these times of budget constraints, local communities need to explore alternate ways to address local health problems and needs. Based on experiences with the Healthy Cities Indiana Program, it is estimated that a city will need approximately $50,000 over a two-year period to establish the healthy city process. This funding would cover consultation, workshops, conferences, and network sessions which will assist community leaders to develop their skills in the healthy city process. The Healthy Cities Indiana Resource Center has on file introductory information on healthy cities including videotapes, audiotapes, bibliography, resources for on site consultation, and is a distributor for Healthy City Papers published by FADL, Copenhagen, Denmark. Specific descriptions and prices can be obtained from Jean Good, Secretary, Healthy Cities Indiana, Indiana University School of Nursing, Room NU 237, 1111 Middle Drive, Indianapolis, IN 46202. S
References 1. Institute of Medicine: The Future of Public Health. Washington, DC: National Academy Press, 1988. 2. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: USDHHS, Public Health Service, 1990.
Prepared by: Beverl C. Flynn, PhD, RN, FAAN, Professorand Director, InstituteofAction Research for Commwruny Health, and Di-
rector, Healthy Cities Indiana, and Melinda S. Rider, M4, Associate Director, Healthy Cities Indiana, Indiana UniversiiySchoolofNursing Departnment of Community Health Nursing, NU 237, 1111 Middle Dnive, Indianapolis, IN 46202 TeL (317) 274-3319.
The Role of the Local Health Department in Traffic Safety In general, local public health departments have not taken an active role in promoting traffic safety. Vehicular crashes have been regarded as unavoidable accidents, behavioral problems, or a law enforcement problem rather than a public health problem. However, the impact of traffic crashes on the public is difficult to overlook. They are the leading cause of death for those under age 44; a major cause of disability, including the loss of more workingyears of life than cancer and heart disease combined; and one of the most expensive health problems.1 Despite their neglect of traffic crashes as a public health problem, health departments have much to contribute in the area of traffic safety. Within the public health mission of assessing, developing policy, and assuring the health of the population, goals of traffic safety should be included. In Ohio, funding has been provided to local communities by the Ohio Department of Highway Safety (ODHS) and the National Highway Traffic Safety Administration (NHTSA) to conduct comprehensive county-wide traffic safety programs; 19 of the 36 programs are currently based in local health departments. These health departments work cooperatively with other community agencies to provide comprehensive programs which generally emphasize safety belt use, not drinking and driving, and maintaining the speed limit. The health departments design activities to meet the needs of their own particular community. This is extremely important in Ohio since the population is very diverse; programs must be designed for large urban areas, very rural areas, small towns, and Amish communities. Traffic safety activities through local health departments occur in many different ways. * Face to face education provides programs for schools or community
groups. * Use of incentives rewards drivers
for safety belt use or encourages competitions between schools.
American Journal of Public Health 511
Notes from the Field * Public information provides traffic safety messages through news articles, radio spots, posters, or marquees. * Use requirements encourage the implementation of safety belt policies at the worksite and encourage the enforcement of safety belt laws. One requirement of all the comprehensive community traffic safety programs is to organize a community task force. The health departments identify community members who may be interested in traffic safety and conduct regular meetings. The task force serves as an advisory group, participates in many of the activities, distributes materials, and coordinates traffic safety activities among various community agencies and groups. Since the response from the health departments involved in the community programs has been so positive, the Ohio Department of Highway Safety has been interested in ways to involve additional health departments. A survey was conducted to determine traffic safety activities in the county health departrnents without comprehensive community programs. With 81 percent of these health departments responding, the following information was gained. * Twenty-four percent of Ohio health departments have a child safety seat distribution program. * Traffic safety activities or materials provided most often by the local health department include: Brochures (56.9%) Posters (40.2%) Message during a clinic visit (32.4%) Displays (16.7%)
512 American Journal of Public Health
Topics most often included were child safety seats (53.9 percent), safety belts (43.1 percent), drinking and driving prevention (30.4 percent), and bicycle safety (25.5 percent). * When asked about using materials provided by ODHS/NHTSA, the health departments indicated a willingness to use resources similar to those already being used, including: Pamphlets or posters (43.1%) Materials for children (24.5%) Stickers (20.6%) Materials for programs (18.6%) Videotapes (17.6%) News releases (15.7%) * The barriers to providing traffic safety activities reflected a lack of staff time rather than a lack of interest by the staff. The perceived problems which may be encountered in providing traffic safety programs included: Not enough staff time (68.6%) Lack of funding (50.0%) Other agencies already providing traffic safety activities (23.5%) Lack of information regarding funding available (19.6%) Lack of interest among clients or community members (17.6%) Lack of interest by staff (9.8%) Findings from this survey revealed an interest on the part of local health departments to provide information on traffic safety for their clients. Currently, a pilot study is being conducted using three health departments which do not have a comprehensive community traffic safety program. Each month for six months, materials are provided by the Ohio Depart-
ment of Highway Safety, including posters and pamphlets, messages to staff and stickers for children, a videotape, news articles, coloring books, and other materials to conduct programs. The health department contact person (a health educator, nurse, or clerk) uses the materials in conjunction with health department clinics, thus the direct costs of this program enhancement are negligible. Preliminary response suggests that the materials are very well received by health department staff and clients. They are not only providing materials for clinic clients but have asked for additional materials for schools, hospitals, pediatric centers, Head Start programs, and Girl Scout troops. Information from this pilot study of three health departments will be used to develop and distribute materials to interested health departments throughout Ohio. Such materials will serve to initiate traffic safety activities through health departments, thus encouraging a more active role in this public health issue. Copies ofthe materials used in this statewide project are available on request from the authors. El
Reference 1. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press, 1985.
Prepared by: Jan Jurs, PhD, Assistant Professor, SchoolofHeakth, Physical Education, and Recreation, Bowling Green State University, Bowlng Green, OH 43403-0248, and Jill Berington, Contract Officer, Ohio Department of Highway Safety, 240 ParsonsAvenue, Colwnbus, OH 43215. Telephone: (614) 466.3250.
April 1991, Vol. 81, No. 4
