Community Level Indicators of Health Related Behavior
What are Community Level Indicators?
Community-level indicators (CLI) measure aspects of the physical, legal, social and economic environment that reflect and are likely to influence the attitudes and behavior of individual community members. They also measure an important step in community-based health promotion interventions, namely environmental factors that programs target to modify individual attitudes and behaviors. CLIs are not individual attributes, such as the prevalence of smoking in a community or the level of physical activity of employees of a company. However, a count of laws establishing public schools as smoke free organizations and of exercise facilities maintained by a worksite are examples of CLIs.
Why are CLIs Important?
CLIs offer a timely way to monitor the health infrastructure of a community. They are a more immediate means to gather information on distant individual health related outcomes of intervention efforts. The ultimate outcome of lower mortality and morbidity rates may be 20 years ahead of an intervention effort, and the timing to accomplish aggregate behavior change in a community are likely unknown. However, community level outcomes related to subsequent health status and behavior outcomes are more immediately accomplished.
CLIs also offer a measurement of healthy lifestyle opportunities. Such measures identify a community's health potential. A community will have difficulty experiencing high levels of healthy behaviors if it provides no place to pursue physical activity, low-fat diet opportunities and smoke free living.
CLIs, compared to measures of individual behavior, are nonreactive, unobtrusive, and inexpensive. The public's awareness of socially desirable forms of behavior may distort survey results. There is little chance of reactivity bias in the measurement of store shelf-space devoted to low-fat milk. Diet recall surveys, on the other hand, are vulnerable to this problem. The differences in costs are dramatic. Many efforts to collect CLIs can be accomplished by intervention agents who have little or no training in epidemiology or behavioral research. Often, this is the only kind of outcome measurement an intervention program can afford to do.
Finally, measurements of CLIs are important when the goals for intervention efforts are explicitly stated as increasing the opportunities to live healthier lifestyles. It helps keep interventions on track when evaluators pay attention to the measurement of such opportunities, rather than only measuring their ultimate behavioral and disease related outcomes.
What is the New York State Department of Health doing with CLIs?
The report titled "Communities Working Together for a Healthier New York" specifies the priorities of the Health Department in supporting the actions of local communities. The identified roles for the state in assisting local communities includes the development of better monitoring and data systems and development of performance measures. Developing systems for collecting and analyzing CLIs is one area where the state can provide tools for evaluating community needs assessment and performance measures.
The Department of Health has made some progress in this area. An instrument has been developed to assess school support for heart healthy eating. Research has been conducted validating the association of food store shelf-space measures for low-fat milk to the milk consumption in a community. A tool to evaluate worksite infrastructure support for heart healthy lifestyle opportunities has been developed. A study is under way presently to assess the association of such worksite attributes with the level of employee's heart health related behavior. The department also has experience in using CLIs to monitor the progress of its coalition based community interventions. The Healthy Heart Program and the Diabetes Control program have both based their coalition intervention monitoring on a system developed, supported, and recommended by the CDC. This system provides a means to measure progress towards and actual implementation of the opportunities for healthier lifestyles in the community established through the coalition. Additionally, the diabetes program has modified the system slightly to conduct cost effectiveness analysis.