ARTICLEHEALTH PROMOTION PRACTICE /MONTH YEAR51January

Using Multilevel, Multisource NeedsAssessment Data for PlanningCommunity Interventions

Susan R. Levy, PhDEmily E. Anderson, MPH

L. Michele Issel, PhD, MNMarilyn A. Willis, MSN, RNBarbara L. Dancy, PhD, MSN

Kristin M. Jacobson, MPHShirley G. Fleming, CNM, DrPH

Elizabeth S. Copper, MPHNerida M. Berrios

Esther Sciammarella, MSMónica Ochoa, MPH

Jennifer Hebert-Beirne, MPH

African Americans and Latinos share higher rates ofcardiovascular disease (CVD) and diabetes comparedwith Whites. These diseases have common risk factorsthat are amenable to primary and secondary preven-tion. The goal of the Chicago REACH 2010–LawndaleHealth Promotion Project is to eliminate disparitiesrelated to CVD and diabetes experienced by AfricanAmericans and Latinos in two contiguous Chicagoneighborhoods using a community-based preventionapproach. This article shares findings from the Phase 1participatory planning process and discusses the impli-cations these findings and lessons learned may have forprograms aiming to reduce health disparities in multi-ethnic communities. The triangulation of data sourcesfrom the planning phase enriched interpretation andled to more creative and feasible suggestions for pro-grammatic interventions across the four levels of theecological framework. Multisource data yielded usefulinformation for program planning and a better under-standing of the cultural differences and similaritiesbetween African Americans and Latinos.

Keywords: planning; community interventions; multi-level; multisource; needs assessment data

Immense disparities exist in risks for certain chronicdiseases among racial and ethnic groups in theUnited States. These disparities are well docu-

mented and appear across the spectrum of U.S. society(Fiscella, Franks, Gold, & Clancy, 2000; Thomas, 2001;Vinicor, Burton, Foster, & Eastman, 2000; Williams &Jackson, 2000). In February 1998, former PresidentClinton authorized the Centers for Disease Control andPrevention (CDC) to allocate a competitive grant forcommunity coalitions to address the disparities inselected chronic diseases. The purpose of this initiative,known as racial and ethnic approaches to communityhealth (REACH 2010), was for these coalitions to elimi-nate disparities in health status experienced by selectedethnic and racial groups (African Americans, NativeAmericans, Asian Americans and Pacific Islanders, andLatinos) in six chosen health areas. These areas areinfant mortality, cancer screening and management,cardiovascular disease (CVD), diabetes, HIV infection/AIDS, and immunizations. This CDC initiative is a two-phase, science-based project requiring extensive partic-ipation by community members and public health pro-fessionals with health promotion programming exper-tise. Phase 1 (the first year) involved a community-based planning process to develop a community actionplan; Phase 2 (Years 2 through 5) is the implementationof the community action plan. The purpose of this arti-cle is to share community assessment data and majorissues regarding the community learned by the evalua-tion team during the Phase 1 participatory planningprocess of the Chicago REACH 2010–Lawndale HealthPromotion Project. The results will use the ecologicalframework for the multilevel community needs assess-

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Health Promotion PracticeJanuary 2004 Vol. 5, No. 1, 59-68DOI: 10.1177/1524839903257688©2004 Society for Public Health Education

ment and subsequent findings. The implications thesefindings have for programs aiming to reduce health dis-parities and prevent and control CVD and diabetes inmultiethnic communities are discussed. Programmaticsuggestions are made along with implementationstrategies.

�BACKGROUND

In the summer of 1999, the Chicago Department ofPublic Health convened a group of individuals con-cerned with racial and ethnic disparities in the healthstatus of Chicagoans to pursue the REACH fundingopportunity. After a review of health department mor-bidity and mortality data, two contiguous communitieson the west side of Chicago were chosen as the projectcommunity area. (The term project community areawill be used to refer collectively to the two communi-ties.) One community is primarily African American,the other primarily Latino, specifically Mexican Ameri-can. Although African Americans and Latinos have dis-tinct cultural practices, they share higher rates of CVDand diabetes compared with Whites. These diseaseshave common risk factors amenable to primary and sec-ondary prevention, including risks associated withsmoking, obesity, sedentary lifestyle, inadequate medi-cal management, and inadequate access to primary care(Farquhar, 1993; Tuomilehto et al., 2001). Behavioralrisk factors for CVD and diabetes are prevalent in boththe African American and the Latino populations. Ratesof obesity and physical inactivity are higher in Latinosand African Americans than in the overall U.S. popula-tion (CDC, 2001), making these two racial/ethnic groupsat especially high risk for CVD and diabetes. The geo-graphic proximity within Chicago of an African Ameri-can and a Latino community provided the project withthe unique opportunity to focus on these behavioral risk

factors amenable to the prevention and control of CVDand diabetes in both racial/ethnic groups.

�METHODS

Planning Process

Community participation began with the initial writ-ing of the competitive grant proposal to the CDC andcontinued through the Phase 1 planning process. Theplanning process was designed to facilitate input bycommunity members in developing a comprehensiveand responsive community action plan. For the purposeof promoting continuity and structure to communityinvolvement in Phase 1 activities, a planning councilwas created. The council was composed of representa-tives from more than 50 community agencies and orga-nizations that may play a role in disease prevention andof community members. Planning council membersincluded individuals from different racial and ethnicbackgrounds with professional expertise across a broadspectrum of fields such as public health, medicine,nursing, community organizing, and evaluation. Repre-sentatives from the American Diabetes Association andthe American Heart Association were on the planningcouncil. Community members also participated, in-cluding persons affected by the targeted health condi-tions, local business people, and religious leaders. Theplanning council was made up of the following fourworkgroups: risk factors and programs, quality of clini-cal care, policy and advocacy, and data and evaluation.The planning council was charged with providing guid-ance and feedback during a comprehensive, multilevelassessment of both needs and resources within the pro-ject community area. All needs assessment data werepresented to the council to ensure the most validinterpretation possible. Based on these needs assess-

60 HEALTH PROMOTION PRACTICE / January 2004

A s s e s s m e n t o f i n f l u e n c e s :

( E c o l o g i c a l M o d e l )

· i n d i v i d u a l

· f a m i l y

· c o m m u n i t y

· p u b l i c p o l i c y

I n t e r p r e t a t i o no f d a t a i n t o

c r o s s - c u t t i n gt h e m e s

S u g g e s t i o no f p r i o r i t i e sf o r p r o g r a m

p l a n n i n g

D e v e l o p m e n t o fc o m p r e h e n s i v e

C o m m u n i t y A c t i o nP l a n

I d e n t i f i c a t i o no f s t r e n g t h s& r e s o u r c e s

A n a l y s i s o fp r o b l e m s &

g a p s

FIGURE 1 Chicago REACH 2010–Lawndale Health Promotion Project, Year 1 Planning Process Framework

ment data, the planning council developed a commu-nity action plan (see Figure 1).

Framework of Needs Assessment

The ecological model of health behavior (McElroy,Bibeau, Steckler, & Glanz, 1988) was the theoreticalbasis for the needs assessment. This model focuses onthe relationship between the individual and his or hersocial environment, positing the following four levels ofinfluence that affect and are affected by health behavior:public policy, community, family, and individual. Byfocusing on these four levels and types of social influ-ence, appropriate interventions can be developed.

The major aim of the community needs assessmentwas to enhance the understanding of the multitude offactors that influence CVD and diabetes in individualsliving in the community area. Planning council mem-bers brainstormed to identify direct and indirect con-tributing factors to CVD and diabetes. From this list, acomprehensive set of approximately 40 project perfor-mance indicators was developed. Project performanceindicators correlate to the four levels of influence onhealth behavior outlined by the ecological model. Indi-cators included were lifestyle risk factors (e.g., the per-centage of adults in the community who are currentlysedentary), medical (e.g., the percentage of adults withelevated cholesterol levels), and individual- and com-munity-level collateral (e.g., the types of sources usedfor health information and the number of community

grocery stores keeping fresh fruits and vegetables instock).

Both quantitative and qualitative data collectionmethods, including focus groups and key informantinterviews, the behavioral risk factor surveillance sys-tem (BRFSS), and community landscape asset mapping(CLAM), were needed and used to obtain substantialbreadth and depth of information. The project perfor-mance indicators ensured that the specific data col-lected would be relevant to the aims of the ChicagoREACH 2010–Lawndale Health Promotion Project andtherefore useful in developing the community actionplan. Specific variables and questions used in data col-lection were chosen to reflect these performanceindicators (see Table 1 for examples).

Data Methods and Sources

Needs assessment data were gathered through threemethods: focus groups and key informant interviews,the BRFSS, and CLAM. Together, these three methodsaddressed all four levels of the ecological model (seeTable 1).

Focus group methodology and open-ended inter-views are uniquely capable of obtaining informationregarding individual and community group perceptionsof specific topics. Focus groups and interviews allowparticipants to explore topics extensively, thereby pro-viding data that reflect a comprehensive view (Kingry,Tiedje, & Friedman, 1990; Krueger, 1988). Focus group

Levy et al. / PLANNING COMMUNITY INTERVENTIONS 61

TABLE 1Levels of the Ecological Model, Data Sources, and Examples of Data

Levels of the Examples of Data and/orEcological Model Data Sources Performance Indicators

Individual Focus groups and key informant interviews Difficulty in obtaining and paying for prescribedmedications

Behavioral risk factor surveillance survey Between 32% and 36% of respondents uninsured

Family Focus groups and key informant interviews Issues related to disease management create stress forthe entire family

Behavioral risk factor surveillance survey 45% of adults have a family member who has or haddiabetes

Community Focus groups and key informant interviews Availability of unhealthy food and limited knowledgeof or access to healthy food make it difficult tocontrol diabetes and hypertension

Behavioral risk factor surveillance survey 78% of respondents not eating five or more fruits andvegetables per day

Community landscape asset mapping Scarce availability of fresh fruits and vegetables incommunity grocery stores; little nutritioninformation in stores and restaurants regardinghealthy food choices

Public policy Focus groups and key informant interviews Feeling unsafe in the community is a source of stressBehavioral risk factor surveillance survey 34% of respondents would like to see more

recreational programs in the communityCommunity landscape asset mapping Minimal police presence

and key informant interviews were conducted in orderto elicit perceptions related to health concerns andidentify community, family, individual, and public pol-icy influences on health behaviors. The guides used forthe focus groups and interviews were based on instru-ments used in previous studies and tailored to the Chi-cago REACH 2010–Lawndale Health Promotion Projectwith input from project staff members and the planningcouncil. Council members identified community resi-dents and health care professionals to participate in thefocus groups and key informant interviews. A total ofeight focus groups with 99 participants and 10 individ-ual interviews were conducted during a 2-week period.In all, 52 African Americans between the ages of 20 and50 or older participated in four focus groups of approxi-mately 10 to 14 people; one of the groups was all male,two were exclusively female, and one was mixed. Atotal of 47 Latino community members between theages of 25 and 50 or older participated in four focusgroups of approximately 10 to 15 people. One wasmixed sex, and the other three were entirely female.Focus groups took place at local community or socialservice agencies, and each group had an observer and arecorder present in addition to the focus group leader.The African American focus groups and interviewswere conducted by an African American member of theevaluation team; the focus groups and interviews withLatinos were conducted by a Latino Chicago Depart-ment of Public Health staff member in the language(Spanish or English) preferred by the interviewee. Ofthe 10 key informants interviewed, 5 were AfricanAmerican and 5 were Latino, 5 were female and 5 weremale, and 4 were health care professionals working inthe community and 6 were community residents.Interviews took place at community agencies or inparticipants’ homes.

The CDC BRFSS survey was used to collect data onindividual-level characteristics such as knowledge, atti-tudes, and behavior. The BRFSS is a standardized tele-phone surveillance instrument that measures adultbehavioral risk factors leading to increases in morbidityand premature mortality rates (CDC, 2001). A total of150 questions from the core BRFSS questionnaire aswell as the diabetes, CVD, and hypertension moduleswere used in the community assessment. A total of 406individuals living in the project community area weresurveyed. The BRFSS was conducted by the SurveyResearch Laboratory, a professional research and ser-vice unit of the College of Urban Planning and PublicAffairs at the University of Illinois at Chicago. The sam-ple design included both a random-digit-dial sample of576 telephone numbers as well as a random sample of1,982 listed telephone numbers. The maximum numberof attempts made to contact an individual at a particularnumber was 20.

CLAM is a community-mapping tool used to identifycommunity-level opportunities for and barriers tohealthy behaviors (Issel & Searing, 2000). CLAM inves-tigates the nature of geography and its relationship to

communities and personal health. It involves space andplace and may identify key explanatory and mediatingvariables related to variations and disparities in healthand chronic disease. The original tool was revised basedon input from project staff members and members of theplanning council and was tailored to the ChicagoREACH 2010–Lawndale Health Promotion Project.Therefore, this version of the CLAM addresses commu-nity and policy influences on health. This method ofdata collection examines the following four types oflandscapes through structured observations: ecological,materialistic, consumption, and therapeutic (Curtis &Jones, 1999). For example, the ecological landscape rep-resents opportunities for clean air, water, earth, andsafety. This is represented in CLAM data by noting thecondition of vacant lots and streets, police presence,street lighting, and smoking in restaurants. City blocks,restaurants, and grocery stores were unobtrusively sur-veyed for factors that contribute to or help prevent CVDor diabetes. A total of nine trained community membersworking in teams of two or three surveyed 45 cityblocks, 29 restaurants, and 24 grocery stores within fivemajor north-south and four major east-west streets atvarious times during a 2-day period.

Debriefing sessions were conducted with the CLAMcommunity surveyors. Discussions of data viewed froman emic perspective can enrich the interpretation ofdata (Maynard-Tucker, 2000). In the case of the CLAM,certain information would never have surfaced or mayhave been misinterpreted had “outsiders” been per-forming the surveillance instead of community mem-bers. For example, investigators on the evaluation teaminterpreted the absence of gang-related graffiti (“tags”)as a positive implication. However, community mem-bers explained that without gang tags, it is unclearwhich areas are gang territory and therefore safe orunsafe.

Data Analysis

Data from the focus groups and key informant inter-views were analyzed first. The evaluation team collec-tively generated five thematic areas. Focus group andkey informant data were then presented to the planningcouncil organized by these themes for discussion andrefinement. The BRFSS and CLAM data were then ana-lyzed and organized according to these refined thematicareas. Again, these data were presented to the planningcouncil for discussion and further development. TheBRFSS data were entered and analyzed using SPSS 9.0for Windows (SPSS Inc., 1998). Descriptive statisticswere calculated for all the BRFSS questions. Selectedquestions were stratified by race, gender, and/or age.CLAM data were entered using SPSS 10.0 for Windows(SPSS Inc., 1999) and aggregated to yield overalldescriptive statistics of the city blocks, restaurants, andgrocery stores.

After the BRFSS and CLAM data were analyzed sepa-rately, findings were then examined through the unify-

62 HEALTH PROMOTION PRACTICE / January 2004

ing lens of the themes. When data from any one sourceyielded a pertinent finding, the other data sources werereviewed to corroborate or impugn that finding. Over-all, findings were generally confirmed across datasources, although as might be expected, each datasource yielded some unique findings. Because datafrom multiple sources were integrated in the needsassessment, the approach taken can be described as tri-angulation (Thurmond, 2001). Triangulation is thecombination of two or more theoretical perspectives,methodological approaches, data sources, investigators,or data analysis methods within the same study. A tri-angulation approach can decrease, negate, or balancethe deficiency of a single strategy.

�FINDINGS

Presentation of the data is organized by the fivethemes derived from the qualitative data. Viewing allresults as such enables a more comprehensive under-standing of the project community area in terms of fac-tors across the ecological levels.

Theme 1: In the project community area, accurate infor-mation on diabetes and CVD is limited. Focus groupparticipants and key informants clearly recognized dia-betes and CVD as diseases affecting their community.These were viewed as problems needing to beaddressed on not only an individual but also a commu-nity level. Community members felt that credible andconsistent health information is not readily accessiblein their community. Focus group participants lackedbasic knowledge of CVD and diabetes risk factors,symptoms, or causes. Community members felt that

community organizations not directly related to health,such as schools and churches, are suitable places to pro-mote the community agenda for diabetes and CVD pre-vention and control. Focus group members expressedfeelings of frustration because health-related pamphletsand other educational materials given to them by physi-cians are overly technical and laden with medical jar-gon. Latino focus group participants discussed thedifficulty of finding Spanish-language materials.

Several questions from the BRFSS measure respon-dents’ knowledge and beliefs regarding the causes,treatment, and complications of diabetes. Knowledgelevels were low. For example, when asked, “What doyou think causes diabetes?” approximately 27%responded that they did not know. A total of 69% eitheragreed or strongly agreed that “just a touch of sugar” isnot really diabetes.

CLAM data supported the view expressed by focusgroup participants about the limited availability ofinformation regarding CVD and diabetes. There was lit-tle information about healthy living present in publiccommunity spaces such as on billboards or publictransportation. Health messages did not appear insidelocal businesses such as currency exchanges orlaundromats.

Theme 2: Community members expressed a strongdesire for more health education and healthy commu-nity activities, including exercise programs, to belocated within the community. Focus group and keyinformant interview participants noted a need for moreopportunities for disease prevention and felt that thecommunity at large would support these programs. Peo-ple knew that obesity, lack of exercise, and smoking

Levy et al. / PLANNING COMMUNITY INTERVENTIONS 63

The Authors

Susan R. Levy, PhD, is Professor Emerita at the University ofIllinois at Chicago School of Public Health and the director of theCenter for Health Promotion and Disease Prevention Research.

Emily E. Anderson, MPH, is a former project coordinator at theCenter for Health Promotion and Disease Prevention Researchat the University of Illinois at Chicago and a doctoral student inhealth care ethics at Saint Louis University.

L. Michele Issel, PhD, MN, is a clinical assistant professor inthe Department of Community Health Sciences at the Univer-sity of Illinois at Chicago School of Public Health.

Marilyn A. Willis, MSN, RN, is the associate director for theInternational Center for Health Leadership Development at theUniversity of Illinois at Chicago School of Public Health.

Barbara L. Dancy, PhD, MSN, is an associate professor of pub-lic health, mental health and administrative nursing in the Col-lege of Nursing of the University of Illinois at Chicago.

Kristin M. Jacobson, MPH, is a doctoral candidate in commu-nity health sciences at the School of Public Health of the Uni-versity of Illinois at Chicago.

Shirley G. Fleming, CNM, DrPH, is the first deputy commis-sioner of the Chicago Department of Public Health.

Elizabeth S. Copper, MPH, is presently completing her MEdand teaching in the Chicago Public School System.

Nerida M. Berrios is the research study programs coordinatorfor Racial and Health Disparities in Community Health ofNorthwestern University in the Department of Urology ofFeinberg School of Medicine in Evanston, Illinois.

Esther Sciammarella, MS, is special assistant to the HealthCommissioner for Hispanic Affairs of the Chicago Departmentof Public Health.

Mónica Ochoa, MPH, is the program director for the Office ofHispanic Affairs of Chicago Department of Public Health.

Jennifer Hebert-Beirne, MPH, is the former REACH projectdirector of the Chicago Department of Health and is currently aconsultant with the Chicago Center for Health Systems Devel-opment and a doctoral student in community health sciencesat the School of Public Health of University of Illinois atChicago.

were barriers to good health. They expressed the desireto make lifestyle changes but did not know where to goor how to begin. Focus group participants were notaware of very many programs in the community relatedto physical activity, nutrition, or general health educa-tion. They mentioned that information on nutrition,healthy cooking, and changing family eating habits wasparticularly difficult to find in the community. Accord-ing to the African American key informant interviews,some formal health education programs had beenimplemented in the community by either a universityor a local health department; however, Latinos appearnot to have had the same awareness of or participationin these programs. African American focus groupparticipants requested health promotion programs thatwere holistic and family oriented.

Data from the BRFSS questions about the use of rec-reational activity and exercise programs in the commu-nity showed that respondents were not using existingservices, possibly because they were not aware of themor because they felt they were unsafe. Additional pro-grams or services that community members stated theywould like to see in their community are recreationalprograms (mentioned by 34% of respondents) such asYMCAs, parks, and basketball courts as well as neigh-borhood safety and violence prevention programs.

The CLAM data confirmed the minimal existenceand use of walking paths in local parks. People wantingto make lifestyle changes would find little informationin community restaurants or grocery stores regardinghealthy food choices.

Theme 3: The high cost of health care and lack of ade-quate insurance coverage are barriers for many commu-nity members, regardless of disease status. The cost ofprescription drugs and related supplies, often not cov-ered even for those with health insurance, is a criticalissue for those diagnosed with diabetes and CVD.According to data from the focus groups and key infor-mant interviews, a significant number of communitymembers have little or no health insurance coverage.Community members, both African American andLatino, depend heavily on free public health clinics oremergency rooms for their health care. Even for thosewith insurance, prescription medications are often notcovered. Individuals diagnosed with CVD or diabetesoften must pull together money for medications fromseveral different sources.

The BRFSS data indicated that between 32% and36% of community members surveyed were unin-sured at the time of the survey, depending on the spe-cific insurance question. A total of 15% of theapproximately 66% who were insured at the time of thesurvey noted that there was a time in the prior 12months when they did not have any health insurance.Latinos in this sample were less likely to be insuredthan were African Americans, although Latinos weremore likely to be employed for wages. Almost 20% of allrespondents, regardless of insurance status, reported

that there had been a time in the past 12 months whenthey needed to see a doctor but could not because of thecost.

The CLAM did not address cost and affordability ofhealth insurance as this cannot be easily observed inpublic places.

Theme 4: In addition to the cost barriers previously dis-cussed, there are sociocultural barriers to health care.Latino and African American focus group and key infor-mant data indicated that factors affecting communitymembers’ health care experiences include treatment byhealth care providers and other staff members, clinicenvironment including cleanliness and condition ofequipment, clinic ownership such as whether owned bya community member or an “outsider,” and languagecompatibility with provider (which was an issue forEnglish and non-English speakers). For African Ameri-can community members, the primary complaint abouthealth care services concerned condescending and dis-respectful attitudes from providers, which can lead to alack of trust in the health care system and noncompli-ance with treatment regimens. The relative scarcity ofSpanish-speaking staff members in clinics was a majorissue in the Latino focus groups, but issues regardingrespectful and caring attitudes similar to those dis-cussed in the African American focus groups also arose.Gender and age affected the use of formal medical ser-vices. Women—particularly younger women withmaternal and child health issues—were most likely touse services because maternal and child health servicesare available in a cluster and therefore are more easilyaccessible. According to the key informant interviewswith health care providers, adult men, both AfricanAmericans and Latinos, dramatically underusedavailable health care services.

The BRFSS data regarding preventive medical ser-vices described health care service use by communitymembers and supported findings from the focus groupsand key informant interviews. The length of time sincerespondents had last visited a doctor for a routinecheckup varied by both race/ethnicity and gender. Afri-can Americans were slightly more likely than Latinos tohave visited a doctor for a routine checkup within thepast year and slightly less likely to have never had a rou-tine checkup. However, the greatest disparity in routinecheckups was between men and women regardless ofrace/ethnicity, and this probably accounted for thosesmall differences. Less than half of all men surveyedhad a routine checkup within the past year comparedwith 76% of women. Almost 10% of men surveyed hadnever had a routine checkup.

The CLAM street-level data revealed a very limitednumber of health providers located in the community.It may be necessary for residents of the project commu-nity area to access services that are at a great distancefrom home. In addition, few buses were seen, whichmay indicate that public transportation services are dif-ficult to use or are unreliable.

64 HEALTH PROMOTION PRACTICE / January 2004

Theme 5: Community members perceive stress in theirlives and stressors in their community as a constantthreat to their health and well-being. The notion ofstress was mentioned frequently in the focus groupsand key informant interviews. The environment wasmentioned as a general source of stress. This includedlack of employment, safety issues, and pervasiveness ofliquor stores and illicit drugs. Another source of stressmentioned by individuals affected by diabetes and CVDand their families was disease management. Stressrelated to disease management includes lack of knowl-edge about the disease by family members as well asmisinterpretation of symptoms, embarrassment, lack ofsupport, and poor understanding of medical regimens.Environmental and family stressors affect disease man-agement and can contribute to feelings of guilt, blame,frustration, depression, and perceived loss of controlover the future.

In the focus groups, diabetes was noted as a diseasethat negatively affects the whole family. This is a signif-icant community issue as 45% of the BRFSS respon-dents have a family member who has or had diabetes.Smoking can be an indicator of stress (Heslop et al.,2001). A total of 26% of surveyed residents currentlysmoke every day or some days; this is slightly higherthan the national average of 23% (CDC, 2001). Smokingis especially prevalent among those who are at high riskfor diabetes and CVD. For example, 42% of smokersreported having a family member who has or had diabe-tes. However, it appears that community members areaware of the health risks related to smoking. Of thosewho reported smoking, 75% have quit smoking for oneor more days in the past 12 months.

CLAM data were consistent with a perceived lack ofsafety, including minimal police presence, poor light-ing, numerous vacant lots, presence of graffiti, and gar-bage on the streets. All of these could potentially con-tribute to stress. The shortage of walking paths may alsobe perceived as a lost opportunity to reduce stressthrough physical activity.

�DISCUSSION AND IMPLICATIONSFOR PROGRAMS

A comprehensive community assessment employingmultilevel data sources suggests a need for health pro-motion programs that are developed with input fromthe community members they will serve, long-term,well-advertised, and easily accessible. Suggested pro-gram activities are organized according to themes paral-lel to those organizing the findings (see Table 2). Activi-ties are diversified and address all four levels of theecological model.

Despite apparent cultural and ethnic differencesbetween African Americans and Latinos, the needsassessment data revealed that both groups have similarconcerns related to diabetes and CVD. Communitymembers’ requests for usable information and compre-hensive, respectful health care are clearly articulated

and strikingly similar. There are no programs suggestedby the needs assessment data that are appropriate forone racial/ethnic group but not the other. Core programcontent will be similar for both African Americans andLatinos; culturally appropriate examples, activities,and printed materials should be designed specific toeach group. In some cases, programs can successfullyaddress cultural differences without having to be deliv-ered to separate audiences. However, for the most part,geographical and language barriers in this communityarea necessitate the delivery of programs to AfricanAmerican and Latino groups separately. To ensure max-imum participation, program recruitment strategies inparticular must be culturally sensitive and specific.However, it is efficient, enriching, and favorable to planand deliver diabetes- and CVD-related health promo-tion programs to Latinos and African Americans underthe auspices of a single community-based healthpromotion initiative.

Dissemination of Health Information

Data revealed a great need in the community for gen-eral diabetes and CVD education and awareness. Healthinformation needs to be presented in a user-friendly,easily understood, and culturally appropriate formatand in both English and Spanish. As an overwhelmingmajority of community members are at high risk for dia-betes and CVD, a media campaign targeting all commu-nity members is recommended. Such a campaignshould focus on the importance of screening as well ason modifying individual health risk behaviors. Mediamessages should be developed with input from con-sumers and community health care providers and tai-lored to reach both African American and Latino com-munity members. Data from the focus groups indicatedthat community members would be enthusiastic aboutproviding input into making such messages relevant totheir community.

A specific media and outreach campaign is recom-mended that targets individuals within the project com-munity area who are at especially high risk for diabetesand CVD. The message needs to focus on reasons forscreening and promoting screening for diabetes, highblood cholesterol, and high blood pressure. Communityoutreach workers could be used to increase awarenessof screening needs and available services. Access to freeor low-cost screening sites in the community could beincreased, possibly at health fairs or sites such as drugstores, pharmacies, grocery stores, churches, and otherinterested community organizations.

Health Promotion Programs

The BRFSS and focus group data showed that Afri-can American and Latino community members aremotivated to increase physical activity, improve eatinghabits, and quit smoking. However, data reflected aninsufficient number of programs in the community or at

Levy et al. / PLANNING COMMUNITY INTERVENTIONS 65

least a lack of awareness of existing services. Currently,available and underused recreational programs, such asthose offered by the Chicago Park District and the Chi-cago Hispanic Health Coalition, can be promoted. Per-ceived safety was cited in focus groups as a barrier to theuse of park facilities, and CLAM data showed a lack ofpolice presence and walking paths. Efforts need to bemade to increase safety at parks, park district buildings,and the neighborhood in general so that communitymembers can feel safe while walking or jogging. Partner-ships can be made with churches, schools, local school

councils, block clubs, and other community and neigh-borhood groups in order to start new exercise programsand walking groups.

Focus group and the BRFSS data indicated a greatwillingness by community members to change individ-ual health behaviors, but the current community envi-ronment is not conducive to healthy eating. Somethingas simple as having nutrition information available atneighborhood grocery stores and restaurants wouldgreatly benefit those on special diets or those trying tochoose healthier foods. Restaurant and store owners

66 HEALTH PROMOTION PRACTICE / January 2004

TABLE 2Program Suggestions by Theme

Theme Program Suggestions Program Objectives

Accurate health information Dissemination of health information Increase awareness of signs andon diabetes and CVD is limited. Conduct media campaign symptoms of diabetes and CVD

Coordinate community outreach Increase awareness of need forIncrease access to screening screening

Increase screeningIncrease detection

Community members desire Health promotion programs Increase number of available programsmore health education and Increase promotion of and collaboration Increase awareness and use of new andhealthy community activities. with currently available physical existings ervices

activity programs Increase availability of healthy foodsIncrease safety at parks and other Help smokers quit

recreational sitesDevelop new physical activity programs

with community groupsProvide nutrition education to restaurant

and store ownersEstablish farmers markets or community

gardensConduct smoking cessation programs

Inadequate insurance coverage Alleviating the high cost of prescription Help community members obtainand the high cost of prescrip- medications needed prescription medicationstion drugs and medical Increase use of indigent pharmaceuticalsupplies are barriers to programsquality health care. Coordinate county indigent pharma-

ceutical program servicesChange local, state, and national health

insurance policy

Sociocultural barriers affect Reducing barriers to quality health care Improve access to and quality of care,health care usage. Educate health care providers, those especially for those diagnosed with

diagnosed with diabetes or CVD, and diabetes and CVDtheir families regarding standards of care

Teach health care providers culturalcompetency skills

Ensure adequate number of health careproviders with Spanish-language skills

Target men for preventive services

Stress is perceived as a threat Stress reduction programs Alleviate stressors in the community,to health and well-being. Conduct disease management support particularly for those diagnosed with

groups for those diagnosed with diabetes diabetes and CVD and their familiesand CVD and their families

Provide physical activity and smokingcessation programs as stated previously

NOTE: CVD = cardiovascular disease.

could be encouraged to offer healthy choices to custom-ers and be given assistance on how to provide custom-ers with nutritional information. A program such as thismight act as an impetus for restaurant owners to providehealthy choices to their customers, particularly once ademand for healthy foods is realized. Other communityprograms such as farmers’ markets or gardening plots,which have been popular and successful in other Chi-cago communities but are not present in this projectcommunity area, could also help promote fruit andvegetable consumption.

The prevalence of smoking in the project communityarea is slightly higher than the national average (CDC,2001). The BRFSS data also showed that a majority ofsmokers are actively trying to quit or have recently con-templated quitting. Smoking cessation programs wouldgreatly benefit community members. Smoking cancause especially severe complications for people withCVD and diabetes. Therefore, low-cost smoking cessa-tion programs tailored to these high-risk individualsshould be made available in the community.

Alleviating the High Cost ofPrescription Medications

The high cost of health care is exacerbated for com-munity members by employment in lower paying jobsoffering no or low-quality health insurance coverage.The cost of drugs and related supplies (e.g., diabetes teststrips) can be substantial, even for those who havehealth insurance. Some insurance plans only cover cer-tain prescription medications or do not cover prescrip-tions at all. Many community members are not able totake advantage of available payment assistance pro-grams; these plans are often extremely complex andtime-consuming and require assistance from the physi-cian. Some community residents, including those whoare not U.S. citizens or permanent residents, may notqualify for these programs. Although influencingnational, state, and local policies related to healthinsurance and employment may be outside the scope ofthe project or may take longer than the project duration,immediate relief can be provided to those who areunable to afford needed medications. For example, par-ticipation in indigent pharmaceutical programs could beincreased by having outreach workers help physicians andpatients fill out forms. County pharmaceutical servicescould also be better coordinated.

Reducing Barriers to Quality Health Care

The BRFSS and focus group data suggested that diag-nosed diabetics in the project community area are notreceiving needed preventive care as recommended bycurrent American Diabetic Association (2001) guide-lines Health care providers, those diagnosed with CVDand diabetes, and their family members need to be edu-cated regarding the importance of flu shots, pneumoniavaccines, foot and eye exams, and hemoglobin A1c mea-

surement. Patients need to be provided with tools thatthey can take to doctors’ appointments, such as check-lists, that inform them regarding what to expect andinstruct them on how to request appropriate care ifthese expectations are not met.

Data indicated that community residents want pro-viders to be more compassionate and respectful as wellas demonstrate a better understanding of the complexand interrelated barriers they experience in trying tofollow medical instructions. These barriers may includefamily, language, culture, and financial constraints. Ahealth care provider education program focusing onculturally competent health care for both African Amer-icans and Latinos could be designed and delivered tocommunity physicians in order to address some of theissues that surfaced during the focus groups. Also, aprogram could be implemented to work with commu-nity clinics to ensure adequate Spanish-speaking staff.

There is a particular need to target both AfricanAmerican and Latino men in the project communityarea to increase their use of preventive services. Com-munity outreach and media efforts could be used. Com-munity health providers need to be made aware of andsupport all health promotion and education efforts, par-ticularly those targeting men in the project communityarea.

Stress Reduction Programs

One strategy for alleviating stress among diabetics,those with CVD, and their families is to create commu-nity-based programs to assist with day-to-day diseasemanagement issues that fall outside of the clinical set-ting. These programs could be structured as peer sup-port groups. Such programs may increase motivation toadhere to treatment regimens. Families of diabeticscould benefit from similar support and educational pro-grams focusing on disease treatment and managementissues. Programs could be delivered in residents’ homesor at accessible community sites.

Smoking can be a sign of stress, but it can also be astressor. Community smoking cessation programs, asdiscussed in the section on health promotion programs,could serve as one potential way to mediate stress in thecommunity. Community walking groups are anotherpositive strategy for stress reduction, particularly iflocal police officers are involved to address safetyconcerns.

�CONCLUSION

The triangulation of data sources enriched interpre-tation and led to more comprehensive, relevant, andfeasible programmatic interventions across the levels ofthe ecological model. The partnership between the uni-versity, local health department, and community mem-bers made the collection of multisource data possible.University resources made potentially expensive datacollection methods such as focus groups or the BRFSS

Levy et al. / PLANNING COMMUNITY INTERVENTIONS 67

cost-effective. Community support bolstered participa-tion to ensure that collected data were representative,and community wisdom enriched the discussion andinterpretation of findings. Multisource data yieldeduseful information for program planning and a betterunderstanding of the cultural differences and similari-ties between African Americans and Latinos.Multisource data also helped the multicultural plan-ning council to gain consensus in the interpretation ofdata and the development of a community action plan.

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