- What is risk reduction? What are protective factors?
- What is the difference between strategies and tactics?
- Who should be involved in selection of risk reduction strategies?
- How to select risk reduction strategies
What is risk reduction? What are protective factors?
You know your group wants to work on preventing a particular health problem in your community. Most community health organizations have found that the most effective prevention programs work on both reducing risks and enhancing protective factors. But what's risk reduction? And what are protective factors?
Risk reduction means finding out what in your community leads to the problem you're trying to prevent and then working to cut down on those factors. For example, if you're working to prevent lung cancer, one of the obvious risks to try to reduce is smoking.
Protective factors are those things that keep whatever it is you're trying to prevent from occurring. For instance, if you work with a coalition to reduce heart disease, a protective factor for your target population would be eating healthy, low-cholesterol food. Protective factors generally help cut down on risks or counteract risks. To demonstrate this, let's look at how the risk and protective factors work from an example from the researchers Hawkins and Catalano, who are experts in risk reduction issues.
Example: Risk and protective factors for substance abuse among young people
- Economic deprivation
- Community disorganization
- Transitions and mobility
- Availability of substances
- Community norms saying it's "okay" to use drugs and alcohol
- Family history of drug abuse
- Family management problems
- Academic failure
- Antisocial behavior
- Friends who use drugs
- Skills training
- Healthy beliefs and clear standards
- Steady, well-paying employment
- Availability of drug-free activities for youth to participate in
- Positive role models
By looking at the above lists, you should be able to pick out several things on the list of risk factors and the list of protective factors that are opposite sides of the coin. Healthy beliefs and clear standards can reduce the risk of community norms saying it's "okay" to use drugs and alcohol, for example. Others, such as bonding, may actually counteract the transitory moving about of people in the community.
As you might have guessed by now, once you've figured out what the risk and protective factors are for the issue you're dealing with, the next step is to work on ways to reduce those risks and increase protective factors. It's not enough simply to say, "Okay, we need to reduce unprotected sex among 18-to-24-year-olds." You'll need to work on strategies to reduce that risk factor, and come up with specific tactics to carry out those strategies.
What is the difference between strategies and tactics?
Strategies and tactics are often mentioned in the same breath, so a lot of people don't really give much thought to the difference between the two. However, when you or your group are working on any sort of plan with your group that involves strategies and tactics, it's helpful to understand the distinction.
A strategy is one of the broad steps in a plan to accomplish a specific goal. Tactics are individual, grounded acts that make up an overall strategy. To make this distinction simpler, let's look at an example that's not related to risk reduction, but should be fun. This is the story of two star-crossed lovers, Steve and Pam, and Steve's strategies and tactics to win Pam's heart.
Example: Steve and Pam
Steve, a dashing young doctoral student, wants desperately to win the love of the beautiful but aloof Pam. His strategy is to woo her with extravagant gestures, and then to declare his love to her in a lavishly romantic manner.
1. Woo her with extravagant gestures
The tactics for this:
- He makes Pam a mix tape of all her favorite songs
- He sends her a dozen birds of paradise (her favorite flower--NOT a dozen squawking birds)
- He takes out a classified ad in the local paper that quotes Shakespeare and calls for the marriage of their minds
2. Declare his love to her in a lavishly romantic yet endearingly goofy manner
The tactics for this:
- Steve, wearing a tuxedo and accompanied by a violinist, surprises Pam at her job.
- He serenades her with a rousing rendition of Led Zeppelin's "Whole Lotta Love"
- He then presents her with an antique pendant shaped like a pair of clasped hands and a plate of baklava, then tells her, "My mom's gooiest baklava isn't as sweet as you are."
We realize this is a pretty silly example, but once you stop rolling your eyes you should be able to see that it demonstrates the difference between strategies and tactics: 1) a strategy is a broad plan you make to reach a goal, and 2) a tactic is a specific step you take toward completing a strategy.
Who should be involved in selection of risk reduction strategies?
Deciding on risk reduction strategies is something you shouldn't do completely on your own. While your organization may come up with some great ideas on its own, it's important to bring members of the community into the process, including people who can make a difference (those who can bring support and reserves to a cause) and people who are experiencing the problem. A community-wide approach works best in most cases.
Including members of the community in this process is advised because:
- It can help change community norms and values, which are often tied to risk and protective factors. For example, if you're trying to do HIV/AIDS prevention work with a community in which casual, unprotected sex is widely accepted, involving key members of the community can start reinforcing the idea that such behaviors aren't okay. This in turn leads to the next reason:
- It creates a wider base of support for changing behavior. The more people you involve, and the more people from a wide variety of different groups, agencies, programs, and projects within the larger community, the better.
- It can give you a better sense of what resources are available to you in the community. Hey, you can't always know everything about area resources, especially in urban environments. Having a good cross-section of representatives from your community, especially those who are involved in government, social service agencies, and local businesses, can help you tune in to what's out there for you to use.
- It can help galvanize public support for your initiative. Having a good cross -section of the community involved in your coalition means they will develop ownership in your efforts. Their support will bring their constituencies along with them.
- It is more likely to lead to long-term changes. Your strategies and tactics are being integrated into your community, leading to greater maintenance, sustainability, and institutionalization.
Who are good people and groups to think about including?
- Local law enforcement
- Religious leaders
- Local government officials
- School administrators, teachers, PTA members, school board members (including school folks is especially advisable if your target population includes youth)
- Health and human services agencies
- Local media representatives
- Youth and parents
- Local businesspeople
- Regular folks from a representative cross-section of the community
You should also include members of the target population you serve in the process. Why should you include the target population?
Including members of your target population is important because:
- Giving the target population a say helps establish trust. In some communities there's a lot of distrust and suspicion regarding public health organizations or any institutions. For example, African Americans can be understandably skeptical about public health efforts because of past violations of their trust like the Tuskegee studies on syphilis, in which adequate treatment was withheld from a group of low -income African American men who had the disease. Finding ways to say, "We value your input," to those communities is essential.
- Affected communities are often stronger and more resourceful than we give them credit for. Many people were surprised, for example, at the innovation and hard work that was demonstrated by the gay community in mobilizing to fight the AIDS crisis. Don't underestimate your target population! Even if they haven't accomplished a lot in prevention efforts before, you might be amazed at how much they accomplish with a little encouragement.
- It can give your group a better understanding of what the community needs. If, when you're planning, you involve people from the group you're aiming at, you always have someone available to help you determine what will and won't work in a given community. It's instant feedback!
- It can also increase community awareness of who you are and what you do. This is always good for any coalition! Monitoring your initiative is vital to sustaining it over the long haul.
How to select risk reduction strategies
Now you have identified the risk and protective factors for your coalition, you have people together, and you're ready to start coming up with strategies and tactics. Where do you begin?
Take advantage of existing information!
First of all, you don't want to reinvent the wheel. There's a lot of existing information out there for community health coalitions to take advantage of. Know your community's history! Has this initiative or something similar been tried here before? Even a failed attempt has valuable information to offer. Take advantage of existing knowledge on risk reduction before you work like crazy to come up with strategies and tactics. Here are some ways you can do this:
Research to find out what other groups with missions similar to your own have done. A trip to the library or a web search can yield a wealth of results. Don't be afraid to just ask others what has worked for their own groups. For example, a free healthy snack program done as part of a child hunger prevention initiative in another city may be just the trick for your own child hunger prevention group. Exchanging information with folks who are doing work similar to your own is usually beneficial to both you and to them. Which leads us to:
Network, network, network! Get to know people who work with groups like yours. That statewide workshop for social service agencies might sound boring, and it may even be on a subject that you know backwards and forwards, but don't dismiss it until you've considered whether there will be any people there who might be good to talk to! Establish a rapport with your peers so that you can exchange information, stories, and suggestions. Take advantage of any opportunities to connect with others--these relationships can be useful to you for lots more than just coming up with risk reduction strategies. Here are a few ways you can get to know people who do similar work to yours:
- Attend conferences and workshops
- Get involved in regional and national coalitions
- Sign on to an email list--there are a great many lists out there for people doing all sorts of work; you may be surprised to find a list for public nutrition educators or AIDS service providers, and you might even find a list made up of people specifically from your region or state.
A word of caution, however--be careful to not assume that what has worked in other communities will necessarily work in your own. When you examine a possible strategy that has been used in another community, think about how it would work with your own community. A needle exchange program that worked marvelously in New York City might meet with a great deal of resistance in a small town in Tennessee, for example.
Finally, conduct your own research and see what original strategies you can come up with on your own. A little ingenuity goes a long way. While many great strategies can be borrowed from other sources, don't be afraid to alter them as much as you see fit, and feel free to create new strategies yourself. You know your community and probably have a good idea of what will work there and what won't.
Characteristics of effective risk reduction strategies
Here are some things that are usually present in an effective risk reduction strategy:
- First and foremost, an effective risk reduction strategy works to increase protective factors. Have we said that enough? Focusing on protective factors helps us guard against moralizing about or demonizing risky behavior, which can alienate those who experience the problem.
- The goals, methods to be used for data collection, evaluation, and feedback, and specific roles and duties of all staff, volunteers, and any other personnel should be clearly defined. Plainly outlining these things ahead of time will save a lot of confusion further into the process!
- The strategy approaches risk reduction in a way that's appropriate to your target population. There are a lot of factors to take into consideration, depending on what group you're working with. For one thing, you should ask yourself whether the strategy is appropriate for the age and maturity levels of people you're aiming at. For example, if you're working with youth, is it appropriate to youth? There are other factors to consider as well. Is it culturally sensitive? Does it take into consideration whether your group is high-risk? A good example of a strategy that is appropriate to the target population is using peer education when working with youth, since a lot of kids who engage in high-risk behaviors are likely to reject anything adults say is lame and stupid.
- Most effective risk reduction strategies employ early intervention. For example, getting to women before they get pregnant or early in their pregnancy to address nutrition for themselves and their babies and help them establish healthy eating habits is better than starting when their children are old enough to enter school. Another example is getting to teens to address what it means to have a baby to take care of--as in the Planned Parenthood poster with the caption that reads "It's like being grounded for 18 years."
- The strategy makes the best possible use of available resources (materials, staff hours, and so on). If it's something your group or coalition will have a hard time affording in terms of money, materials, or time, then you're probably better off trying to come up with something else.
Example: Making Good Use of Available Resources
An adult literacy and basic education program in New England filled a need they had for a health education component when they got a grant, taken from tobacco tax money, from the Department of Public Health to do a smoking reduction program. They hired a coordinator, bought materials, and started by simply trying to reach every student in their program with information, activities, and alternatives to smoking. Ultimately, the coordinator ended up training a group of students as a health team. The health team put on two different student-run conferences about smoking and health. They also trained other students and other people in the community who weren't part of the program at all.
In the long run, for between $35,000 and $55,000 a year (the grant grew over time ), they reached over 200 people annually, helped many stop smoking, and changed the whole attitude toward smoking among their students, who in turn had a strong impact on the communities they lived in. In addition, the whole health program became part of their curriculum, expanded far beyond smoking to such areas as violence prevention, breast cancer prevention and detection, and other health areas, and provided curriculum for adult literacy in reading, writing, math, research skills, science, etc.
- If addressing more than one risk factor, it's probably best to use more than one strategy. It's rare for any one strategy to adequately address several different risks. For example, a problem like domestic violence has many factors, such as the abuser's personal history of being abused, alcoholism, isolation, unemployment or underemployment, and lack of skills for economic advancement. Clearly, no one strategy can address all of these factors--so it will take multiple strategies to make a true impact where domestic violence is concerned.
Questions to ask when evaluating prevention strategies you're considering:
- Does the strategy address known risk factors?
- How will the strategy reduce risk and/or increase protective factors?
- Is the strategy likely to reach your target population?
- Is the strategy set up in a way in which its effectiveness can be evaluated?
Common types of risk reduction strategies
Risk reduction strategies are usually split into two types: those meant to change individual behavior and those related to organizational and community development.
Strategies related to changing individual behavior include:
- incentives or disincentives--finding ways to penalize or discourage risky behavior and reward or encourage protective behavior (for example, high taxes on cigarettes as a disincentive, lower insurance rates for smokers as an incentive)
- increasing (or reducing) time and effort for target behaviors
- providing support (some tactics that could be used to do this are peer education and risk reduction counseling)
- arranging mentor programs in which older or more experienced people work to help others change their behavior
- enhancing resources--working to raise more money, improve materials, connect better with other programs and services, or increase public awareness of the resources that are available to them
- changing your program to remove barriers or make it more accessible to the people using it (for example, school breakfast programs, making more WIC distribution centers, parent nutrition education at school pick-up-time, etc. to work against child hunger)
- changing policy (creating, modifying, or terminating)
- providing information (some tactics that could be used to do this are informational campaigns, community outreach, peer education, and risk reduction counseling)
- modeling (a tactic that could be used to do this is peer education)
- skills training (some tactics that could be used to do this are peer education and risk reduction counseling)
- providing feedback on progress (some tactics that could be used to do this are peer education and risk reduction counseling)
Strategies related to organizational and community development include:
- public awareness and media campaigns (some tactics that could be used to do this are information campaigns, street outreach, community outreach, peer education, and direct action)
- community assessment and monitoring
- building coalitions with other community groups
- changing the level of access to products and services (making cigarettes less available for minors to buy, for example)
- developing resources to enhance family and peer support
- enforcement of existing policies and laws
- advocacy and nonviolent protest (some tactics that could be used to do this are information campaigns and direct action)
- changing policies and laws (some tactics that could be used to do this are information campaigns, community outreach, street outreach, and direct action)
Common tactics used in risk reduction
There are many, many tactics that can be used in risk reduction. Here are a few of the most common--but remember, the tactics you use are only limited by your own imagination!
- Information campaigns - This is probably the most commonly used tactic in risk reduction. Educating the public about how to cut down on their risks for certain health problems is a common and widespread practice. Some of the methods to get out information might include advertisements, posters, brochures, public service announcements on radio or television, speakers, and informational hotlines.
- Street outreach - This involves sending outreach specialists into a given area to make face-to-face contact with the target population. Some street outreach activities include canvassing, setting up information tables, or distributing information or supplies. The regular contact that street outreach provides between your coalition and your target population tends to have a pretty strong impact on risky behavior.
- Community outreach - This differs from street outreach because it's more often done in a group setting - workshops, presentations, lectures, and so on. The impact on behavior is usually limited because they're single-encounter experiences, but they're still good ways to get information out there. If you use community outreach, you should probably back it up with other tactics as well.
- Peer education - In peer education, people who are themselves members of your target population go into the community to act as positive role models for behavior and distribute information. Peer education can be very effective, because your target population gets to see people like themselves who not only come to them to talk about less risky behavior, but also model that behavior in their own lives. Peers can do one-on-one counseling, speaker's bureaus, or other activities.
- Risk reduction counseling - Risk reduction counseling is intensive interactive work usually done with people who are at a particularly high risk. Someone from your coalition's staff gets together with the client or clients to give them straight talk about risky behavior and work with them to build skills to change that behavior. It's often one-on-one, but can be done through small group meetings as well.
- Direct action - Direct action is term used to describe a range of political actions or "media stunts" taken to directly confront or highlight the issue or authority you're trying to address. If you want to make a big statement publicly, direct action might be a tactic to consider. Some examples of direct action are demonstrations, symbolic actions, street theater, trespass actions, occupations and sit-ins, and blockades. Clearly, direct actions are often disruptive and more confrontational than other methods and, depending on what you do, people involved may end up being arrested. Look into other ways of campaigning for change before you do a direct action, because direct action's confrontational nature can alienate and polarize the public, especially if you haven't tried other ways of getting your message out. If using direct action tactics it is very important that you painstakingly plan it out and try to anticipate how to counter any negative public reaction to your actions.
The strategies and tactics discussed in this section are by no means the only ones that can be used to reduce health risks in your community. This section is simply meant to give you some understanding of how you can design strategies and tactics to address the risks you're battling. As we said, pay close attention to what has worked in other communities, particularly those that are similar to your own, and don't be afraid to come up with your own original ideas too. You may find that some combination of your own original ideas and ideas adapted from other sources works best for your community.
Guidelines for Health Education and Risk Reduction Activities. Centers for Disease Control (1995). Core Elements of Health Education and Risk Reduction Activities. Guidelines for Health Education and Risk Reduction Activities
Fawcett, S. B., Paine-Andrews, A., Francisco, V., Richter, K. P., Lewis, R. K., Williams, E. L., Harris, K. J., Winter-Green, K., in collaboration with Bradley, B. and Copple, J. (1992). Preventing Adolescent Substance Abuse: An Action Planning Guide for Community-Based Initiatives. Lawrence, KS: University of Kansas.
Fawcett, S. B., Francisco, V., Paine-Andrews, A., Fisher, J. L., Lewis, R. K., Williams, E. L., Richter, K. P., Harris, K. J., Berkley, J. Y., with assistance from Oxley, L., Graham, A., and Amawi, L. (1994). Preventing Youth Violence: An Action Planning Guide for Community-Based Initiatives. Lawrence, KS: University of Kansas.
Fawcett, S. B., Harris, K. J., Paine-Andrews, A., Richter, K. P., Lewis, R. K., Francisco, V., Arbaje, A., Davis, A., Cheng, H. in collaboration with Johnston, J. (1995). Reducing Risk for Chronic Disease: An Action Planning Guide for Community-Based Initiatives. Lawrence, KS: University of Kansas.
Hawkins, J. D., Miller, J. Y. and Catalano, R. F., Jr. (1992). Communities That Care. San Francisco, CA: Jossey Bass.