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Section 2. Understanding Risk and Protective Factors: Their Use in Selecting Potential Targets and Promising Strategies for Intervention

    Example 1: Risk and protective factors that may be related to disparities in health outcomes associated with race and ethnicity

    Here, risk and protective factors are separated into three broad categories by who is affected by, or can affect, that factor.

    This example is adapted from Promoting Health for All: An Action Planning Guide for Improving Access and Eliminating Disparities in Community Health. See Resources for a full citation.

    Knowledge and skill (personal)
    Consumers/Local Residents Health Care Providers Broader Agents/Allies
    • Knowledge (e.g., of preventative health practices, self-care, resources for health care)
    • Beliefs (ie, about causes and consequences of health behaviors and outcomes, e.g., effects of diet, physical activity)
    • Skill (e.g., in accessing available services, advocating for needed services, language spoken)
    • Education and training (e.g., years of formal education)
    • Knowledge (e.g., of local culture, client health needs)
    • Belief (e.g., about what consumers value)
    • Skill (e.g., cultural competence, languages spoken)
    • Education and training (e.g., extent and adequacy of training)
    • Knowledge (e.g., of the problem of access/disparities)
    • Beliefs (e.g., about how our health is bound up in that of others)
    Experience and history (personal)
    Consumers/Local Residents Health Care Providers Broader Agents/Allies
    • Experience with health systems (e.g., discrimination in seeking services)
    • Experiences of prior health care (e.g., pain, no improvement)
    • Cultural norms and religious practices (e.g., diet, healing practices)
    • Experience with service provision (e.g., respect shown to consumers)
    • History of working with consumers (e.g., hostility, no improvement)
    • Community norms for racial and ethnic harmony (e.g., history of race/ethnic relations )
    • History of collaboration in public problem solving (e.g., involving those most affected and those most responsible)
    Biology/Genetics
    Consumers/Local Residents
    • Type and degree of existing health (e.g., pre-existing conditions, risk markers )
    • Cognitive, mental or physical ability (e.g., mobility impairment, psychiatric disability, cognitive ability)
    • Chronic illness (and requirements for care)
    • Gender (e.g., women or men may be more at risk for particular health outcomes)
    • Age (e.g., infants, adolescents, or older adults may be more at risk for particular health outcomes)
    • Genetic predisposition (e.g., diabetes)
    		  
    Support and services (environmental)
    Consumer/Local Residents Health Care Providers Broader Agents/Allies
     
    • Availability and continuity of services and support (e.g., continuity of care from providers; peer support)
    • Social support and ties (e.g., through neighbors, faith communities)
    Access, barriers, and opportunities (environmental)
    Consumer/Local Residents Health Care Providers Broader Agents/Allies
    • Communication access/barriers (e.g., languages spoken)
    • Physical access/barriers (e.g., transportation)
    • Communication access/barriers (e.g., available interpreters)
    • Physical access/barriers (e.g., distance and physical access to facilities)
    • Human resources (e.g., too few providers for need; availability of providers from ethnic community)
    		  
    Consequences of efforts (environmental)
    Consumer/Local Residents Health Care Providers Broader Agents/Allies
    • Competing requirements to participation (e.g., child care, work)
    • Time costs (e.g., waiting time for service, convenient hours of service)
    		  
    Policies and living conditions (environmental)
    Consumer/Local Residents Health Care Providers Broader Agents/Allies
    • Living conditions (e.g., homelessness, adequate housing, heat/cooling, clean drinking water)
    • Poverty/financial resources (e.g., not enough money for basic needs, for needed health services)
    • Financial barriers and resources (e.g., not enough money for needed health care, for prevention)
    • Policies (e.g., requirements for insurance coverage, co-payments, refusal of service)
    • Public accommodations for participation (e.g., available child care, transportation )
    • Employer accommodations and policies (e.g., workplace health services, flextime policies to permit participation, health insurance policies)
    • Government policies (e.g., distributive policies that assure access to care)
    • Poverty and deprivation (e.g., policies supporting economic development, education, and housing in neighborhoods of concentrated poverty)

     

    Example 2: Substance use among young people

    Information in this example comes from Drs. David Hawkins' and Richard Catalano's book Communities that Care. See Resources for a full citation.

    Researchers David Hawkins and Richard Catalano have done extensive research on the risk and protective factors associated with substance use, particularly among young people in the United States. They determined that the risk and protective factors in the environment include all of the following. (Note that the heading itself gives the risk factor with the corresponding protective factor following in parentheses.)

    • Economic deprivation (affluence)
      Those who live in deteriorating neighborhoods with little or no hope of a better future are much more likely to abuse alcohol and other drugs than those who live in more affluent communities.
    • Community disorganization (organization)
      There are more problems related to substance use in areas where there is little sense of community; where people don't feel as if they are part of a greater whole.
    • Transitions and mobility (stability)
      The more young people move to new environments, the more likely they are to use drugs. These transitions can be as typical as changing from middle school to high school, but changes are more likely to increase risks when they are more significant, such as frequent moves to new cities or towns.
    • Availability of substances (lack of availability)
      The easier it is for people to get a hold of illegal substances such as drugs, the more likely they are to use them.
    • Community norms saying it's "okay" to use drugs and alcohol (community views that say it's not okay)
      An example of this might be students in a college town, where excessive drinking among younger students is seen as a type of rite of passage to adulthood and not as a public health problem.

    Hawkins and Catalano also determined that some of the individual or personal risk and protective factors for substance use include the following things. Again, protective factors are in parentheses.

    • Family history of drug abuse (family history of appropriate use or nonuse)
      Children who have parents who are alcoholic or who abuse drugs are much more likely to have drug problems themselves. This is true for both girls and boys, but is a higher risk for boys, for whom a genetic link for alcoholism has been established.
    • Family management problems (family strengths)
      These include a lack of clear expectations of what a child is supposed to do, a lack of someone to pay attention to what a child is doing, and inconsistent or overly harsh discipline.
    • Academic failure (academic success)
      Children may fail in school for a variety of reasons, but it appears that just not succeeding increases the likelihood of substance use problems.
    • Antisocial behavior (strong, positive social skills)
      This may include aggressive behavior among small children, misbehaving in school, skipping school, or getting into fights with other children.
    • Friends who use drugs (friends who don't approve of drugs)
      This is one of the risk factors that has consistently predicted the use of drugs. Children whose friends use drugs are much more likely to do so than those whose peers don't use drugs, even if they don't generally experience other risk factors.

    Some of the protective factors (this time, with the associated risk factors in parentheses) Hawkins and Catalano have found for substance use include:

    • Bonding (lack of caring adults)
      Research has consistently shown that close relationships with non-drug users are one of the cornerstones of keeping adolescents from experimenting with drugs. Young people who have adults who care about them, and who help strengthen their values or beliefs of what is strong, ethical behavior are likely to have a clear idea about what is right, and the strength to behave in an appropriate manner.
    • Skills (lack of competence)
      Children need to have skills to feel like they are contributing members of their family. If children are given the chance to help out with responsibilities, and are also given adequate training for those responsibilities (for example, they are taught to cook dinner, or to help tend the family garden), they will feel useful and successful. They will be less likely to start abusing alcohol or other drugs in search of the positive recognition they aren't getting at home.
    • Healthy beliefs and clear standards (mixed messages)
      Living in a community, attending a school, and being part of a family where beliefs and standards are clearly against the use of drugs is a strong protective factor against experimentation. On the other hand, if children receive mixed messages, this could become a risk factor. For example, the message to a child is clear when the family goes out to eat, and the waitress asks if the family would prefer the smoking or nonsmoking section. If mom says, "Non smoking, please, we worry about our children inhaling second hand smoke," the message against cigarettes is clear to the children, even if the reply wasn't directed to them. On the other hand, a father who instructs his children not to use alcohol over his fourth beer sends a message that is much less clear.

    Example 3: Determination of which risk and protective factors to focus on for teen substance use

    Members of a small anti-drug coalition in rural Mississippi wanted to decide which risk and protective factors they should address. Using the table below, several people sat down and discussed which risk and protective factors were both important and changeable. Then, they ranked what they had said. The smaller the number they used, the more important the risk or protective factor (or, the easier it was to change.)

    This is what they found:

    Risk or protective factor Importance   Changeability   Final value
    Family history of drug abuse 1 + 3 = 4
    Community norms saying it's "okay" to use drugs and alcohol 1 + 1 = 2
    Transitions and mobility 2 + 3 = 5
    Availability of substances 1 + 2 = 3

    When all of the information was in front of them, they realized that their choices were easier to make. Although they all agreed that a family history of drug abuse was a very important risk factor, they realized that, given their limited budget, there wasn't a whole lot they could do about that risk factor right now. Similarly, with the category "transitions and mobility," they all agreed it was at least somewhat important, but again, there wasn't a whole lot they could do. Besides, the community was relatively stable; there weren't a lot of people moving in and out, and so this factor seemed a little less important.

    However, all of the members felt that changing community norms and lessening the availability of substances were important risk factors that they could do quite a bit about. They could talk to people, start media campaigns, and conduct "stings " on stores that were selling alcohol to people under 21. The members decided to concentrate on these two risk factors as part of their current strategic plan. They also decided to come together again and reevaluate their work in six months.

    Example 4: Risk and Protective Factors for Sexual Violence Prevention

    This infographic highlights the connections between risk and protective factors and social determinants of health at the various levels of the social ecology, and can be used to link sexual violence prevention with anti-oppression and related public health issues in order to create more effective change.

    Risk and Protective Factors Chart

     

    Download a PDF of this chart.

     

     

    Contributor 
    Jenette Nagy
    Stephen B. Fawcett