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

Have you ever wondered why some people in our communities have better outcomes than others? Why some children do well in school while other children - equally capable - face greater barriers? Why people in the same community may experience unequal health outcomes? Have you wanted to help change these outcomes?

There are many different and interrelated causes of problems and desired outcomes. If your organization can understand these causes, it can focus its intervention to better contribute to community improvement. This can help your organization and community work toward the conditions and outcomes you envision.

So, where do you begin in trying to make these changes? We believe one very good way to go about it is to consider the risk and protective factors that may contribute to a particular problem or desired outcome.

What are risk and protective factors? They are aspects of a person, group, environment, or life experience that make it more likely (risk factors) or less likely (protective factors) that people will experience a given problem or achieve a desired outcome. For example, smoking is a risk factor for cardiovascular disease. Regular physical activity can be a protective factor for cardiovascular health.

Risk and protective factors are key to figuring out how to address community health and development issues. It's a matter of taking a step back from the problem, looking at the behaviors, experiences, systems, and conditions that contribute to it, and then figuring out how those conditions can be changed or strengthened.

For example, in an effort to prevent harmful substance use, an approach that uses risk and protective factors to direct interventions might increase young people's access to positive activities, supportive adults and peers, accurate information, coping and decision-making skills, and environments that support healthy choices.

We suggest that you consider risk and protective factors as one of your early steps when you are writing or revising the strategic plan for your initiative.

In this section, you will learn more about risk and protective factors and their role in identifying the changes in your community that your organization wants to make. Specifically, we are going to look at:

• A more in-depth understanding of risk and protective factors
• When to look at the risk and protective factors for the issue that's important to you
• How to identify the specific risk and protective factors for your focus area
• How these factors can help your organization identify the people and communities who may benefit most and select strategies for making a difference

Ready? Then let's dive in!

What are risk and protective factors?

As we said above, risk and protective factors are aspects of a person or group, their environment, and their life experiences that make it more likely (risk factors) or less likely (protective factors) that people will develop a given problem or achieve a desired outcome. Risk factors increase likelihood; they do not determine what will happen to a particular person or community.

Often, risk and protective factors can be considered flip sides of the same coin. For example, a family history of alcohol use disorder may be a risk factor for developing problems related to alcohol. On the other hand, growing up in a family where parents and caregivers talk openly about alcohol, model healthy choices, and provide consistent support may be protective. Research suggests that the accumulation of risk factors can increase the likelihood of adverse outcomes in health, education, and development.

Another term used for protective factors is "assets." So-called "asset-based" approaches put the emphasis on strengths and resources that support positive outcomes. These assets may exist within individuals, families, organizations, neighborhoods, cultures, or broader community systems.

We generally group both risk and protective factors into two broad categories: those that occur in the environment, both socially and physically, and those that relate to individual characteristics and experiences. These categories interact with one another and should not be considered in isolation. Let's look at personal factors first.

Personal Factors

Personal factors are characteristics, knowledge, experiences, skills, and circumstances that differ among individuals. They include an individual's knowledge, skills, experience, history, health, and genetic makeup. Here is more specific information on the types of personal factors that may contribute to risk and protection:

Knowledge and Skill:

• Knowledge, including knowledge about available choices, possible consequences, and available resources
• Beliefs, such as ideas about the causes of problems or the consequences of choices
• Skills, including being able to navigate one's environment, communicate, make decisions, and set and accomplish goals
• Education and training, such as formal education, community-based learning, or specialized training

Experience and History

• Experience, such as experiences of care and support, maltreatment or neglect, overcoming barriers, or successfully attaining goals
• Cultural norms and practices, including values, traditions, and expectations that may influence behavior and well-being
• Social and structural position, including experiences of discrimination, exclusion, privilege, or access to opportunity

Biology/genetics

• Existing health, including current health status and health conditions
• Cognitive, mental health, and physical functioning, including disability-related factors and access needs
• Chronic health conditions, including needs for ongoing care, accommodations, or other supports
• Age and sex or gender, when these are relevant to the particular health or development issue
• Genetic predisposition or family history, such as a family history of diabetes, cardiovascular disease, or alcohol use disorder

Environmental Factors

Environmental factors are conditions that affect people within a community rather than being unique to one individual. The environment includes the conditions in which people live, learn, work, play, and interact - their households, neighborhoods, schools, workplaces, and larger communities. These may include aspects of the social environment, including relationships, social support, norms, policies, and community connections. They also include aspects of the physical environment, including access to resources, exposure to hazards, transportation, housing, and other living conditions. Environmental factors fall into the following categories:

Support and services

• Availability and continuity of social support and relationships, such as with family, friends, neighbors, mentors, and others
• Availability of appropriate services, including services that are accessible, responsive, and appropriate to community needs
• Availability of resources, including human, organizational, financial, and material resources

Access, barriers, and opportunities

• Physical access and barriers, including distance, transportation, accessibility, and physical access to services
• Communication access and barriers, including language access, interpreters, translation, accessible communication formats, and technology
• Competing requirements for participation, including work, caregiving, school, transportation, or other responsibilities that can make participation difficult

Consequences of efforts

• Social encouragement and discouragement, such as whether family, peers, institutions, or community norms support particular behaviors
• Incentives and disincentives, including monetary and material gain or loss and access to desired benefits
• Time costs and delays, including the time and effort required to take action, meet needs, and access services

Policies and living conditions

• Policies, such as those affecting access to benefits, enforcement of laws, workplace conditions, and eligibility for services
• Financial barriers and resources, including whether people have sufficient resources for needed goods and services and how resources are distributed
• Exposure to hazards, including toxic chemicals, air pollution, unsafe environments, or other environmental risks
• Living conditions, such as the availability and quality of housing, food, clothing, heating and cooling, transportation, and clean drinking water
• Economic hardship and inequities in resources and opportunity, including difficulty meeting basic needs and unequal access to income, services, and other resources

General principles about risk and protective factors

Before going further, let's look briefly at some general principles about risk and protective factors. These apply across risk and protective factors and across personal, social, physical, and environmental conditions. Research has consistently shown us that:

• Many risk and protective factors are related to multiple community outcomes. That is, they may influence more than one community health and development concern. As such, they can give you a useful place to start in developing your own lists of risk and protective factors. For example, economic hardship and limited access to resources can affect health care access, educational opportunities, nutrition, housing, and other outcomes. On the other hand, a young person having a strong relationship with a caring adult can be an important protective factor across a number of health and development outcomes.

• Not all risk and protective factors are equally influential. Some factors may have a stronger relationship with a particular outcome than others. For example, peer substance use may be an important factor to consider in adolescent substance use prevention. It's important to consider the relative importance of each risk and protective factor because this will help you prioritize your actions later on.
• Risk and protective factors can accumulate and interact. Greater exposure to multiple risk factors may increase the likelihood of an adverse outcome, while multiple protective factors and assets may help support positive outcomes. For example, cardiovascular risk may be influenced by the combination of tobacco use, physical inactivity, blood pressure, cholesterol, nutrition, health care access, and other factors rather than by any single factor alone.

When do you want to learn about the risk and protective factors for your issue?

So, you believe risk and protective factors are important, but are unsure when your initiative should address them. The answer depends in great part on the stage of development of your group - how long you've been around, what you are doing now, your resources, and so on.

Generally speaking, the rule is the earlier, the better. If your organization is already up and running, you might want to look at risk and protective factors before you revise the strategic plan for your initiative. That's something you will probably want to review regularly as conditions, priorities, and available information change.

If you are planning a new initiative or if your organization is starting a new program - perhaps your Youth Coalition recently received a grant to reduce adolescent pregnancy - then the time to start is after you have developed your long-term goals, but before you've developed the road map, or "model of change," that will get you to them.

If your organization is using the "VMOSA" (Vision, Mission, Objectives, Strategies, and Action Plan) approach to planning, you will want to look at risk and protective factors after you've developed your vision and mission, but before you get to the more specific goals outlined in the objectives, and definitely before you develop your strategies. This is because risk and protective factors will sometimes influence your objectives, but they generally fit hand in glove with your strategies, as well as the desired community and system changes that implement those strategies. Let's look at a specific example.

This is the point at which the coalition may want to study risk and protective factors. The LVHCC found that strong relationships with parents, caregivers, and other supportive adults were protective factors for child health and development, while school disengagement was associated with poorer outcomes. Further study suggested that some students faced barriers such as limited academic support, language-access needs, and insufficient culturally and linguistically responsive resources. Altogether, the coalition identified a range of risk and protective factors for child health and well-being. These findings led the coalition to develop a number of objectives and strategies, including the examples below.

• Two of our several objectives are: 1) Within two years, increase meaningful parent, caregiver, and adult interaction with children under 2 years of age by 40%; and 2) Within four years, increase the percentage of young people graduating from high school by 25%.

Remember: Your objectives are specific, measurable results of the work done by your organization. They include the practical details, including how much of what will be accomplished by when.

• Two of our strategies for supporting children and young people in school include: 1) Involving caring adults in talking with or reading to young children; and 2) Increasing the number of bilingual or multilingual teachers and other language-access supports in area schools.

Remember: Your strategies explain how you are going to achieve your goals; they are broad ways to address the mission. Most organizations use multiple and complementary strategies, for example providing information and enhancing skills, improving access and reducing barriers, strengthening services and supports, and changing policies or environmental conditions.

How do you identify risk and protective factors and use them to select people, communities, and strategies for your intervention?

Once you have an understanding of risk and protective factors, as well as when you should include them in your planning, the time is right to identify the particular risk and protective factors that your organization will address. The following few pages offer one possible way to go about doing this.

Review data and information about candidate risk and protective factors for the issue your community is facing.

You can do this by either gathering data that is already available or compiling your own if what you need doesn't seem to have been collected. And of course, you can also combine these two options by using the general data that already exist and supplementing them with information gathered by your organization and community partners.

Let's look briefly at both of these options - gathering and compiling data - and how you might go about each of them.

Gathering available data.

If information is already available, use it. Data on risk and protective factors may already be available for many of the issues of importance to your community. This includes topics such as substance use, cardiovascular diseases, adolescent pregnancy, child maltreatment, access to health care, school success, and a host of other community problems or goals.

To find this information, you can start with ideas given in this section for both general and issue-specific risk and protective factors. From there, you can search credible online sources, check your local library, or contact state agencies, local health or education departments, community organizations, or universities.

If you already know the risk and protective factors for the problem or goal you are working on, you're halfway home. The next step is to find current, reliable data to understand which risk and protective factors are most important in your community and how local conditions compare with appropriate benchmarks.

Historical example: Percentage of Kansans with selected risk factors for cardiovascular diseases

The table below is retained as a historical example of how state and national data can be compared. For current planning, use the most recent reliable data available.

	Kansas	National
Physical Inactivity	50%	56%
Obesity	26%	24%
Smoking	22%	23%
Hypertension	21%	21%
High Cholesterol	18%	18%

Source: 1992 Behavior Risk Factor Surveillance System, Kansas Department of Health and Environment

Developing your own information.

Sometimes, however, there just isn't information available on the topic that you are researching. Or, you might have general information on risk and protective factors, but also want to know which specific factors are important in your community, how people experience them, or the extent to which they exist locally. Then, you'll need to use other methods to develop the information you need. Although they are discussed more fully in other sections of the Community Tool Box, let's touch here briefly on several possibilities.

• The "But why?" technique. This is a method often used to identify underlying factors that contribute to a community issue. The "But why?" technique examines a problem by asking what caused it. Each time an answer is given, a follow-up "But why?" is asked. For example:

From the brainstorming done here, you might identify factors such as competing work and caregiving responsibilities, limited access to affordable childcare, and the need for more flexible educational or family supports. This technique is especially useful early on for developing possibilities that can then be explored through conversations with people affected, focus groups, surveys, or existing data.

Focus groups

Focus groups can also give you a better understanding of the issue. They are small-group discussions designed to gather participants' experiences, perspectives, and ideas. Depending on the purpose, a focus group may bring together people who share certain experiences or characteristics when doing so helps participants feel comfortable speaking openly. The composition of the group should be based on the questions you are asking rather than assumptions about who will or will not feel comfortable together.

One advantage of focus groups is that they can provide context, lived experience, and a deeper understanding of how people feel about an issue. Although a survey can provide systematic information about patterns across a larger group, focus groups can help explain what those patterns mean to community members and why they may exist.

Surveys

If you have the resources and would like to make your results more systematic, you can conduct a survey to find out which risk and protective factors are important in your community. It's possible that you will want to test some of the information you found using the "But why?" technique, compare local information with broader data, or develop or adapt a survey to address these topics.

Select risk and protective factors to be addressed by your comprehensive intervention.

Now that you have determined what the likely risk and protective factors for your issue are, the next step is to decide to what extent each of these factors should influence your strategic plan. There may be some factors on which you want to spend a great deal of time and resources, and others that you may not want to address directly, at least at the beginning. Two key questions can help you sort out how much weight you want to give to each risk and protective factor:

• Does it strongly influence the issue? Is a given risk or protective factor strongly associated with the outcome you hope to change, or is the relationship weaker? For example, peer substance use may be an important factor to consider in adolescent substance use prevention. The relative importance of a risk or protective factor can often be explored through existing research, local data, community experience, surveys, and other forms of evidence.
• How changeable is it? Most factors fall into one of three broad categories, or "degrees of changeability":
  • Some risk and protective factors can be changed substantially. For example, high cholesterol may often be improved through changes in nutrition and physical activity and, when appropriate, medication and clinical care.
  • Some risk and protective factors may be modified but not completely eliminated. An example might be access to alcohol or other substances among young people. Communities may be able to reduce access through policy, enforcement, retailer practices, education, family engagement, and other strategies, even if complete elimination is unrealistic.
  • Finally, some factors cannot be changed directly. Family history and genetic predisposition, for example, may influence the likelihood of developing some health conditions, including alcohol use disorder. These factors should not be used to label people or assume an outcome is inevitable. Instead, they can help identify opportunities to strengthen protective factors, supportive relationships, prevention resources, and early access to appropriate services.

One way to decide which factors to prioritize is to consider those that appear to have a strong relationship with the outcome and that your organization or partnership has a realistic and equitable opportunity to influence.

By answering the two questions above, you can start to decide the appropriate mix of risk and protective factors that you want to address. The next step is to decide how many of these factors your initiative has the resources and partnerships to pursue effectively.

It is quite common for an organization to address a mixture of risk and protective factors. How extensive your list is may be determined in large part by the people, partnerships, time, funding, and other resources available. Most organizations will not be able to address every factor at once, and some factors will have a higher priority than others. You will therefore have to make thoughtful choices about priorities.

But remember: positive outcomes can be supported by strengthening multiple protective factors and community assets. If your organization cannot address all of the factors needed to make a meaningful difference, consider forming a partnership with other groups that can contribute complementary strengths and resources.

Once you have considered all of this, make a list of the risk and protective factors your initiative will try to change or strengthen. You will want to have this list handy as you move to the next step.

Use information about risk and protective factors to identify people and communities who may benefit most.

Once you have decided which risk and protective factors are important and potentially changeable, your next step is to identify the people and communities who may benefit most from your intervention. This may include people who experience greater exposure to particular risk factors, have less access to protective resources, or are affected by systems and conditions connected to the issue.

Be careful not to use risk information in ways that stigmatize people or imply that an outcome is inevitable. Risk and protective factors can help identify where resources, opportunities, policy changes, or additional support may be useful, but they should be considered alongside community strengths, lived experience, and the priorities identified by people most affected.

Other considerations include cost, reach, feasibility, equity, and the likely benefit of different approaches. These choices have ethical implications. People or communities with the greatest barriers should not automatically receive less attention simply because reaching or serving them may require additional resources.

If the intervention you are planning is fairly new and there isn't yet much evidence about how it will work in your community, you might begin with a well-defined pilot group while involving community members in planning and evaluation. A pilot can help you learn and improve before expanding the effort, but participants should not be selected simply because they make success easier to demonstrate.

The table below shows how candidate personal and environmental factors can be used to help identify people and communities who may benefit from the intervention.

Use the information about the types of risk and protective factors to select promising strategies or components for the comprehensive intervention.

At this point, you have decided what you want to change or strengthen - the specific risk and protective factors your organization has chosen. You have also identified who may benefit most and who should be involved. The next step is to organize all of this information to help you develop your initiative's strategies - how you are going to get things done.

The table below shows how risk and protective factors, the people and communities involved, and strategies are all interrelated.

Using risk and protective factors to select people, communities, and strategies (components) for a comprehensive intervention

	What Candidate Risk and Protective Factors	Who People or Communities Who May Benefit	How Strategies for the Comprehensive Intervention
Personal	Knowledge and skills Knowledge Beliefs Skills Education and training	People who would benefit from additional information, education, training, or skill-building opportunities	Provide accessible information and opportunities to build knowledge and skills; engage participants and community partners in designing relevant approaches
Personal	Experience and history Experience Cultural norms and practices	People who have experienced maltreatment, discrimination, exclusion, or other barriers to achieving their goals People whose social or cultural environments may include factors that increase or reduce risk	Strengthen services, relationships, and support Expand opportunities and address barriers
Personal	Biology and genetics Existing health Cognitive, mental health, and physical functioning Chronic health conditions Age and sex or gender Genetic predisposition or family history	People living with health conditions or disabilities who may benefit from accessible services, accommodations, prevention, or other supports	Strengthen accessible services, supports, accommodations, and preventive resources
Environmental	Support and services Availability and continuity of social support and relationships Availability of appropriate services Availability of resources	People experiencing social isolation, unmet support needs, or limited access to appropriate services and resources	Strengthen services, relationships, resources, and support
Environmental	Access, barriers, and opportunities Physical access and barriers Communication access and barriers Competing requirements for participation	People facing barriers to services, participation, communication, transportation, accessibility, or opportunity	Improve access, reduce barriers, and expand opportunities
Environmental	Consequences of efforts Social encouragement and discouragement Incentives and disincentives Time costs and delays	People whose participation or choices are affected by social expectations, limited incentives or resources, work or caregiving responsibilities, time, or other competing demands	Adjust incentives, supports, expectations, and conditions to make desired actions more feasible
Environmental	Policies and living conditions Policies Financial barriers and resources Exposure to hazards Living conditions Economic hardship and inequities in resources and opportunity	People and communities experiencing economic hardship, inequitable access to resources, unsafe or unhealthy conditions, or disparities in outcomes	Modify policies, systems, resource allocation, and environmental conditions

For a concrete example of the above, consider the following example from an organization working to improve quality of life in an urban neighborhood. It lays out just a few of the group's identified risk and protective factors, the people and partners connected to them, and possible strategies. After each risk or protective factor, its category from the table above is listed in parentheses.

Risk and Protective Factors for a High Quality of Life in the Neighborhood	People, Communities, or Partners Involved	Strategies (Components of the Intervention)
Limited incentives for businesses to invest in the neighborhood (Consequences - incentives/disincentives)	Local residents, small and large business owners, economic development organizations, and public officials	Change incentives and conditions - consider targeted incentives, technical assistance, or other strategies that support businesses that meet community priorities and contribute to local economic opportunity
Lead paint and other housing hazards (Policies and living conditions - exposure to environmental hazards)	Residents of affected housing, property owners and managers, housing organizations, building inspectors, and public health agencies	Modify policies and practices - enact and enforce appropriate housing safety requirements Work with residents, property owners, building inspectors, and health departments to identify and address housing hazards
Community experience, leadership, and knowledge of overcoming barriers (Experience - protective factor/asset)	Local residents, neighborhood leaders, and community organizations	Strengthen community leadership - support resident-led advocacy, leadership development, shared decision-making, and opportunities for community members to shape policies and neighborhood improvements

In Summary

Having a solid understanding of risk and protective factors, along with the people and communities most affected by them, gives you an excellent base from which to develop strategies for your initiative. By reducing or changing important risk factors, strengthening protective factors and community assets, and addressing the systems and conditions that shape people's opportunities, your organization and its partners can work more effectively toward the outcomes the community has identified.