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

Learn how to work effectively to address the community issues in the manner you have envisioned by reducing risk factors and enhancing protective factors.

 

Have you ever wondered why some people in our communities have better outcomes than others? Why some children do well in school while other kids - equally intelligent - do not? Why different people in the same community have unequal health status? Have you wanted to 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 allows your organization to transform your community into the community 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 be partially responsible for a particular problem or desired outcome.

What are risk and protective factors? They are the aspects of a person (or group) and environment or personal 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, if a person smokes, that is a risk factor for having a heart attack. If he walks two miles a day, that's a protective factor against that same heart attack.

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 and conditions that originally caused it, and then figuring out how to change those conditions.

For example, in an effort to prevent substance use, an approach that uses risk and protective factors to direct interventions might give young people healthy activities in which to participate, positive role models, and the assertiveness training to be able to "Just say no!" when they are offered alcohol or other drugs.

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 will help your organization identify who should most benefit (the targets of change) and how to make a difference (your strategies)

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) and environment and 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.

Often, risk and protective factors can be considered flip sides of the same coin. For example, a family history of alcoholism is considered a risk factor for becoming an alcoholic. On the other hand, growing up in a family in which parents talked frankly with their children about alcohol (and didn't abuse it themselves) may be considered a protective factor. Research suggests that the greater the number of risk factors, the greater the chances of adverse outcomes on health, education, and development.

Another term used for protective factors is "assets." So-called "asset-based" approaches put the emphasis on the positive (protective), not the negative (risk), factors that contribute to outcomes. As with risk factors, research suggests that the greater the number of assets, the more likely are positive outcomes.

We generally group both risk and protective factors into two categories: those that occur in the environment (both socially and physically) and those that are personal characteristics of individuals. Let's look at the personal factors first.

Personal Factors

Personal factors are things that are unique to each individual (or group ). They include an individual's knowledge, skills, experience, history, and genetic makeup. Here is more specific information on the types of personal factors that contribute to risk and protection:

Knowledge and Skill:

• Knowledge, including knowledge about what can and should be done and its consequences, available resources
• Beliefs, such as ideas about the causes of problems or the consequences of choices
• Skills, including being able to influence your environment, set and accomplish goals, et cetera
• Education and training, such as years of formal education or specialized training

Experience and History

• Experience, such as history of abuse and neglect, care and caring, or ability to attain one's goals
• Cultural norms and practices, including what behaviors are appropriate and acceptable
• Social status, such as history of discrimination or privilege in work, social, or service situations

Biology/genetics

• Type and degree of existing health, including current health status
• Cognitive, mental or physical ability, such as the ability to process information, mobility or physical impairment, or mental illness
• Chronic illness, including requirements for care or specialized needs
• Gender and age, as they might increase risk or protection
• Genetic predisposition, such as having a family history of diabetes or alcoholism

Environmental Factors

Environmental factors are factors that affect a specific group of people in each community; they are not specific to each person. The environment refers to the conditions in which each individual lives - their household, their neighborhood or town, and the larger community. These may include aspects of the social environment, including the norms and behaviors of their families, friends, and others in their community. It also involves aspects of the physical environment, including access to resources, exposure to hazards, and overall living conditions. Environmental factors fall into the following categories:

Support and services

• Availability and continuity of social support and ties, such as with family, friends, neighbors, and those with different experiences
• Availability of appropriate services, such as for basic and specialized needs
• Availability of resources, including human and material resources

Access, barriers, and opportunities

• Physical access and barriers, including distance and physical access to services
• Communication access and barriers, including languages spoken and access to interpreters (if appropriate)
• Competing requirements for participation, including those things that make involvement difficult, such as having to work or care for children

Consequences of efforts

• Social approval and disapproval, such as whether family and peers encourage or discourage particular behaviors
• Incentives and disincentives, including monetary and material gain or loss and likely prospects for getting desired benefits
• Time costs and delays, including the time and effort for taking action, meeting needs, and getting access to services

Policies and living conditions

• Policies, such as those that affect who gets benefits, enforcement of laws, workplace policies, and eligibility requirements for services
• Financial barriers and resources, including not having enough money for needed goods and services and how resources are allocated
• Exposure to hazards, including to toxic chemicals, air pollutants, or risky situations
• Living conditions, such as the adequacy and availability of decent housing, food, clothing, heat/cooling, and clean drinking water
• Poverty and disparities in status, such as not having enough money for basic needs and disparities or differences in income and social status.

General principles about risk and protective factors

Before going further, let's look briefly at some general principles about risk and protective factors. These are things that are true for all of the "subtypes" of factors: risk and protective, personal and environmental, social and physical. Research has consistently shown us that:

• Many risk and protective factors are related to multiple community outcomes. That is, they are important factors in almost all community health and development concerns. As such, they can give you a good place to start in developing your own lists of risk and protective factors. For example, poverty is a risk factor for teen pregnancy, substance use, and inadequate access to health care. On the other hand, a child having a strong relationship with a caring adult is a protective factor against substance use, dropping out of school, committing criminal actions, and so on.

• Not all risk and protective factors are created equal. Some risk and protective factors are much more influential than others. For example, having friends who use drugs has been shown to be a very significant risk factor for a teen to start using drugs. It's a much stronger risk factor than simply having the substances available in the community. It's important to consider the relative importance of each risk and protective factor because this will help you prioritize your actions later on.
• The more risk factors a person has, the greater the likelihood they will engage in a given unhealthy behavior. And conversely, the more protective factors or assets they have in their corner, the less likely they are to engage in that behavior. For example, if you smoke heavily, eat a diet high in cholesterol, don't exercise, and have high blood pressure, it's much more likely that you will have a heart attack than if your only risk factor is a poor diet.

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 to this question depends in great part on the maturity 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 probably want to be looking critically at every one to two years, anyway.)

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 try to reduce teen 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 in their community, early bonding with parents is a protective factor for having healthy children, while dropping out of school is a risk factor for poor health. Further study showed that many students drop out of school in Lumberton Valley because of poor study skills and a limited command of English. Altogether, they were able to come up with 20 different 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 current objectives are: 1) By December 2010, to increase by 40% parent and adult time spent talking with children under 2 years of age; and 2) By 2012, to have made a 25% increase in youth graduating from high school.

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 helping children stay in school include: 1) Involving caring adults in talking with or reading to young children; and 2) Increasing the number of bilingual teachers 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 behavior change strategies (for example, providing information and enhancing skills, modifying access and barriers, and changing the consequences of certain behaviors ).

How do you identify risk and protective factors and use them to select the targets 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 supplement them with information gathered by your organization.

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 there for many of the issues of importance to your community. This includes topics such as drug abuse, cardiovascular diseases, teen pregnancy, child abuse and neglect, 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 generic and some issue-specific risk and protective factors. From there, you can do a web search, check out your local library, or call supporting state agencies, local health or education departments, or local universities.

If you already know the risk and protective factors for the problem or goal you are working on, you're halfway home. All you have to do is find the data, usually available from state agencies or city offices, to see which risk and protective factors are most important for your community and how your community compares to others. The information you find might look something like this:

Percentage of Kansans with selected risk factors for cardiovascular diseases

	Kansas	National
Sedentary Lifestyle	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 out there on the topic that you are researching. Or, you might have general information on risk and protective factors, but you also want to know which specific risk and protective factors are important in your community, or the extent to which they exist locally. Then, you'll need to use other methods to determine these particular risk and protective factors and their importance. Although they are discussed more fully in other sections of the Community Tool Box, let's touch here briefly on several ways you can develop the information you need.

• The "But why?" technique. This is a method often used to identify underlying problems that affect 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 can conclude that two possible risk factors for dropping out of school include friends who have dropped out of school and a lack of study skills. This technique is especially useful early on to bring up possibilities that can be substantiated with focus groups, surveys, or pre-existing data.

Focus groups

Focus groups can also give you a better understanding of the problem. Focus groups are made up of small groups of people with similar backgrounds so they will feel comfortable talking openly about what concerns them. The members of a group are generally about the same age, the same sex, and/or members of the same ethnic group. When you have a focus group you can ask participants what they believe contributes to risk or protection for the concern.

One advantage of focus groups is that they can give you a lot of information about how people truly feel about something and about the emotions surrounding an issue. Although a survey (mentioned below) can give you a lot of facts about what you want to do, focus groups can take those statistics and add a human face.

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 exist that 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, comparing it to national data, or by developing (or modifying) 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 directly address at all, 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 very important in order to modify a given behavior, or is it less important? For example, we said above that one of the most important risk factors for teen drug abuse is having friends who use drugs. That's probably a much stronger risk factor than is the transition of moving from junior high to high school. The strength of a given risk or protective factor can usually be determined either through existing literature, or by doing a survey of risk and protective factors, as was mentioned above.
• Can it be easily changed? Most factors fall into one of three categories, or "degrees of changeability":
  • Some risk and protective factors can be completely changed. For example, high cholesterol, which is a risk factor for cardiovascular diseases, can generally be completely changed through a strict regimen of diet and exercise.
  • Some risk and protective factors may be modified, but you are unable to change them completely. An example of this type of factor would be changing the availability of alcohol and other drugs, a strong risk factor for youth substance use. Your coalition may be able to make it harder for young people to obtain these drugs, but it is doubtful you will be able to make them completely unavailable.
  • Finally, there are some risk factors that you will not be able to affect directly. For example, a genetic link has been discovered for boys in relation to alcoholism. However, even though you can't modify these risk and protective factors directly, you do not want to ignore them. Instead, you might consider them when you are designing your strategic plan. If you know these factors exist, you can often compensate for them, at least in part, by using them to identify those who might particularly benefit from enhanced interventions. For example, you might build a mentoring program for boys with a family history of alcoholism into your program to help counteract that particular risk factor.

One way to decide which factors to target is to choose those that you found to have a very strong correlation to the risk behavior and that you can easily change.

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

It is quite common for an organization to address a mixture of risk and protective factors. How extensive your list is might be determined in large part by how many people and what other resources you have to help do the work. It's very likely that your organization is at least somewhat limited, and won't be able to target all of the risk and protective factors you have noted. Even if you can target all of them, some will have a higher priority than others. So, the bottom line is that you will have to make some hard choices about priorities.

But, remember: chances of achieving positive outcomes increase with the amount of assets/protective factors in place. So if your organization cannot do something that is sufficient to make a difference, consider forming a partnership with other groups that can supply other needed pieces.

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

Use information about who is affected by multiple risk factors to help select your "targets of change."

Once you have decided what risk and protective factors are both important and changeable, your next step is to decide whom you will target with your interventions. Often, it makes sense to aim your programs at people who you have determined are at particularly high risk for a certain problem. These are generally the people who have the greatest number of risk factors (and/or the fewest protective factors) in their corner. If you don't know who these people are, you can learn more in much the same way you gathered other information in step one - from focus groups, surveys, local health or education departments, and so on.

Other things to consider, however, might include cost factors and estimates of the likelihood of success. Would it be significantly cheaper or easier to target people who are only at a moderate risk for the health or developmental concern? These choices have ethical implications.

If the intervention you are planning is fairly new and there isn't yet much evidence of whether or not it will work, you might want to start with those who are most likely to benefit. That way, you are setting yourself up for success, and you can use that accomplishment to build on as your organization becomes more mature.

The table below shows how candidate personal and environmental factors can be used to help identify potential targets or beneficiaries of 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 (the specific risk and protective factors your organization has chosen). You have also decided whom you are going to target. 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 individuals your initiative is targeting, and strategies are all interrelated.

Using risk and protective factors to select targets and strategies (components ) for a comprehensive intervention

	What Candidate Risk and Protective Factors	Who Potential Targets or Beneficiaries of the Intervention	How Strategies for the Comprehensive Intervention
Personal	Knowledge and skills Knowledge Beliefs Skills Education and training	Those with less formal education or training	Providing information and enhancing skills (eg, of targets and agents of change)
Personal	Experience and history Experience Cultural norms and religious practices	Those with a history of neglect, discrimination, or inability to attain their goals Those with family or cultural practices that increase risk of adverse outcomes	Enhance services and support Modify opportunities
Personal	Biology and genetics Type and degree of existing health Cognitive, mental and physical ability Chronic illness Gender and age Genetic predisposition	Those with existing health impairments or physical or mental disabilities	Enhance services and support
Environmental	Support and services Availability and continuity of social support and ties Availability of appropriate services Availability of resources	Those who are socially isolated, who have specialized needs, or who lack resources	Enhance services and support
Environmental	Access, barriers, and opportunities Physical access and barriers Communication access and barriers Competing requirements for participation	Those with limited access and few opportunities	Modify access, barriers, and opportunities
Environmental	Consequences of efforts Social approval and disapproval Incentives and disincentives Time costs and delays	Those who lack social approval, incentives, or have competing requirements	Change the consequences
Environmental	Policies and living conditions Policies Financial barriers and resources Exposure to hazards Living conditions Poverty and disparities in status	Those living in poverty, with limited social status, or for whom there are inequalities in outcomes	Modify policies

For a concrete example of the above, consider the following example from an organization working to improve the quality of life in an urban neighborhood. It lays out just a few of the group's targeted risk and protective factors, targets of change, and 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	Targets (or Beneficiaries)	Strategies (Components of the Intervention)
Lack of incentives to open businesses in the neighborhood (Consequences - incentives /disincentives)	Small (and large!) business owners	Change the consequences -- Offer tax breaks to business owners who set up shop in the neighborhood
Lead paint in apartments (Policies and living conditions - exposure to environmental hazards)	Local residents	Modify policies - Enact and enforce laws regarding housing safety; Work with local building inspectors and health department to identify apartments with lead paint
Experience in overcoming obstacles/changing their environment (Experience)	Local residents	Provide information and enhancing skills -- offer advocacy training for local residents

In Summary

Having a solid understanding of risk and protective factors (and the people you target as beneficiaries) gives you an excellent base from which to develop strategies for your initiative. By reducing risk factors and enhancing the protective factors (assets) surrounding a given community issue, your organization can work effectively to address the community issues in the manner you have envisioned.