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Programs & Organizations > Chronic Disease Prevention > A Framework for Contra Costa County

A Framework for Contra Costa County

Introduction to this document

This Framework is organized into four sections:
  1. Overview, including a description of the purpose of the Framework, its intended audience, why the Framework is important, and a definition of chronic disease;
  2. Profile of the county and scope of the problem, including a demographic description of Contra Costa and a summary of local chronic disease health trends;
  3. Planning process which describes what the process entailed, the participants involved, what criteria were used in setting priorities, the risk factors to be addressed, and the target populations for prevention efforts; and
  4. Plan for action, which outlines the goals, objectives, and sample chronic disease prevention activities that local communities could undertake.

Section I: Overview

A.Why Is This Framework Important?

Chronic disease is the leading killer in Contra Costa and the single biggest cause of diminished quality of life. While it is commonly believed that chronic disease affects mostly the elderly, cancer alone, for example, is second only to unintentional injury in the years of potential life lost (YPLL) to Contra Costa residents 65 years and younger (See Appendix B, Data). Similarly, cardiovascular diseases (CVD) are the leading cause of death for those over 40 years of age.1

Most chronic diseases can be prevented or managed with early diagnosis and appropriate education and treatment. Although chronic diseases account for about two-thirds of all medical expenditures nationally, a recent study showed that state health departments allocate only about 3% of their budgets to prevention and control efforts. Local health departments typically spend even less. Those concerned with the public's health have an obligation to inform and educate themselves on this key public health issue and to work toward making chronic disease prevention and early intervention a priority.

Experience has shown that many chronic disease prevention efforts are not particularly effective, especially in high-risk, low income, ethnically diverse communities. The greatest success has been achieved using comprehensive systems approaches. Hence, this Framework goes beyond traditional approaches, which either focus on individual diseases or on single risk factors, to focus on creating an overall healthier environment that supports a spectrum of healthy choices.

The Framework developers recognized the critical links between a supportive environment and an individual's ability to successfully make difficult lifestyle changes. A supportive environment is one in which healthy messages are emphasized, health promoting policies are enacted, healthy options are made accessible, affordable and attractive, and reinforced by community norms.

B. Purpose of Framework

Mission

With chronic disease as the leading killer of Contra Costans and a major cause of diminished quality of life, education, advocacy and action to prevent chronic disease is critical. By setting out a series of goals, objectives and guiding principles, Chronic Disease Prevention: A Framework for Contra Costa County can provide a common vision for chronic disease prevention and serve as a roadmap for public health professionals working in partnership with the community to reduce chronic disease in Contra Costa County.

The overall mission of the Framework is for community residents, local government, community organizations, the Health Services Department (HSD) and others to work together to create a healthier community environment, particularly in high-risk communities. It aims to increase the ability of these communities to reduce chronic disease incidence and death by reducing their exposure to key risk factors. This will be accomplished by: (1) increasing and enhancing the environmental cues (such as advertisements and media messages) and supports that promote good health; (2) reducing the number and impact of environmental cues and supports that promote poor health; and (3) creating and strengthening community norms that support health-promoting behaviors through collaborative planning with communities, specific educational programs, media campaigns, policy and advocacy efforts, and improved economic development.

This Framework is also intended to:

  • set standards for monitoring local chronic disease prevention efforts
  • establish priorities for new programmatic areas and approaches
  • identify opportunities for partnerships between the County and the community
  • identify existing services and set priorities for filling gaps in programs and data
  • identify and improve access to funding sources

Definition of Chronic Disease

It is important to note that not everyone exposed to risk factors will acquire a chronic disease and that certain chronic diseases are more prevalent among certain communities. Genetic predisposition can also be a factor in acquiring a chronic disease. Management and prevention of chronic disease require addressing environmental factors as well as education and individual behavior.

Although chronic disease can be very broadly defined, this Framework defines it as those illnesses traditionally identified as chronic disease by the health care and research community. Framework participants hope the definition will broaden in the future when appropriate.



Section II: Profile Of County And Scope Of Problem

A.Profile of Contra Costa County

Contra Costa County is the second largest Bay Area county, encompassing 800 square miles, including the urban shoreline along San Francisco Bay as well as agricultural land in the Delta Region. The County encompasses rural farms, heavily industrialized urban areas, suburban communities, pockets of affluence and poverty and a burgeoning minority, immigrant and refugee population. 1990 Census data indicates that overall, the population has grown by 22% in the past decade, with certain groups showing dramatic increases. Between 1980-1990, the Asian/Pacific Islander population grew 144.5% and the Latino population 62.5%.2

West Contra Costa County, which includes the City of Richmond, contains the highest concentration of ethnic minorities. Fully 70% of the African American population, 43% of the Asian and Pacific Islanders and 30% of Latinos live in this area. South County is predominantly Caucasian, with people of color constituting barely 10% of the communities there. Although Central County is 80% Caucasian, there are significant pockets of poverty and ethnic concentration. One third of the county's Latino population lives in East Contra Costa County.

B. Local Chronic Disease Trends

Chronic diseases account for 78% of all deaths in Contra Costa, resulting in over 3,500 deaths per year.3 While the death rate for heart disease has declined, other chronic diseases are a growing problem in the county:

  • The county's cancer death rate is higher than the state average (based on preliminary age-adjusted rates from the Cancer Surveillance Section). Among the 15 most populous counties in California, Contra Costa ranked second in incidence rate for breast, ovarian, and prostate cancers. Although incidence rates for breast cancer are highest among White women, the death rate from breast cancer is higher for African American women.
  • Death rates from cardiovascular and respiratory diseases are higher than statewide rates and are rising. The rates for women dying of these diseases are increasing.
  • Richmond, Pittsburg, and Antioch have significantly higher hospital discharge rates for chronic diseases than other cities and the county overall. Richmond's rate of hospitalization for female reproductive cancers is more than double the county's overall rate.


Section III: Process For Developing The Framework

This Framework represents three years of research and development by the County Health Services Department's Public Health Division and the Public and Environmental Health Advisory Board (PEHAB), with input from residents and community leaders throughout the county. The incentive came from PEHAB's 1992 Health Status Report, which recommended the development of a comprehensive chronic disease prevention framework for Contra Costa. The Chronic Disease Subcommittee of PEHAB was formed (see Appendix A for list of members), and together with Public Health Division (PHD) staff of the Health Services Department (HSD), the group began to develop a framework.

A.Steps in Framework Development

The steps involved in developing this Framework included: (1) collecting and reviewing existing health and risk factor data by the Subcommittee to determine population groups and regions of the county at greater risk for chronic disease; (2) a planning retreat (involving an expanded group of community members, PEHAB members, Health Department staff, and representatives of the State Department of Health Services) to get input and begin identifying overall strategies and approaches; and (3) follow-up meetings with residents and community leaders in key regions of the county to further refine and prioritize strategies for improving the health of communities. A detailed account of the data on which the original planning was based and the outcome of the two planning meetings. Updated data on chronic disease in the County, compiled in October 1996, is included in Appendix B.

B.Defining Chronic Disease

The first major point of discussion in the early phases of planning was how to define chronic disease. At the planning retreat, it became clear that many members of the community define chronic disease somewhat differently than many health care providers. Participants agreed that the scope of the definition is limited by available data and the fact that funding for programs and services tends to be narrow and specific. Thus, as availability of data and funding priorities change over time, the proposed definition may need to be revised and expanded. The definition of chronic disease, as used in this Framework, is found on page 2.

C.Risk Factors

Risk factors are genetic or environmental factors that are likely to increase an individual's susceptibility to disease. Researchers have identified several factors that place someone at greater risk for chronic disease, including: tobacco exposure, high-fat diet, lack of regular physical activity, poverty, and for some chronic diseases, air pollution or long-term exposure to certain cancer-causing substances. Since most chronic diseases share several of these risk factors, prevention efforts that reduce these common risk factors can reduce the rates of many chronic diseases simultaneously.

Using the above list as a starting point, retreat participants brainstormed a long list of risk factors at the retreat. Afterward, they prioritized six risk factors to be addressed in the chronic disease prevention framework:

  • Unhealthy environment, including exposures to environmental toxins in the community and work setting, and inadequate access to healthy messages, activities, programs, and products
  • Poor diet/nutrition
  • Lack of regular physical activity
  • Low socioeconomic status (income/level of poverty, education, occupation)
  • Stress
  • Tobacco exposure

In addition to the risk factors, community participants noted the importance of strengthening protective factors that have positive health effects on a community. These include individual self esteem, strong sense of community, and a network of social support.

A brief description of each of the six factors follows:

1.Lack of Access to A Healthy, Toxic-Free Environment, and Healthy Messages, Activities, Programs & Products:
A healthy community can be defined as one that combines a clean and safe physical environment with a social and political setting that promotes and encourages healthy lifestyle choices through positive health messages, health promotion and health protection policies, availability of affordable healthy products and activities, and accessible prevention programs and screening services.

Although the impacts are sometimes difficult to quantify, exposures to toxins, either in the community or work environment, are often linked to chronic disease. Nationally, studies have shown an increase in the number of deaths from heart disease on days with high levels of air pollution.4 People in certain occupations are also at higher risk of chronic disease, either because of extreme stress or occupational exposures to carcinogens and other toxic agents. For example, bus drivers with high rates of self-reported stress have higher rates of gastro-intestinal and musculo-skeletal complaints.5 Similarly, workers in the shipbuilding industry and in oil refinery construction and maintenance have suffered high rates of asbestos-related cancer and lung disease.

Within Contra Costa, certain neighborhoods contain a disproportionate number of hazardous materials industries, particularly oil refineries. Residents and workers are extremely concerned about the health impacts of exposures to toxic chemicals that are either routinely or accidentally released from these facilities. Numerous small businesses located throughout the county also handle lead and other toxic substances; if handled or disposed of improperly, these can lead to community exposures.

Limited access to health-promoting services, including early medical screening and prevention programs, as well as restricted access to healthy products, activities and messages were major environmental risk factors identified in the planning. Low income communities with limited access to healthy choices often have a high concentration of unhealthy choices readily available. For example, many of these neighborhoods have easy access to low nutrient, high calorie foods but have inadequate access to a nutritious diet; similarly, in many neighborhoods, youth can get tobacco easily, but don't have a safe place for physical activity.

2.Poor Diet: Current evidence strongly suggests that diets high in fat (especially saturated fat), cholesterol, and sodium, and low in fiber, fruits and vegetables, contribute significantly to chronic diseases.6 Recent figures attribute 35% of all cancers and 20-30% of all premature heart disease to diet.7 The average American consumes a high-fat diet, with about 37% of total calories from fat, and consumes fewer than three servings daily of fruits and vegetables.8

Many factors contribute to a poor diet. First, low nutrient, high calorie foods are heavily advertised and readily accessible, particularly in low income neighborhoods.9 Second, many people lack access to accurate and culturally appropriate nutrition information. Third, a large number of Contra Costa residents are "food insecure" - that is, they must resort to charitable emergency food sources for sufficient healthy food, often because food and cash assistance benefits are insufficient and/or because affordable, nutritious food is lacking in their neighborhoods. In 1991, only 59% of those eligible for food stamps in this county were being served, indicating that many people eligible for food stamps did not receive them. Also, the number of people requiring food assistance has grown dramatically. Between 1987 and 1992, service at charitable emergency food pantries nearly doubled.10

Current dietary guidelines from the U.S. Community Nutrition Institute include the following:

  • Balance the food eaten with physical activity, to maintain or improve weight
  • Choose a diet with plenty of grain products, vegetables, and fruits
  • Choose a diet low in fat, saturated fat, and cholesterol
  • Eat a variety of foods
  • Choose a diet moderate in sugars, salt and sodium
  • Consume alcoholic beverages in moderation, if at all11

3.Insufficient Physical Activity:
Despite evidence demonstrating that regular exercise reduces rates of chronic disease, most Americans don't meet current minimum recommendations. A 1989 article in the Journal of the American Medical Association found death rates for women of "low fitness" 16 times higher for cancer and eight times higher for cardiovascular disease compared to women of "high fitness." For men of "low fitness," death rates are five times higher from cancer and eight times higher from cardiovascular disease, compared to men of "high fitness." Additionally, a study involving more than 10,000 men found that involvement in a moderately vigorous sports program reduced risk of death by 23%.12 Yet in 1994, half of all Californians surveyed said they did not exercise regularly, and 23% reported they got no exercise. (California Behavioral Risk Factor Survey, 1994 Update. California Department of Health Services, Cancer Surveillance Section)

Local factors that contribute to a sedentary lifestyle include the ready availability of automated transportation, long commutes to jobs, expensive fees at private fitness clubs, lack of security at many public parks and facilities, and the need for additional work-site exercise promotion programs.

Current federal recommendations for minimum exercise are 30 minutes of physical activity, accumulated throughout the day, on at least five days each week (Centers for Disease Control and Prevention and the American College of Sports Medicine).

4.Low Socioeconomic Status (SES):
Low socioeconomic status (as measured by low income or low educational level) is a consistent and powerful predictor of chronic diseases such as heart disease, regardless of behavioral risk factors status and access to health care.13 Communities with lower educational and income levels suffer disproportionately higher rates of many other chronic diseases including cancer, diabetes, and asthma than more affluent communities.14 In Contra Costa, regions with the highest rates of hospital discharge for chronic diseases are also those with the lowest socioeconomic status.

5.Stress:
Stress was defined by the retreat participants to include fear, depression, racism, sexism, homophobia, post-traumatic stress, and the impact of California's Proposition 187 on immigrants (this proposition denies health care and many other basic services to undocumented immigrants).

Studies have shown that people who lack social and community ties were more likely to die early than those with more extensive contacts. These findings are independent of self-reported physical health status, socioeconomic status, and health practices (such as tobacco use, alcohol use, obesity, physical activity, and use of preventive health services).14

6.Tobacco Exposure:
Tobacco use and second-hand smoke exposure are among the leading preventable causes of premature death due to cancer and cardiovascular disease. Contra Costa County adults currently smoke at a slightly higher rate (16%) than the state average (just over 15%). Of all groups compared, non-Hispanic white adolescents have the highest rate of smoking prevalence in the county, at 25%. Use of smokeless tobacco is also more prevalent among 18 to 30 year old males in Contra Costa, with prevalence rates of 8.5%. There is also a new trend toward smokeless tobacco use among Hispanic males in the county.15

Despite considerable gains in other areas in the last seven years, smoking prevalence among youth has increased, and the average age of first tobacco use has declined to age nine. Current problems include tobacco use portrayed by the media and advertisers as glamorous behavior, neighborhoods targeted for billboards advertising tobacco, and tobacco that is frequently more accessible than healthy foods in these areas.

D. Populations at Risk

Another major discussion at the sub-committee meetings and at the retreat was the identification of priority groups for prevention efforts. Given limited resources, it was decided to focus efforts on those most at risk including groups with high incidence of chronic diseases, increased exposure to risk factors, or who experience significant barriers that delay their seeking early screening care. An initial list was determined based on a review of local hospital discharge and other health data and the California Behavioral Risk Factors Survey data. Community members who reviewed this list added other groups which, while not identifiable through available health data, are nonetheless at increased risk for chronic disease: immigrants; women aged 50 to 65 (noted as a key time for prevention efforts); families; the working poor; and gays and lesbians. Community members also noted the potential danger of stigmatizing and ostracizing particular groups, such as immigrants, when acknowledging their higher rate of chronic disease. Focus must be maintained on identifying those environmental factors such as the stresses of relocation and acculturation that place certain groups at higher risk.

As a result of this input, the following expanded list describes the priority groups for the Framework:

  • African Americans, Latinos, and Southeast Asians
  • Children and youth
  • Gays and lesbians
  • Immigrants
  • Low income and working poor
  • Pregnant women, especially smokers and other substance abusers
  • Residents of the city of Richmond and its unincorporated areas, as well as San Pablo, Pinole, Pittsburg, and Antioch
  • Women over the age of 50

E.Gaps in Chronic Disease Prevention Programs

As the first step to becoming more responsive to community concerns, strengths, resources, and priorities, the planning group spent considerable time getting feedback on the current chronic disease prevention activities within the Public Health prevention programs, and on creating a set of guiding principles for future efforts.

The most pressing gaps identified in current approaches to chronic disease prevention were:

  • Lack of proven effective strategies:
    Evaluation of prevention efforts has been difficult because of the long lag time between exposure and development of chronic diseases and the lack of good local health data and lifestyle trend information.
  • Need for integration:
    Chronic disease prevention should be integrated into existing community programs and institutionalizedinto Health Services Department-wide activities.
  • Unavailability of long-term and flexible funding sources:
    Funders need to make a long-term commitment to provide ongoing chronic disease prevention funding and create flexible funding guidelines that allow programs to respond to emerging and urgent community-identified needs. Categorical funding needs to be replaced by more comprehensive approaches.
  • Failure to address poverty and low socioeconomic status as key risk factors:
    Individual change needs to be addressed in the context of environmental support for healthy behavior. In particular, steady employment is critical to an individual's ability to make healthy choices.
  • Lack of culturally appropriate health messages and health options:
    Not only must messages be communicated in the native language of the target audience, but low literacy and non-literacy must be addressed, and cultural norms and practices must be respected. One component to helping people make healthy choices is to offer a range of options that would appeal to a variety of cultures.

A number of these gaps are addressed through the goals described in Section IV.

F.Guiding Principles for Chronic Disease Prevention Efforts

Although local chronic disease prevention program efforts have usually been constrained by categorical funding (such as tobacco prevention or breast cancer), this Framework builds on a number of successful strategies and approaches that have already been developed. The Health Services Department's Tobacco Prevention Program, Breast Cancer Partnership (BCP), and Lead Poisoning Prevention Program (LPPP), for example, have forged strong partnerships with schools, businesses, community-based organizations, advocacy groups and the faith community. The County's Tobacco Prevention Program used a county-wide coalition approach, coupled with local neighborhood mobilization campaigns, to drive a successful roll-out of 16 local tobacco control ordinances in five years, despite intense opposition from the tobacco industry. LPPP and the BCP have used mini-grants, hands-on training and technical assistance to tailor education and prevention to specific population groups and to integrate prevention efforts in established and trusted community-based organizations. The Healthy Neighborhoods Project (HNP), which utilizes community assessment mapping as an organizing tool to help residents define their own health concerns and develop action plans, has tapped a talented, diverse, and committed group of local health advocates. HNP's efforts have led to more effective use of existing resources and networks.

Combining the successful elements of current programs with the identified gaps, planners articulated five guiding principles that need to be incorporated into all chronic disease prevention efforts. (Appendix D includes more specific examples for each principle.) A clear message was delivered that the Health Department, in particular, needs to continue to expand its commitment to these principles:

1.Maximize Community Involvement and Strengthen Community Capacity to Reduce Chronic Disease:
Community residents and leaders will be involved in determining local chronic disease priorities and approaches and in developing and delivering prevention education activities. This will help insure that activities reflect the cultural diversity of local communities and tap into their own strengths and resources. The Health Services Department and others will also work through existing community agencies, organizations, neighborhood groups, and formal and informal networks to deliver programs and services at the community/neighborhood level. Efforts will be made to tap into existing community events and gathering places, such as churches, community centers, day care centers, and schools. Local agencies will be recruited to conduct neighborhood and regional outreach efforts.

2.Foster Health Services Department-Community Partnerships:
Through the initial planning process, a number of priority partnership opportunities were identified for the HSD and the community. Potential partners include schools, workplaces, the faith community, housing authorities, tenant councils and other neighborhood groups, businesses, unions, and existing collaboratives such as Healthy Start or Healthy Neighborhoods Project. See Appendix D for examples of activities for various proposed partners.

3.Promote Community Economic and Employment Development:
PHD/HSD and others who work with this Framework should incorporate job training and employment opportunities for community residents into their own chronic disease prevention programs, and serve as a resource and provide technical assistance for the types of partnerships illustrated above. Several HSD programs have begun providing employment opportunities to community residents through individual stipends for community workers and mini-grants or short-term contracts with community-based organizations. However, these strategies do not necessarily build long-term community capacity or create permanent jobs. Specific recommendations for HSD to begin creating institutionalized employment opportunities are located in Appendix D.

4.Utilize Media Advocacy Strategies:
Media strategies should focus on (1) countering environmental cues that promote poor lifestyle choices, especially among youth and communities of people of color, and (2) reducing the volume of negative messages. Media advocacy should use popular media channels and ethnic networks. Messages need to be simple, easy to remember, and contain positive themes that acknowledge the strengths of the community.

5.Advocate for Policies That Protect Public Health:
The focus of the health field should be redirected to put more emphasis on prevention strategies. Policy makers should be educated on an expanded definition of a healthy community that incorporates quality of life indicators. Advocacy for legislation and policies that protect the public's health and create environmental support for healthy behaviors need to be included in every program seeking to prevent chronic disease through reduction of risk factors.

Local policy changes could include; (1) restricting advertising and billboards that carry unhealthy promotions and messages; (2) improving access to healthful options such as farmer's markets and exercise facilities; and (3) improving access to early cancer detection and other early screening services. Organizational and institutional changes that foster and encourage lifestyle changes must also be included. Workplace incentives for people to maintain good health are needed. For example, work sites could promote exercise for employees (by offering longer breaks for exercise) and small employers could obtain assistance in buying health insurance for their employees at discounted rates.



Section IV: Contra Costa Chronic Disease Prevention Framework

A. Risk Factor Goals and Desired Outcomes

This Framework provides a series of six goals, corresponding to each of the risk factors identified previously, for chronic disease prevention in the County. Each goal is followed by a list of desired outcomes and suggested activities for achieving that outcome. The goals and activities that follow are purposefully broad, to allow communities creativity in developing programs that respond to their specific situations. They incorporate the guiding principles described in Section 3 and attempt to address the gaps identified in existing programs. The HSD will create a companion piece to this Framework which will specify those activities, including outcome and evaluation measures, for which it would be the appropriate lead agency.

1.Access to A Healthy Toxic-Free Environment and to Health-Promoting Services, Messages, Activities, Programs and Products

Goal

Reduce the impact of chronic disease risk factors, particularly in high-risk communities, through reductions in exposures to environmental toxins in the community and workplace, improved access to healthy messages, activities, programs, and products, and decreased access to unhealthy influences.

Desired Outcomes
  1. Increased volume of positive health messages and decreased volume of negative messages in the community leading to increased awareness of and support for health-promoting behaviors, policies and choices
  2. Reduced barriers (e.g. cost, transportation problems, unavailability of child care, cultural insensitivity, non-user friendly language) to community using health-promoting services, programs, products and activities
  3. Improved community awareness and use of health-promoting programs, including: a) early medical screening and prevention education programs; b) healthy products, such as affordable, accessible, and nutritious food choices; and c) safe outdoor places for physical activity and work site exercise programs
  4. Reduced availability of unhealthy activities and products, particularly in low income and ethnically diverse communities, and among youth, seniors, and pregnant women
  5. Decreased exposure to environmental toxics in the community and in the workplace
  6. Increased number of partnerships with local and county community economic development group which will encourage planning and development policies that support local businesses that provide healthy products, activities and services for residents, and which do not pollute the environment
Examples of new activities to achieve these outcomes:
  • Work with communities and local policy makers to promote and fund policies and programs that support healthy behaviors through education, protective public health policies, improved access to healthy lifestyle options, preventive and early screening health care services, institutional incentives, etc.
  • Work with local governments and community development agencies to create and promote local development plans that will: (1) decrease access to unhealthy products, e.g., tobacco and alcohol; (2) increase access to healthy products, e.g., fresh food outlets, particularly in low income communities, and among children, youth, and seniors; and (3) increase funding for community-based prevention and education programs.
  • Work with local health care providers, local government, and communities to increase access to preventive and early screening programs for cancer, diabetes, hypertension, and other chronic diseases by providing transportation and child care options, decreasing language barriers, and making services affordable.
  • Work with communities, local government, media and others to educate the public and advocate for policies that will reduce or restrict the number of unhealthy messages in high-risk communities, such as tobacco-promoting billboards or other advertisements near schools or in low income communities.
  • Work with local media to encourage coverage that educates the public, promotes positive health messages, and counters unhealthy messages.
  • Work with various sectors of the community to institutionalize risk factor education and risk factor reduction policies, e.g. schools incorporating nutrition education and healthy food options on site, employers developing work site exercise programs with incentives for participation, and PTAs conducting education on second hand smoke.

2.Increasing Physical Activity

Goal

Reduce the impact of chronic disease risk factors, particularly in high-risk communities, through reductions in exposures to environmental toxins in the community and workplace, improved access to healthy messages, activities, programs, and products, and decreased access to unhealthy influences.

Desired Outcomes
  1. Increased volume of positive health messages and decreased volume of negative messages in the community leading to increased awareness of and support for health-promoting behaviors, policies and choices
  2. Reduced barriers (e.g. cost, transportation problems, unavailability of child care, cultural insensitivity, non-user friendly language) to community using health-promoting services, programs, products and activities
  3. Improved community awareness and use of health-promoting programs, including: a) early medical screening and prevention education programs; b) healthy products, such as affordable, accessible, and nutritious food choices; and c) safe outdoor places for physical activity and work site exercise programs
  4. Reduced availability of unhealthy activities and products, particularly in low income and ethnically diverse communities, and among youth, seniors, and pregnant women
  5. Decreased exposure to environmental toxics in the community and in the workplace
  6. Increased number of partnerships with local and county community economic development group which will encourage planning and development policies that support local businesses that provide healthy products, activities and services for residents, and which do not pollute the environment
Examples of new activities to achieve these outcomes:
  • Work with communities and local policy makers to promote and fund policies and programs that support healthy behaviors through education, protective public health policies, improved access to healthy lifestyle options, preventive and early screening health care services, institutional incentives, etc.
  • Work with local governments and community development agencies to create and promote local development plans that will:
    (1) decrease access to unhealthy products, e.g., tobacco and alcohol;
    (2) increase access to healthy products, e.g., fresh food outlets, particularly in low income communities, and among children, youth, and seniors; and
    (3) increase funding for community-based prevention and education programs.
  • Work with local health care providers, local government, and communities to increase access to preventive and early screening programs for cancer, diabetes, hypertension, and other chronic diseases by providing transportation and child care options, decreasing language barriers, and making services affordable.
  • Work with communities, local government, media and others to educate the public and advocate for policies that will reduce or restrict the number of unhealthy messages in high-risk communities, such as tobacco-promoting billboards or other advertisements near schools or in low income communities.
  • Work with local media to encourage coverage that educates the public, promotes positive health messages, and counters unhealthy messages.
  • Work with various sectors of the community to institutionalize risk factor education and risk factor reduction policies, e.g. schools incorporating nutrition education and healthy food options on site, employers developing work site exercise programs with incentives for participation, and PTAs conducting education on second hand smoke.

3.Increasing Physical Activity

Goal

Build and sustain a community environment that supports incorporating moderate exercise into daily activities for children, adults, and seniors.

Desired Outcomes
  1. Increased awareness and commitment in the community and among policy makers to the value of daily physical activity to prevent chronic disease and improve health
  2. Increased number of policies and programs promoting regular physical activity in communities and the workplace
  3. Increased number of adults, including seniors, in priority low income communities who engage in regular light to moderate physical activity through increased availability, accessibility, and attractiveness of physical exercise opportunities
  4. Increased number of children who engage in daily moderate-level physical activity
Examples of new activities to reach these outcomes:
  • Make information available to neighborhood groups, churches, resident councils, and other formal and informal community networks, on alternative ways to be physically active and on local physical activity resources.
  • Work with employers and health plans to develop physical activity promotion and incentive plans.
  • Assist community and faith groups in developing and promoting family-centered and singles-oriented physical activity events and in incorporating physical activity opportunities into existing events.
  • Inventory community-wide physical education curricula and activities. Publicize successes and work with others on ways to increase their efforts.
  • Work with residents, Park and Recreation Departments, neighborhood watch groups, local elected officials and others to improve attractiveness and safety of local parks and other open spaces through installment and maintenance of good lighting, clean-up efforts, and other safety and maintenance measures.
  • Develop social marketing and other campaigns to promote the importance of physical activity and to publicize successful efforts.
  • Work with schools and community colleges to develop and promote physical activity programs for youth and adults.

4.Improving Socioeconomic Status and Overall Health Status

Goal

Incorporate into the plan strategies and methods that will improve the socioeconomic status of low income communities, thereby improving their overall health status.

Desired Outcomes
  1. Increased number of job training opportunities in the health field through integration of job training for local residents into 50% of all newly funded chronic disease programs
  2. Increased number of local residents who are better prepared for the job market as a result of participation in educational and skill building training events in the health field
  3. Increased number of formal working relationships/partnerships between community and economic/business interests to provide opportunities such as job training and mentoring programs
  4. Increased number of local businesses employing community residents
Examples of new activities to reach these outcomes:
  • Incorporate stipended internships or paid positions into all newly funded HSD chronic disease prevention proposals, prioritizing applicants in the following manner:
    (1) low income residents of the target community, including youth; (2) low income residents of the region; and (3) low income residents of Contra Costa.
  • Create partnerships and mobilize communities to advocate for policies that ensure health coverage and adequate income for all residents.
  • In writing grants or developing new chronic disease programs, include activities that support local economic development opportunities.
  • Assist local employment development programs and health agencies in securing funding to create or expand health-related job training and internship programs, especially in chronic disease prevention.
  • Explore potential partnerships with Community Redevelopment Agencies, Housing Authorities, Employment Development Department, Private Industry Council, developers and others, to help secure funds and provide technical assistance to potential and existing businesses to assist them in offering services that promote healthy lifestyles and counter risk factors for chronic disease. Businesses might include local grocery stores, farmer' markets, local catering businesses, physical activity and recreation centers, non-alcoholic social centers, etc.

5.Stress Management

Goal

Strengthen the community's overall ability to respond to stress by enhancing the capacity of families, adults and children to manage stress.

Desired Outcomes
  1. Increased community capacity to respond to stress through identification of community networks and resources, development of shared sense of communities, and mobilization of community resources to support individuals and family
  2. Increased skills of individuals, and families to identify and manage personal stress effectively
Examples of new activities to reach these outcomes:
  • Incorporate stipended internships or paid positions into all newly funded HSD chronic disease prevention proposals, prioritizing applicants in the following manner: (1) low income residents of the target community, including youth; (2) low income residents of the region; and (3) low income residents of Contra Costa.
  • Create partnerships and mobilize communities to advocate for policies that ensure health coverage and adequate income for all residents.
  • In writing grants or developing new chronic disease programs, include activities that support local economic development opportunities.
  • Assist local employment development programs and health agencies in securing funding to create or expand health-related job training and internship programs, especially in chronic disease prevention.
  • Explore potential partnerships with Community Redevelopment Agencies, Housing Authorities, Employment Development Department, Private Industry Council, developers and others, to help secure funds and provide technical assistance to potential and existing businesses to assist them in offering services that promote healthy lifestyles and counter risk factors for chronic disease. Businesses might include local grocery stores, farmer' markets, local catering businesses, physical activity and recreation centers, non-alcoholic social centers, etc.

5.Stress Management

Goal

Strengthen the community's overall ability to respond to stress by enhancing the capacity of families, adults and children to manage stress.

Desired Outcomes
  • Increased community capacity to respond to stress through identification of community networks and resources, development of shared sense of communities, and mobilization of community resources to support individuals and family
  • Increased skills of individuals, and families to identify and manage personal stress effectively
Examples of new activities to reach these outcomes:
  • Provide support to community groups in establishing and maintaining social support settings, such as parks, community centers, etc.
  • Develop programs and activities that create stress buffers for children, such as recreational opportunities, adult mentors, etc.
  • Identify and publicize Information and Referral sources in the community that will help people find available resources to manage life and stress.
  • Work with family-focused programs such as Healthy Start, Head Start, and related services to integrate stress management into adult curricula.
  • Incorporate stress management techniques into physical activity, tobacco, and nutrition programs where appropriate.
  • Educate health care providers, teachers, day care providers and other providers to identify and make referrals for stress management assistance in interactions with individuals, parents, and families.
  • Use community mapping and other methods to identify environmental stressors and community resources, and to develop strategies to reduce stresses and enhance resources.

6.Reducing Tobacco Exposure

Goal

Eliminate the impact of tobacco exposure through integration of tobacco prevention efforts into HSD, the community, and local government agencies.

Desired Outcomes
  1. Reduced impact of environmental tobacco smoke
  2. Reduced youth access to tobacco
  3. Reduced pro-tobacco influences, especially in low income communities, and on girls and women
Examples of new activities to reach these outcomes:
  • Develop a comprehensive policy to reduce the impact of tobacco on Contra Costa youth through increased cues to promote smoke-free lifestyles, youth cessation programs, mobilization of the school community and other measures.
  • Direct prevention and education to pregnant women and others in the community by working with women's health programs to incorporate tobacco prevention information and raise awareness about the hazards of environmental tobacco smoke.
  • Provide training and technical assistance to community-based organizations and county agencies on policy, media advocacy and tobacco information, and encourage and monitor their adoption of activities into their ongoing work.
  • Initiate media advocacy campaigns and events to increase awareness and advance policy initiatives.
  • Mobilize schools to create related policy changes, reduce youth consumption, and institutionalize tobacco prevention curricula.
  • Advocate for statewide policy change, such as raising the tobacco tax.

Section V: Evaluation Measures

The Spectrum of Prevention is one way that the Community Wellness & Prevention Program organizes its activities and evaluates its public health efforts. The Spectrum describes six levels of intervention aimed at different segments of the community:

  • Elected officials and other policymakers: Create new laws or regulations that protect the public's health.
  • Organizations and Institutions: Develop organizational practices, policies, and incentives that will support healthy behaviors and reduce environmental hazards. This area often overlaps with policy and legislation.
  • Coalitions and Networks: Work with community organizations, businesses, the faith community, providers, and others to develop broad-based prevention efforts through joint planning and coordination.
  • Providers: Recruit, educate, and provide training to health care and other service providers to enhance efforts to reduce risk for chronic diseases.
  • Community/Media: Raise the level of awareness of chronic disease in communities including educating the media regarding important chronic disease prevention messages.
  • Individual: Increase people's knowledge and skills so they will adopt healthy behaviors and reduce their risk of chronic disease.

Successful chronic disease prevention initiatives require collaboration and intervention at several of these levels simultaneously to build the necessary critical mass of support. The following chart describes the outcomes expected as a result of implementing the Framework, indicates which level(s) of the Spectrum of Prevention need to be targeted, and lays out examples of potential measures to evaluate our success.

EVALUATION CRITERIA Level of Intervention
Sample Outcomes of Intervention Individual Community/Media Providers Coalitions/Networks Org/Inst/Policy

Outcome: Increase in availability of health-promoting products, activities, and programs

Possible Measures: increased number of outlets selling affordable, healthy foods; increased number of exercise opportunities; and increased employment training programs for residents

   
X
     
X

Outcome: Increased number of health-promoting messages in communities

Possible Measures: more billboards advertising healthy choices, new ad campaign messages that support healthy behaviors

   
X
       
X

Outcome: Decrease in unhealthy environmental cues (messages and products)

Possible Measures: reduced number of alcohol and fast food outlets, reduced number of tobacco billboards in target regions

   
X
       
X

Outcome: Decreased environmental toxins in the workplace and in neighborhoods

Possible Measures: reduction in number of community and workplace "incidents" of toxic release; fewer cars, and increased use of less polluting means of transportation

   
X
   
X
 
X

Outcome: Increased funding for comprehensive chronic disease prevention

Possible Measures: more funders prioritizing broad chronic disease prevention efforts; increased number of new grant-making efforts in chronic disease prevention among private foundations and government agencies

           
X
 
X

Outcome: Increased incorporation of chronic disease prevention into workplace and economic development policies

Possible Measures: increase in the number of policies that support physical activity, healthy diet, stress reduction, tobacco cessation; and local business agreements to hire neighborhood residents

             
X

Outcome: Increased awareness of chronic disease issues, risk factors, and impact in the community

Possible Measures: greater number of community events incorporating chronic disease prevention education; increased knowledge among community leaders about impact of chronic disease in their communities; greater community mobilization around local initiatives impacting chronic disease risk factors

   
X
   
X
 

Outcome: Increase in media coverage and messages around chronic disease prevention.

Possible Measures: increased number of articles emphasizing prevention, risk factors; increased number of media requests for information on chronic disease prevention; more accurate framing of chronic disease prevention and risk factor reduction

   
X
       
X

Outcome: Increased involvement by activist, volunteer, faith, business, and community-based organizations

Possible Measures: more organizations incorporate chronic disease prevention into their mission and priorities; more participation in chronic disease prevention activities by new groups; and increased number of requests from new groups for chronic disease prevention education

           
X
 

Outcome: Increased number of health care providers giving comprehensive chronic disease prevention education and screening for risk

Possible Measures: development of protocols for broader risk factor screening; more health care providers requesting materials and participating in chronic disease prevention and training

 
X
   
X
   
X

Outcome: Decrease in risk factor behaviors.

Possible Measures: increased number of residents who have reduced dietary fat and increased consumption of fruit and vegetables; decreased number of people using tobacco; and increased number of people exercising regularly

 
X
 
X
 
X
   
X

Section VI: Role Of The Health Services Department/CW&PP In Carrying Out Framework

The success of the strategy outlined in this Framework depends upon our ability to tap the unique skills, perspectives, and experiences of a broad spectrum of stakeholders. Local health departments can play a key, although not solo role in the advancement of the chronic disease prevention agenda. The Contra Costa County Health Services Department (CCHSD) serves an important function in: (1) acting as convener and catalyst to mobilize the various segments of the community on chronic disease issues; (2) helping define and addressing community-identified concerns; (3) providing a public health perspective to the issue raised; (4) maintaining the multi-cultural context which advocates for all groups; and (5) developing a comprehensive overall approach that weaves individual neighborhood's interests with broader community health interests.

The CCHSD is already involved in chronic disease prevention education, early screening, and disease management programs. This Framework will focus more intensely on broader risk factor reduction and expand the efforts into the general Contra Costa community. HSD and CW&PP staff bring to this partnership their expertise in chronic disease prevention and general public health issues and trends, as well as their skills in building coalitions, developing sound health service and prevention programs, and evaluation. In several of the risk factor areas, however, the HSD is not the expert. Its strength lies in its ability to bring key partners together, to facilitate a process of identifying common goals and potential collaborations, to assist in finding funds, and to provide training and technical assistance in the relevant health issues to those groups new to the field. Where specific risk factors are being addressed by CW&PP programs, such as diet and nutrition, physical activity and tobacco exposure, a separate companion plan which outlines these activities is being developed.

Section VII: How Can You Get Involved In The Framework?

Here are some ways everyone can help create a healthier community and workplace environment and reduce the impact of risk factors that lead to chronic disease:

  • Have a discussion about the Chronic Disease Framework at your place of worship, neighborhood association, tenant's group, or with other groups or networks. We can provide a facilitator to help your group find ways to get involved.
  • Get your workplace to adopt some of the policies, programs, or activities outlined in the Framework. Examples might include a healthy food choices policy, exercise incentive program or on-site exercise program, stress management or other support program, smoking cessation program, etc.
  • Get your organization to adopt a part of the Framework in your community. We can help you figure out the best way to get involved.
  • Organize your friends, neighbors, and others to support the Framework. Write letters to public and elected officials and the media, letting them know this issue is a priority.
  • Join a local task force or advisory group working on chronic disease issues, such as the Public and Environmental Health Advisory Board, Tobacco Prevention Coalition, and the Food and Nutrition Policy Consortium.

Suggested Actions For Specific Groups

  • Policy Makers and Elected Officials: Incorporate chronic disease prevention and risk factor reduction into proposed policies or planning efforts. Adopt one or more of the policies mentioned in the Framework. Direct some local government resources or other support to chronic disease prevention efforts.
  • Business Community: Initiate policies or programs that encourage healthy choices or activities among your employees (e.g. - healthy food choices on-site, exercise incentives, and workplace programs). Support job training programs or economic development efforts such as those described in the Framework. Partner with community agencies and the Health Services Department to develop plans for local businesses that would employ area residents. Mentor other businesses willing to get involved.
  • Providers: Advocate for, support, and attend provider training on chronic disease prevention and risk factor reduction approaches. Incorporate more risk factor assessment, education, and referrals into protocols, procedures, and screening forms for clients.
  • Media: Become more informed about chronic disease issues, programs, and relevant policies in this county. Pursue stories that will convey chronic disease prevention and risk factor reduction messages. Put health stories into the context of risk factor prevention.
  • Health Services Department and other County Agencies: Identify links between your program's efforts and the activities proposed in the Framework. For agencies not typically involved in direct health care, such as Community Development, Housing Authority, Employment Development, etc., initiate discussions to identify potential interfaces and opportunities to collaborate on chronic disease prevention. Our staff is available and interested in meeting with you to explore these further.

References

  1. CORE Profiles, Deaths from Heart Disease & Stroke in California Counties, Report #3, 1996.
  2. Gasiaroiocz, Chiang et al. Contra Costa County: Profile of Ethnic & Immigrant Populations. Newcomer Information Clearing House. May, 1994.
  3. Morgan, M.A., "1992 Status of Health in Contra Costa County," produced by PEHAB.
  4. Dockery DW, Arden Pope C, Xu X, Spengler JD, Ware JH et al. An Association between Air Pollution and Mortality in Six U.S. Cities. The New England Journal of Medicine, 1993; 329 (24):1753-1759.
  5. Winkleby, MA, Ragland, DR, Syme, SL. Self-reported stressors and hypertension: evidence of an inverse association. American Journal of Epidemiology, 1988; 127(1):124-134.
  6. US Department of Health and Human Services. The Surgeon General's Report on Nutrition and Health. 1988.
  7. Barnard, N.D., Nicholson, A., Howard, J.L. "Integrating Prevention Into Health Care Policy." Physician's Committee for Responsible Medicine, Washington, D.C., 1993:2-3.
  8. Prevention Program. A Healthy Perspective on Health Care Reform: The Chronic Disease Prevention Dividend. 1994.
  9. Freedman, Alix. Wall Street Journal. Deadly Diet: Amid Ghetto Hunger, Many More Suffer Eating Wrong Foods. December 18-20, 1990.
  10. Contra Costa County Hunger Task Force. Hunger in the Midst of Affluence. 1993.
  11. USDA, USDHHS. Dietary Guidelines for Americans. 1995.
  12. Blair, SN, Kohl, HW, Paffenbarger, RS, Clark, DG, Cooper, KH, Gibbons, LW. Physical fitness and all-cause mortality. Journal of the American Medical Association, 1989; 262(17):2395.
  13. Kaplan, GA and Keil, JE. Socioeconomic Status and Cardiovascular Disease: A Review of the Literature. American Heart Association Medical/Scientific Statement, approved February 17, 1993.
  14. Chronic Disease Epidemiology and Control. American Public Health Association, 1993.
  15. Berkman, LF and Syme, SL. Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. American Journal of Epidemiology. 1979; 109(2)186-204.
  16. Contra Costa County Tobacco Prevention Program, personal communication. October, 1995.

Appendix A Chronic Disease Planning Participants

Ms. Myrna Allums
Kaiser Permanente
PEHAB Sub-Committee member

Ms. Nancy Baer
HSD Prevention Program

Mr. Jim Becker
Delta 2000

Dr. Marv Bohnstedt
California Department of Health Services

Dr. Wendel Brunner
Public Health Director
Contra Costa Health Services Department

Mr. Frank Camargo
Familias Unidas

Ms. Galen Ellis
HSD Tobacco and Lead Prevention

Ms. Julie Freestone, Facilitator
HSD Tobacco Prevention Project

Ms. Mary Fujii
UC Cooperative Extension

Ms. Diane Harrison
City of Richmond

Mr. Art Hatchett
Director, Richmond Housing Authority
PEHAB Sub-Committee Member

Mr. Dave Hobbs
Administrative Analyst, City of Pittsburg

Ms. Chicky Irizarry
El Pueblo Resident Council

Ms. Suzette Johnson
Substance Abuse Prevention

Dr. Paul Kimsey
California Department of Health Services


Dr. John Lee
Merrithew Memorial Hospital

Ms. Juliette Linzer
American Lung Association

Dr. Chuck McKetney
Center of Family & Community Health
UC Berkeley
Ms. Bessanderson McNeil
UCSF Hypertension Research
PEHAB Sub-Committee member

Ms. Mary Anne Morgan
HSD Community Wellness & Prevention Program
PEHAB Sub-Committee staff

Ms. George Rountree
English Action Center

Ms. Melody Steeples
HSD Community Wellness & Prevention Program
PEHAB Sub-Committee staff

Ms. Sandra Swanson
Community Leadership Development Institute

Ms. Suzanne Teran*
CCC Health Services Department
PEHAB Sub-Committee Staff

Ms. Joyce White*
Community Leadership Development Institute
PEHAB Sub-Committee member


Appendix B Updated Local Health Data Appendix C Data Resources

  1. Pandora 1991-1993, The Codman Research Group, Inc., Hospital Admission Data by patient residence.
  2. Dept. of Health Services, Health Data Summaries, Contra Costa County, Calif. 1992.
  3. Profile of Alcohol & Drug Use During Pregnancy in California, Perinatal Substance Exposure Study Scientific Report, 1992.
  4. "Trends of Cardiovascular Disease Risk Factors in California", The California Heartline, Winter 1994.
  5. "The Application of Health Promotion in the African American Community", African American Health Promotion Task Force, S.F., 1994.
  6. Human Population Lab, data on Heart Disease, 1994.
  7. Asthma data: Michael Lipsett, California Dept. Of Health Services.
  8. Cancer Incidence and Mortality by Race/Ethnicity in Calif., 1988-1990, released March 1993.
  9. The Calif. Action Plan to Prevent Cardiovascular Disease, A Report of the California Cardiovascular Disease Prevention Coalition.

Appendix D Specific Strategies for Implementing the Guiding Principles

1. Foster Health Department-Community Partnerships

Examples of types of partnership activities that could be implemented include:

Schools and Workplaces
  • Work with teachers and others to jointly design and incorporate prevention education into existing curricula; include school and workplace officials in planning and program development.
  • Partner with the Employment Development Department, Private Industry Council, ESL programs, and job training and volunteer coordinating agencies to integrate health promotion and prevention education into training programs and to encourage health careers.
Faith Community
  • Work with local health ministries organizations such as GRIP, IMAP, and other inter-faith alliances to promote chronic disease prevention messages.
Community-Based Organizations (CBO's)
  • Work through agencies based in "priority" neighborhoods and communities to identify local chronic disease trends and incorporate appropriate chronic disease prevention into the CBO's existing activities where possible.
  • Participate in community festivals, concerts, food drives, and other events in order to inform people about healthier behavioral options.
Existing Collaboratives
  • Provide training, technical assistance, and other resources as available to existing health promotion and health advocacy programs, to enable them to incorporate chronic disease prevention efforts into their work, and to reach people where they are already getting services, as an alternative to creating new structures or programs.
Housing Authorities/Resident Councils/Neighborhood Groups
  • Work with local communities through resident tenant councils and other formal and informal networks to (1) educate on health issues, and (2) help communities map local assets, identify their own concerns, and organize to address chronic disease prevention in their own neighborhoods.

2.Promote Community Economic and Employment Development

PHD/HSD will incorporate job training and employment opportunities for community residents into its own chronic disease prevention programs, and serve as a resource and provide technical assistance for the types of partnerships illustrated above. Several HSD programs have begun providing employment opportunities to community residents through individual stipends for community workers and mini-grants or short-term contracts with community-based organizations. However, these strategies do not necessarily build long-term community capacity or create permanent jobs. Specific recommendations for HSD to begin creating institutionalized employment opportunities are to:

  • Establish resident-staffed programs and activities at neighborhood sites.
  • Incorporate skill-building training for residents wherever possible.
  • Appoint an HSD-community liaison to stimulate partnerships among community agencies, local government, community redevelopment and other agencies to identify and pursue opportunities for local economic development.
  • Provide local groups with technical assistance and support to secure funding to conduct their priority activities.
  • Collaborate with communities in accessing and linking with local government and other key policy makers in order to influence local policies on employment and economic development.

3.Utilize Media Advocacy Strategies

Media strategies should focus on (1) countering environmental cues that promote poor lifestyle choices, especially among youth and communities of people of color, and (2) reducing the volume of negative messages. Media advocacy should use popular media channels and ethnic networks. Messages need to be simple, easy to remember, and contain positive themes that acknowledge the strengths of the community. Successful strategies include:

  • Billboard, poster, radio, television and print media campaigns to increase awareness of issues and encourage information-seeking.
  • PSAs with simple, easy to remember messages.
  • Use of familiar personalities, peers, and local community leaders who reflect the diversity of the population, in order to appeal to the target audience.
  • Provide media training and technical support to HSD's community partners to build their capacity to utilize media advocacy.

Advocate for Policies That Protect Public Health: The focus of the health field should be redirected to more emphasis on prevention strategies. Policy makers should be educated on an expanded definition of a healthy community, which incorporates quality of life indicators into health data assessments. Legislation and policies that protect the public's health and create environmental support for healthy behaviors need to be included in every program seeking to prevent chronic disease through reduction of risk factors.

Local policy changes could include (1) restricting advertising and billboards that contain unhealthy promotions and messages through advertising and billboards or (2) improving access to healthful options such as farmers' markets and exercise facilities. Organizational and institutional changes that foster and encourage lifestyle changes must also be included. Workplace and health insurance incentives for people to maintain good health are needed, For example, work sites could promote exercise for employees (by offering a longer breaks for exercise) and small employers could get assistance in buying health insurance for their employees at discounted rates.

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