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Rigorous evaluation of community-based programs can be costly, particularly when a representative sample of all members of the community are surveyed in order to assess the impact of a program on individual health behavior. Community-level indicators (CLIs), which are based on observations of aspects of the community other than those associated with individuals, may serve to supplement individual-level measures in the evaluation of community-based programs or in some cases provide a lower-cost alternative to individual-level measures. Because they are often based on observations of the community environment, CLIs also provide a way of measuring environmental changes--often an intermediate goal of community-based programs. The Centers for Disease Control and Prevention convened a panel of experts knowledgeable about community-based program evaluation and cardiovascular disease (CVD) prevention to develop a list of CLIs, and rate their feasibility, reliability and validity. The indicators developed by the panel covered tobacco use, physical activity, diet and a fourth group that were considered 'cross-cutting' because they related to all three behaviors. The indicators were subdivided into policy and regulation, information, environmental change, and behavioral outcome. For example, policy and regulation indicators included laws and ordinances on tobacco use, policies on physical education, and guidelines for menu and food preparation. These indicators provide a good starting point for communities interested in tracking CVD-related outcomes at the community level.

Large, well-funded, community heart health programs (CHHPs) have successfully focused on improving the cardiovascular health status of entire communities. CHHPs attempt to reduce the prevalence of risk factors associated with high rates of coronary heart disease mortality: high blood pressure, elevated serum cholesterol, smoking, overweight, and sedentary lifestyle. Program components include community organization, needs assessment, priority and evaluation, and program maintenance. Organizing the community, assessing needs and resources, and setting priorities generally occur concurrently, followed by implementing interventions. CHHP activities include social marketing, direct behavior-change efforts (including skills training, health education, and contingency management), screening (including counseling and referral), and policy and environmental change. Because State-sponsored efforts will seldom have the resources of federally-funded demonstration projects, they must pay particular attention to the "3 As" of community interventions: affordability, acceptability, and adequacy. Attention to these principles and the critical program components outlined in this paper facilitate the planning, development, implementation and evaluation of the next generation of CHHPs.

State Health Agencies play a critical role in the Nation's efforts for health promotion and disease prevention. This role is especially critical in efforts to reduce the burden of CVD through community-based programs. Resources SHAs need to facilitate implementation of community-based CVD prevention programs fall into three general categories: (a) Adequate time to plan, carry out and evaluate, (b) Financial resources to support staff, community organization and demonstration programs, and (c) Personnel with requisite technical expertise, skills and technological resources. Six critical activities for building state-level CVD program capacity include: (1) Forming a statewide CVD oversight committee, (2) Developing a state CVD plan, (3) Developing quality assurance standards and guidelines, (4) Developing new paradigms of community assessment and evaluation, (5) Planning for institutionalization, and (6) Translation of research to application. SHA roles vary from direct service delivery to serving as a linking agent, transferring information and resources and coordinating efforts between agencies.

Public health departments nation-wide are implementing community-based cardiovascular disease (CVD) prevention programs. Many such programs are turning for guidance to three research and demonstration projects: the Stanford Five City Project, the Pawtucket Heart Health Program, and the Minnesota Heart Health Program. This article summarizes some of the lessons learned in these projects and recommends strategies for the new generation of CVD prevention programs. The core of a successful program is the community organization process. This involves identification and activation of key community leaders, stimulation of citizens and organizations to volunteer time and offer resources to CVD prevention, and the promotion of prevention as a community theme. A wide range of intervention settings are available for health promotion. As is true for the workplace, places of worship are receptive to health promotion programs and have access to large numbers of people. Mass media are effective when used in conjunction with complementary messages delivered through other channels, such as school programs, adult education programs, and self-help programs. Community health professionals play a vital role in providing program endorsement and stimulating the participation of other community leaders. School-based programs promote long-term behavior change and reach beyond the school to actively involve parents. Innovative health promotion contests have widespread appeal and promote participation in other community interventions. In the area of evaluation, health program participation rates are appropriate primary outcome measures in most community-oriented prevention programs. Other program evaluation priorities include community analysis and formative evaluation, providing data to fine-tune interventions and define the needs and preferences of the community. It is premature to comment conclusively on the effectiveness of community-based CVD prevention programs in reducing population risk factor levels. However, it has been demonstrated that a broad range of intervention strategies can favorably modify the health behaviors of specific groups in communities such as employees and school children.

This study evaluated a methodology for obtaining information on the prevalence of risk behaviors for human immunodeficiency virus infection (HIV) in the general population. From two census tracts in an upper midwestern urban community, 334 households were identified at random. One adult between the ages of 18 and 55 years in each household was asked to complete a confidential questionnaire about knowledge and attitudes toward acquired immunodeficiency syndrome (AIDS) and risk behaviors for HIV infection. Half the responders were also asked to provide a blood sample for HIV serotesting. Response rates to the behavior questionnaire were high (85 to 90 percent). However, only 72 percent of those asked to provide a blood sample agreed to do so. Survey results showed low rates of HIV risk behavior in this population sample. The median number of lifetime sexual partners was five for men and three for women, and most reported contacts exclusively with persons of the opposite sex. Eleven percent of the men and 5 percent of the women reported having had sexual partners of the same sex during their lifetime. Seven percent of men and 3 percent of women reported same sex partners in the last 12 months. Very few reported extremely high-risk behaviors (that is, only one man reported multiple sexual partners with anal intercourse in the previous year). About one in five survey respondents reported having changed his or her behavior because of the AIDS epidemic, usually by being more selective about and reducing the number of sexual partners. Success of the methodology employed in this survey gives reason for optimism that population-based surveys of behavioral risks for HIV infection are feasible.

Trustful behavior was defined in terms of the consecutive numbers of matching-to-sample problems worth money that each subject worked during sessions that ended in an equitable distribution. Two stages of acquisition are inherent in this definition; the first stage requires acquisition of an equitable method of distributing reinforcers (cooperation) to show that the within-session deviations (trust) from equity that develop during the second stage are temporary and are not part of an inequitable method of distributing reinforcers. Previous research has indicated that a contingency to trust is necessary to override the aversiveness of the inequity inherent in trusting and to produce consistent and maximal trust (half of the problems worked consecutively by each subject). The present experiment examined such a contingency. The trust contingency was an increased requirement for changing the direction of problem allocation. Only the subject who had been allocated a problem could change that allocation, by pulling a lever 45 or more times. On the other hand, no separate responses were required to allow the person who worked the last problem to also work the next one (passive trust). Hence, giving a problem was the only way to increase the distribution of problems to the other person and hence prevent oneself from receiving all of the reinforcers. All eight pairs of subjects cooperated from the outset. Trusting behavior developed for all four pairs exposed to the contingency to trust and expanded to maximal levels by the second session for three of the four pairs.

This study determined whether a two-person exchange situation contained natural contingencies for trusting behavior or whether external contingencies were necessary. Pairs of college students worked matching-to-sample problems for money. On each trial there was one problem and the subjects determined which of them would solve it. Trusting behavior was defined as an increase in the number of consecutive problems each subject allowed his partner to work during sessions that also ended with an equitable distribution. Simply, trust was a temporary deviation from equity. A subject could give the problem to the other person (cooperate), or not respond and let the other person take the problem (share). Other possibilities were for both subjects to try to take the problem (complete), or for neither subject to respond and thereby let the person who worked the last problem also work the next one (passive trust). When only four lever pulls were required to distribute a problem (no external contingencies to reach either equity or trust) subjects reached equity, but only minimal trust (strict alternation of single problems) developed in 18 sessions. When 30 or 60 lever pulls were required to distribute a problem (smaller response requirement for passive trust and therefore a contingency for trust), trusting behavior developed after a few sessions (fixed ratio 30) or after several trials of the first session (fixed ratio 60) and it ordinarily expanded gradually to 10 to 15 consecutive problems through passive trust. The aversiveness of the inequity involved in trusting appears to necessitate a contingency for acquisition. Once trust develops, however, this aversiveness is reduced as subjects learn the inequity is only temporary (e.g., once trust was acquired at fixed ratio 60 it was maintained at fixed ratio 4, which would not initially produce it), and the direction of the inequity appears to become of questionable importance (e.g., being behind was alternated over rather than within sessions and usually not in a systematic manner).