The following results were obtained from performance measure reports CDC received from the 40 Steps communities. For interventions implemented during 2003 through 2006, communities reported generic names for interventions, evidence-based sources, population sector receiving the intervention, and diseases or risk factors each intervention addressed. For example, a community may have reported that it implemented diabetes self-management education classes (intervention) on the basis of evidence of effectiveness reported in the Community Guide to Preventive Services (source of evidence) for community members (sector) diagnosed with diabetes (disease) who were overweight or obese (risk factor). By 2006, Steps communities had implemented approximately 1,500 interventions; 94% of the interventions were evidence-based, and 74% addressed 2 or more diseases or risk factors. The most common interventions implemented during 2003 through 2006 targeted individuals ().
The Most Common Interventions Implemented by Steps Communities, 2003-2006
Beginning in 2007, when Steps communities shifted their focus to the implementation of PSE change strategies, performance measure reporting also included the number and type of strategies implemented in each sector. By this time, all of the communities had implemented interventions that addressed 2 or more diseases or risk factors; 85% addressed all risk factors, 93% implemented at least 1 intervention at all levels of the SEM, and 85% addressed access to health care or quality of care. Steps communities implemented approximately 2,300 PSE change strategies during 2007 through 2010 ().
Most Common Policy, Systems, and Environmental (PSE) Change Strategies Implemented by Steps Communities, 2007-2010
PSE change strategy examples
Fruit and vegetable promotion
A large urban area implemented a countywide community gardens project to increase access to affordable local produce. This Steps community partnered with a university cooperative extension service to provide outreach and training to residents interested in starting a community garden. The project resulted in the creation of 31 neighborhood produce gardens with 1,085 participating gardeners. Partnerships were established with food pantries and other emergency food providers, and thousands of pounds of produce were donated. The project also led to policy changes; project staff worked with the city council and city planning agency to pass new zoning legislation. Their success led to implementation of 7 additional gardens that received a total of $30,000 in grants from local foundations and businesses.
School-based health education policy
One of the school-based interventions implemented by a Steps community involved a policy that added the health education curriculum Planet Health to the academic curriculum in 16 middle schools, reaching 4,200 students. The Planet Health curriculum was chosen because it has been shown to decrease rates of obesity and disordered eating behaviors among girls, significantly reduce time spent watching television for boys and girls, and increase fruit and vegetable intake, knowledge of nutrition, and healthy activities among students (19
). Students learned about the benefits of good nutrition and physical activity while building skills in language arts, health, math, science, and social studies. School teachers and staff received annual training on integrating this curriculum into daily classroom learning activities. After 1 year of using this curriculum, approximately 90% of teachers reported that it had a positive effect on both students' and their own health habits.
Comprehensive worksite wellness initiative
One Steps community established a "Healthiest Business Challenge" that awarded points for worksite participation in initiatives such as walking programs, healthy-meeting food policies, stairwell-use campaigns, and establishment or modification of written smoke-free worksite policies. Challenge winners received awards during a Chamber of Commerce meeting and recognition in a local business journal. During the first 3 years of the initiative, 34 businesses and approximately 6,750 employees completed the challenge. Approximately 80% of the participating businesses implemented or upgraded at least 1 worksite policy related to nutrition, physical activity, or smoking cessation. This initiative is now being conducted throughout the state (20
Policy for health care providers
A partnership between a Steps community and a hospital resulted in implementation of a policy requiring health care providers to focus on patients' tobacco use and cessation efforts. Providers from various disciplines were trained to follow the 5 A's model (21
), a 2-minute strategy shown to increase tobacco-use cessation by encouraging health care providers to 1) ask patients abouat tobacco use, 2) advise them to quit, 3) assess patients' willingness to quit, 4) assist in cessation attempts, and 5) arrange for patient follow-up. Providers were also encouraged to refer patients to the state quitline, where intensive counseling was provided. Approximately 550 health care providers were trained on the 2-minute intervention, and the hospital changed its patient intake and education forms to reflect the new process. As a result of the new policy, total calls to the quitline from health care provider referrals quadrupled in 1 year, and calls increased 50% compared with those made in a neighboring county with similar demographics.
Researchers have increasingly recognized the importance of PSE change to achieve widespread and sustainable improvements in health behaviors (22
). They also acknowledge the challenges of implementing strategies (25
). Successful PSE change strategy implementation often depends on the assumption that voters and stakeholders, who are often large corporate entities, will accept serious changes to the food, school, and built environments. Schools and local governments encounter budgetary barriers to implementing these strategies (eg, mandating physical and nutrition education in schools often requires hiring new staff, offering healthier cafeteria foods costs more, and constructing bicycle paths and sidewalks requires transportation funds that are already limited). Legal and constitutional hurdles can restrict efforts to place limits on advertising of unhealthy products, and contractual concerns may thwart attempts to change vending practices, especially in schools that benefit from proceeds. Steps communities encountered these challenges, yet they were able to collectively implement approximately 2,300 PSE change strategy interventions during 2007 through 2010.
Steps communities also experienced challenges identifying short-term health outcomes. Long-term health outcomes associated with their work are unknown. Systemwide changes in health behavior (eg, students at an elementary school who collectively increased their fruit and vegetable consumption) were not always observed in the short term. Data and descriptions of interventions were based on self-report, and although validity and reliability concerns associated with this method of data collection arose, CDC staff conducted comprehensive, in-person site visits and validated intervention descriptions and the existence of all reported interventions.