Planning FOR COMMUNITY HEALTH PROMOTION : A RURAL EXAMPLE Health-care literature seems to indicate a trend toward better organization of health education activities, which is reflected in descriptions of health coalitions, consortia, networks, multi-institutional arrangements, health councils, and clusters. Single institution, community health-promotion programs should be a "thing of the past" in today's society, yet, often these programs are still conducted in this manner. With limited funds available and growing competition for funding, local health agencies must improve on coordinating and organizing health programming. In an effort to respond to the need for community organization and planning for health education, the Centers for Disease Control's Division of health Education developed an intervention effort through which community health promotion programs could be planned on a local level. The program is called PATCH(planned Approach To Community Health) and it attempts to create a collaboration among federal, state, and local health agencies. PATCH has the standard health program planning components and includes: agency organization, data collection and analyses, problem identification and priority setting, intervention planning and implementation, and evaluation. The PATCH project is currently implemented in 12 state. Ohio was one of the first PATCH states; three pilot sites in the state were selected to conduct the program by the Ohio Department of health Education and Promotion. These sites consisted of an urban area,  a mid-sized community, and the rural country's efforts in planning for community health promotion. PHASE 1 - COMMUNITY갃 갃 ORGANIZATION Holmes Country is an entirely rural area with a population of 30,000 located in the northeast section of Ohio. Residents are 99.9% white and the eastern portion of the country is the center of one of the largest Amish settlements in the world. Approximately one-third of the country population is Amish, thus only 43% of people aged 25 years and older have completed a high school education. Many of the Amish children attend one of the 96 parochial schools (1st through 8th grades). Total enrollment is 3,029 students and the teachers are mostly Amish. The country has the usual array of the health related agencies and services. The first task of PATCH was to organize these agencies so that a core group or local advisory group could be established. In this rural area, it involved telephoning the agency and asking them to send a representative to an organizational meeting. Of 15 agencies contacted, eight have continued to support and participate in PATCH. These include the health department, park district, hospital, office on aging, cooperative extension, Head Start, counseling center, and country office of education. The health department is the lead or coordinating agency having a doctoral level prepared health educator. The first meeting involved orienting the agencies to PATCH and seeking a commitment to the project. Many of these agencies had interacted on an informal basis and collaborated on programs as dictated by time, money, and need. Theses agencies did not have trained health educators or formal health education programs (except the schools), but they did have a "connection to health education: by nature of there activities and clientele. Phase I included a training session on process activities in conducting a community health needs assessment. During this session, participants identified sources os health data and organized for its collection to include a community opinion survey, mortality and morbidity data compilation, and behavioral risk factor survey. PHASE 2 - DATA갃 갃 COLLECTION AND ANALYSES Key community people were identified for interviews to obtain opinions on the county's leading health problems. Assurances were made that residents from a variety of professions and jobs and from all districts of the county would be interviewed. forty residents were interviewed and asked open ended questions, one of which was "what do you think are the most important county health problems? "The top four health problems identified were alcohol/drug abuse, obesity, mental health problems and teenage pregnancies a forced choice survey of health problem areas was also given to the key informants and the highest ranked issues were family martial problems overweight/nutritional problems alcohol abuse belief in health myths and smoking. mortality and morbidity data were assembled to determine trends and outstanding health problems sources for these data were the Ohio department of health's vital statistics annual reports for 1979 through 1986. data are reported in frequencies and rates by county with rates usually expressed per 100,000 people. using rates however was not considered the best way to interpret data especially when dying to make comparisons with state data. in a rural area with low numbers of death for a disease per year a difference of four or five deaths can greatly change the rate. for example in 1984 there were 17 cerebrovascular deaths with a rate of 57.8 per 100,000 in 1985 there were 22 deaths with a rate of 74.8 per 100,000. to better interpret the data the percentage of the total number of deaths was used for the leading causes of death. over this 8 year period 43.4% of residents died from heart disease 17.6% from cancer 8.0% from cerebrovascular disease. 5.5% from accidents and 3. 5% from pneumonia and influenza. a table of the percentage distribution by age group was developed to pinpoint age group perhaps at higher risk for certain diseases it was found that 71.1% of those who died from heart disease were 70years and older for Ohio it was 67.1% of this age group. one cause of death nonmotor vehicle accidents. reflected a disparity between Ohio and holmes county when data were tabulated in this manner. only 5.7% of the Holms population over 70  years old died from these accidents. while for ohio 34% were over 70 Years of potential life lost (YpLL) data were figured and ohio's YPLL indices (based on 70 years) ranked cancer heart disease and accidents as the leading causes of early deaths. For Holms county accidents were the number on YPLL cause of death followed by cancer and heart disease. there was a greater difference between the county YPLL index for accidents (36.1 years) and cance (8.4years). two behavioral risk factor surveys (BRFS) were conducted to determine prevalence of 11 risk factors associated to six health areas: obesity exercise smoking seat belt use alcohol use and hypertension. a telephone BRFS was administered among non amish and a door to door survey was needed for the large amish population. a random digit dialing survey technique was used for the telephone survey and multistage cluster sampling procedures were used in the door to door interview survey. The cdc's BRFS was used for both surveys and only adult 18 and older were included in the interviews conducted and 400 door to door interviews. obesity was based on the 1959 metropolian height/weight tables and defined as 120% or more of ideal weight in the telephone survey 29.4% were obese and among amish 34.8% met this criterion. persons were considered sedentary when reporting less than 10 minutes leisure-time physical activity and less than three times per week. for the non amish 62.4% were sedentary while 92.0% amish lacked regular physical activity. data on current cigarette smoking were gathered and only 4.8% amish smoked while 22.4% in the telephone survey were current smokers. seat belt use was determined based on frequency of wearing a seat belt when driving or riding in a car. in the non amish belt and 68.9% sometimes seldom or never wore a seat belt. of amish 54.0% seldom or never used a seat belt and 73% sometimes, seldom, or never wore one. three risk factors for alcohol use were measured binge drinking was defined as having five or more drinks on at least on occasion in the past month only 0.3% of amish had indicated doing this while 11.1% of non- amish reported this activity. drinking and driving was also assessed and 0.3% of the amish and 2.5% of the non amish popualtion reported this behavior Finally heavy drinking was defined as totaling 60 or more drinks during the past month. only 3.7% telephone respondents and no Amish met this creterion. the last risk factor measured was hypertension. persons reporting they had ever been told they were hypertensive was one area examined and 21.8% of the non amish and 8.8% of the amish population indicated this was true for them. another measure was persons indicating they had been told they were hypertensive an that their blood pressure was still high. very few had uncontrolled hypertension with only 0.8% non-amish and 0.5% Amish reporting this situation. The final hypertension measure was a combination of persons reporting ever having been told they were hypertensive being on medication or the fact that their blood pressure was still high. in the telephone survey 16.7% reported this while 8.3% amsih indicated this controlled uncontrolled hypertension status. These BRFS data were compared to Ohio BRFS figures. For both survey populations Holmes county had a higher percentage at risk than Ohio for obesity. sedentary lifestyle, and seat belt use. Ohio was higher than Holmes County in smoking, binge drinking, heavy drinking, drinking and driving, uncontrolled hypertension, and controlled/uncontrolled hypertension. Only non-Amish were higher than Ohio in having ever been told they hypertension. Phase3 -Problem Identification and prioritizing once data were gathered, tabulated, and analyzed, the local core group and the ODH and CDC representatives were brought together again. During this meeting, data were scrutinized to pinpoint specific health problems and perhaps unique health issues for the county. Several areas of belt use was very high in comparison to Ohio and the nation. This seemed to fit the typical rural characteristics of driving behavior and the higher rate of accidents resulting in injuries and deaths. It was believed smoking and alcohol use were lower than the state and nation due to the large Amish and related conservative religious groups in the eastern half of the county. These behaviors are discouraged and/or not tolerated among the church groups. The high rate (92%) of Amish qualifying for the sedentary activity level was surprising at first glance since Amish take pride in their work ethnic. The question, however, deals with leisure activities more suited to the non-Amish population. For example, it requests information on such activities as jogging, walking,     bicycling, gardening, or hiking. Most of the leisure activities listed would not be condoned by the church or not performed enough to fulfill the requirement of greater than 20 minutes for at least three times a week. Although many Amish walk or ride bikes as a means of transportation, very few reported the activities in the survey. Accidents and injuries were identified as a priority health problem and the core group requested that additional information be gathered to better specify the health problem. Accidents data were obtained from two local sources, the hospital emergency room and sheriff's office. THe sheriff's office had recently initiated a computer program for tracking motor vehicle accidents and had no data form earlier years. The sheriff was very cooperative in helping obtain information requested and even changed the program format to isolate the project's needed information for future assessment and trend analysis. The hospital emergency room had tabulated visits by location of the accidental injury. That is, it could be determined if injuries/fatalities occurred at home, work, or in a motor vehicle. The Ohio Department of Highway safety provided county data though annual reports on the traffic accidents. These reports outline data regarding such areas as alcohol industrial Commission of Ohio provided data on work-related injuries outlining degree of injury and cause and type of accident. Finally, death certificates were reviewed to extrapolate the nature of injury death. This was done to determine type of motor vehicle accident and nomotor vehicle accident. This was a tedious task since the vast majority of local health departments do not have vital statistison computer and death certificates were checked by hand. Phase4 -Intervention planning and implementation The core group convened again to examine the additional accident data and to plan intervention strategies. A deputy from the sheriff's office was invited to speak on motor vehicle accidents. Holmes County has an exceptionally high traffic accident rate per 100 licensed drivers and has and has 800 to 900 accidents per years. This is due in part to the rural terrain, large deer population, high volume of tourists traveling to the county, and the large number of slow moving vehicles. it was discovered that the greatest concentration of accidents occur on main state highways and in areas where visibility is good for drivers. Traffic fatalities were more likely to happen on these highways as well, and were attributed to mix of high rates of speed, sudden stops, slow-moving vehicles, and carelessness resulting from watching Amish and scenery rather than the road and traffic. Almost 60% of injuries treated at he hospital emergency room were due to accidents at home, 30% were form accidents at work, and the remainder were form automobile accidents. The county averages 6 deaths and 323 injuries per year from motor vehicle accidents. Approximately 10% of all accidents are alcohol-related. There were three outstanding types of work-related accidents. being struck by falling objects, overexertion, and caught in, on, or between something. Most individuals were men,  20 to 34 years old. Goals were established and community level objectives were written that expressed intent to resolve or reduce the accident/injury problem. During the Phase 4 meeting, accident risk-factor behavior was reviewed to better understand motivations and characteristics conductive to accidents/injuries. For example reason were discussed why people do not wear seat belts. target groups were tourists, and local commercial truckers. Core group members then decided on intervention strategics for reducing injuries/accidents. A community-wide public awareness campaign was considered to be the best means to address the motor vehicle accident issue. A list of activities was developed to conduct the campaign and included slogans and artwork contests, creation and distribution of awareness material, and evaluation of the campaign. Phase 5 - Program evalution For each intervention conducted, an evaluation is planned to determine effectiveness of that efforts. The overall PATCH program will be evaluated in several ways. First, the behavioral risk-factor surveys have provided a baseline measure of selected health behavior for the two county groups. The BRFS will be conducted again 5-years postprogram initiation to determine any changes. Also, community opinion will be solicited a second time to see if programs have had an impact on perceptions of county health problems. Mortality and morbidity data will continue to be monitored for change in leading causes of death and illness and  disability. Goals for the project's health priority areas are written to reduce incidence of these mortality causes. For example, one project goal is to reduce the mortality rate form injuries in motor vehicle accidents from 22 to 18 per 100,00 in Holmes County by December 1990. The current rate is 20.4 per 100,000. No assessments have been made at this writing in Holmes County PATCH. Of course, evaluation is planned as the project continues; the expectation is the program will have an impact on the prioritized health problem. Benefits of a planned, coordinated project There are many benefits in taking a planned and coordinated approach to community health promotion. assembling the local core group has resulted in a more formal network of agencies. participants have learned more about other agency activities and created avenues for shared programming. Professional material has been exchanged among group members. Health problems that were noted as future tasks for PATCH, but not prioritized, have been addressed though select agency efforts. For example, tobacco contracts monies were obtained to develop and implement a youth smoking and smokeless tobacco education program which was cooperatively crated between the health department and cooperative extension 4-H agent. Additional program monies have been received primarily due to the PATCH project. Funding agencies are impressed with the baseline data collected and the ability to outline the health problem for proposed programs. The tobacco contract mentioned above also secured money for a worksite smoking policy seminar for area businesses and industries. An Ohio Department of Highway safety belt education and incentive program. Other spin-off activities have included the development and implementation an Amish school health education curriculum. Data from the Amish BRFS were shared with the parochial school superintendent and three Amish teachers. It was decided that health teaching could be done to address the behavioral problems found in the survey. The public school are evaluating the school health curriculum and during this assessment PATCH data will be used to make curricular adjustments and revisions. The coordinator of PATCH data will serve as a member of the curriculum committee. Finally, an important benefit is that local residents seem more responsive and interested when county data are presented. A sense of ownership is developed, and concern and support are more readily provided when the presenter can use such terms as "us" and "we"  the core group develops a similar attachment and responsiveness to the project when local data are collected and then used for programming. A shared focus and direction are established that many programs cannot crate and claim. Some Thoughts for health promotion Organizing for community health promotion does not just happen overnight. A great amount of time and support must be committed to the effort. Agencies must be willing to work cooperatively. Rural areas may find this easier than larger communities where programs compete directly for clientele and monies. From the onset of the project, participants should experience a sharing of activities and decision making and old "turf" issues must be set aside. further, face to face interaction may reduce any friction or tension that exists between agencies. Early in the project, participants must decide on how the group will function. who will be the key member to organize and do the administrative work for the group. Other activities can then be shared by members, such as coordinating the data collection phase or evaluating programs. In later stages of the planning project, contact with agency members is less frequent and requires special efforts to keep people informed. Memoranda, newsletters, and telephone calls are possible avenues for keeping participants abreast of program activities and additional data or information, and for solicitation of input on problem areas and program direction. The systematic accumulation of community health data is as important step in community health-promotion organization and planning for several reason. First, it enables the documentation of local problems, creates need and direction for activities, and provides charting for program progress. Second, local data enhance the relevance of community awareness and programming. Residents develop a sense of ownership for the problems and the responses to then. Third, specificity of data can and should be used by all particiating agencies. it seems apparent that there must be activities to sustain a collaborative project. Evaluating progress and continuing or extending programs are two means to keep the project active and ongoing. Another consideration is finding ways to renew interest, support, and enthusiasm for old and new intervention efforts. Two types of planning in neighborhoods Introduction This paper distinguishes between two types of planning in neighborhoods: "sub area planning" in which central planning agencies deconcentrate facilities or functions to subareas, and "neighborhood planning" in which community residents develop plans and programs for themselves. This distinction is overdue and not trival. Little of the growing discussion of neighborhoods draws this distinction or carefully discriminates among alternative meaning and objectives. Yet each type of planning has its own ends, and much of what passes today as neighborhood planning is subarea planning in disguise. This exercise also has implications for planning research and education. Although many American planners trace their historical roots to the neighborhoods, planning in neighborhoods remains a relatively undeveloped area of professional specialization. As a result, there is a tendency to accept either widely varying or singualrnotion of planning in neighborhoods which embrace all forms of practice. This can be a source of confusion to those who study or teach about planning in neighborhoods. My aim here is to contribute to a greater measure of clarity in conceptualizing domains of practice in the field. i believe that such clarification could help reduce confusion, sharpen the research and action agenda, and make the whole enterprise more purposeful Subarea planning Subarea planning is an episode in the history of municipal government reform. This history is now new, although the current episode can be traced to citizen participation movements in the 1960. This demand originated with the organized actions and protests of minorities and then spread throughout the society. The once-held image of  Americans as apathetic gave way under a stampede of civil rights movements, consumer coalitions, neighborhood associations, and other citizen organizations. Government agencies were frequently the target of these actions. Public confidence in government declined drastically. One study found more than half of those Americans surveyed were "alienated and disenchanted, feeling profoundly impotent to influence the actions of their leaders" Most of these people expressed potential to become active in government if the means were available and they could have impact. without such assurances, however, the growing belief was that independent citizen organizations and local units were more effective than government in solving problems and getting things done. government itself was perceived as " vast, remote , inaccessible " Several advisory commissions recommended reforms to narrow the gap between officials and citizens. Some turned toward the neighborhoods. One commission advocated neighborhood subunits with elected councils, another little city halls with decentralized services, and another metropolitan government with neighborhood districts. One president advocated  "creative federalism"  involving neighborhood groups in social planning, another  "new partnership" with neighborhoods, government, and business as partners in development. Government agencies responded with official programs to expand participation in local subareas. Between 1968 and 1976 there were over 25 hearings in Congress focusing on the need for greater participation, and participation became part of most federal domestic programs. For example, the Housing and Community Development Act of 1974 promised to provide residents with "adequate opportunity to participate in the planning, implementation, and assessment of the program," and was interpreted to include subarea programs in addition to traditional public hearings and citizen advisory boards. American city governments developed a wide range of participation structures and methods. nearly one in three cities adopted some method of decentralization, two in three some type of citizen committee to advise city hall. City planning agencies shared in this movement for reform. Traditional planning had come under attack from citizens frustrated by unsolved social problems and organized to oppose planning programs perceived as intrusive or unresponsive to local needs. 해석가능하신지요??