Prevention is a privilege: Implementing drug-free community coalitions in Black communities

Community-based interventions for youth substance use prevention require high levels of capacity to organize and coordinate community resources to support youth development and create opportunities to prevent youth substance use. This project aimed to better understand what Black prevention practitioners perceive as the requirements for a successful drug-free community coalition. Black prevention practitioners, who were engaged in drug-free community funded coalitions, had discussions about coalitions as a strategy for youth substance use prevention in Black communities. These facilitated discussions resulted in consensus over a set of nine core principles regarding successful youth substance use prevention coalition building in these communities.

Organizational and coalition strategies for youth violence prevention: A longitudinal mixed-methods study

This longitudinal study identifies espoused change orientations and actual youth violence prevention (YVP) practices over five years by 99 public and nonprofit organizations in one city. Annual key informant interviews provided both qualitative and quantitative data, including organizational collaborative network data. Data were also obtained on participation in a citywide YVP coalition, juvenile arrests and court referrals. On average, organizations both in and outside the coalition adopted a problem-focused as often as a strengths-based change orientation, and were only marginally more oriented toward empowering community members than professionals and changing communities than individual youth. Most surprisingly, YVP coalition members adopted more of a tertiary (reactive/rehabilitative) than primary prevention orientation compared to nonmembers. The number of different YVP strategies implemented increased over five years from mainly positive youth development and education interventions to those strategies plus mentoring, youth activities, events and programs, and counseling youth. Network analysis reveals dense initial collaboration with no critical gatekeepers and coalition participants more central to the city-wide organizational network. Coalition participation and total network collaboration declined in Years 3-5. Youth violence arrests and court referrals also declined. The coalition was marginally involved in successful community-collaborative, school-based interventions and other strategies adopted, and it disbanded a year after federal funding ended. Despite, or possibly due to, both national and local government participation, the coalition missed opportunities to engage in collective advocacy for local YVP policy changes. Coalitions should help nonprofit and public organizations develop more effective change orientations and implement commensurate strategies at the community level.

A Qualitative Study of Health Equity's Role in Community Coalition Development

Opioid overdose deaths are dramatically increasing in the United States and disproportionately affecting minority communities, with the increasing presence of fentanyl exacerbating this crisis. Developing community coalitions is a long-standing strategy used to address public health issues. However, there is a limited understanding of how coalitions operate amid a serious public health crisis. To address this gap, we leveraged data from the HEALing Communities Study (HCS)-a multisite implementation study aiming to reduce opioid overdose deaths in 67 communities. Researchers analyzed transcripts of 321 qualitative interviews conducted with members of 56 coalitions in the four states participating in the HCS. There were no a priori interests in themes, and emergent themes were identified through inductive thematic analysis and then mapped to the constructs of the Community Coalition Action Theory (CCAT). Themes emerged related to coalition development and highlighted the role of health equity in the inner workings of coalitions addressing the opioid epidemic. Coalition members reported seeing the lack of racial and ethnic diversity within their coalitions as a barrier to their work. However, when coalitions focused on health equity, they noted that their effectiveness and ability to tailor their initiatives to their communities' needs were strengthened. Based on our findings, we suggest two additions to enhance the CCAT: (a) incorporating health equity as an overarching construct that affects all stages of development, and (b) ensuring that data about individuals served are included within the pooled resource construct to enable monitoring of health equity.

Expanding opportunities for chronic disease prevention for Hispanics: the Better Together REACH program in Pennsylvania

Background

Hispanics in Lebanon and Reading, Pennsylvania, experience high levels of socioeconomic and health disparities in risk factors for chronic disease. In 2018, our community-academic coalition "Better Together" received a Racial and Ethnic Approaches to Community Health (REACH) award to improve healthy lifestyles. This report describes our work-in-progress and lessons learned to date from our REACH-supported initiatives in Lebanon and Reading.

Methods

For the past 4 years, our coalition has leveraged strong community collaborations to implement and evaluate culturally-tailored practice- and evidence-based activities aimed at increasing physical activity, healthy nutrition, and community-clinical linkages. This community case report summarizes the context where our overall program was implemented, including the priority population, target geographical area, socioeconomic and health disparities data, community-academic coalition, conceptual model, and details the progress of the Better Together initiative in the two communities impacted.

Results

To improve physical activity, we are: (1) creating new and enhancing existing trails connecting everyday destinations through city redesigning and master planning, (2) promoting outdoor physical activity, (3) increasing awareness of community resources for chronic disease prevention, and (4) supporting access to bikes for youth and families. To improve nutrition, we are: (1) expanding access to locally-grown fresh fruit and vegetables in community and clinical settings, through the Farmers Market Nutrition Program to beneficiaries of the Women, Infants, and Children (WIC) program and the Veggie Rx to patients who are at risk for or have diabetes, and (2) providing bilingual breastfeeding education. To enhance community-clinical linkages, we are training bilingual community health workers to connect at-risk individuals with diabetes prevention programs.

Conclusions

Intervening in areas facing high chronic disease health disparities leads us to develop a community-collaborative blueprint that can be replicated across Hispanic communities in Pennsylvania and the United States.

Community Gardens: A Catalyst for Community Change

Community gardens are increasing in popularity and are associated with extensive physical and mental health benefits, increased access to fresh produce, and increased social connections. However, evidence is primarily from research in urban and school settings, and little is known about the role of community gardens in rural settings as part of policy, systems, and environmental (PSE) changes to promote health. This study explores the implementation of community gardens as part of an obesity prevention project, titled Healthier Together (HT), in five rural Georgia counties with limited food access and high obesity prevalence (>40%) using a mixed-methods research design that included data from project records, a community survey, interviews, and focus groups with county coalition members. Nineteen community gardens were implemented across five counties, 89% distributed produce direct to consumers, and 50% were integrated into the food system. Few (8.3%) of the survey respondents (n = 265) identified gardens as a food source, but 21.9% reported using an HT garden in the past year. Themes emerging from interviews (n = 39) and five focus groups suggested community gardens were a catalyst for broader community health change by increasing awareness of the value and absence of healthy food and generating excitement for future PSE initiatives to more comprehensively address food and physical activity access. Practitioners should consider placement of rural community gardens to optimize access to and distribution of produce as well as communication and marketing strategies to increase engagement and leverage gardens as gateways for PSE approaches to improve rural health.

Perspectives From Extension Staff on Building and Sustaining Community Wellness Coalitions

BACKGROUND

Community wellness coalitions are an important part of functioning program infrastructure and have been effective in promoting policy, systems, and environmental (PSE) change, especially when paired with technical support by a community champion or Extension staff. PSE strategies are critical to support long-lasting behavior change but can be challenging to implement. Extension is an established and equipped organization that has potential to help community overcome those challenges. The aim of this article was to identify and describe experiences of Extension staff working as community coaches.

METHODS

A mixed-methods design to assess the impact of Extension staff working with Community Champions included a quantitative Extension Coaching Confidence Scorecard and an Extension Key Informant Interview.

RESULTS

The total Extension Coaching Confidence score significantly increased from pre- to post-intervention (55.1 ± 35.3 vs. 81.7 ± 37.7, p = .03). Five facilitators and two barriers to wellness coalition development were identified by Extension staff.

DISCUSSION

The results of this study indicate that the model of community coaching used was effective at addressing the foundational components of the Component Model of Infrastructure (CMI). However, comprehensive training for Extension staff in the CMI and technical assistance are needed in order to build capacity, achieve outcomes, and promote sustainability.

IMPLICATIONS FOR PRACTICE

Individuals seeking to transition to PSE work should be provided with a foundation of specific, targeted training in the CMI and evidence-based technical assistance methods. Practitioners should recognize the essential role of community champions in PSE work. Completing the Extension Coaching Confidence Scorecard periodically can inform evolving training needs.

Evolution of a Coalition Network during a Whole-of-Community Intervention to Prevent Early Childhood Obesity

Background: Community coalitions often lead and coordinate "whole-of-community" childhood obesity prevention interventions. A growing body of work suggests that coalition network ties, which facilitate transmission of information and advocacy, may be a key part of how such leadership operates. This study provides an understanding of the structure of coalition networks and how this structure changes over time. Methods: We administered semiannual network surveys during a pilot whole-of-community intervention in Somerville, MA (2015-2017). Participants included 16 multisector coalition members and their nominated discussion partners ("first-degree alters") related to childhood obesity prevention. Coalition and first-degree alter respondents named up to 20 discussion partners and reported ties' interaction frequency and perceived influence. Networks were assessed with visualization, descriptive analysis, and exponential random graph models. Results: Total network included 558 stakeholders representing community-based organizations, parents, health care, childcare, universities, among others. Size and membership varied over time. We observed the largest network (n = 256) during intervention planning, and the largest proportion of stakeholders communicating frequently (daily/weekly) about childhood obesity prevention during the peak intervention period. Networks were sparsely interconnected (1%-3% of possible ties observed) and most and least centralized at baseline and follow-up, respectively. Over time, ties were increasingly perceived as influential and siloed within community groups. Conclusions: The network's extensive evolving membership may indicate access to a wide range of resources, ideas, and an ability to broadly disseminate intervention messages. The attenuating network hierarchy over time may have supported more equal participation and control over intervention efforts. Future research should assess generalizability of network patterns, network influences on implementation processes, and possible network interventions.

What Works in Community-Led Suicide Prevention: Perspectives of Wesley LifeForce Network Coordinators

Community coalitions have been recognised as an important vehicle to advance health promotion and address relevant local health issues in communities, yet little is known about their effectiveness in the field of suicide prevention. The Wesley Lifeforce Suicide Prevention Networks program consists of a national cohort of local community-led suicide prevention networks. This study drew on a nationally representative survey and the perspectives of coordinators of these networks to identify the key factors underpinning positive perceived network member and community outcomes. Survey data were analysed through descriptive statistics and linear regression analyses. Networks typically reported better outcomes for network members and communities if they had been in existence for longer, had a focus on the general community, and had conducted more network meetings and internal processes, as well as specific community-focused activities. Study findings strengthen the evidence base for effective network operations and lend further support to the merit of community coalitions in the field of suicide prevention, with implications for similar initiatives, policymakers, and wider sector stakeholders seeking to address suicide prevention issues at a local community level.

Psychological sense of community and motivation toward collective social change among community coalition members of color in the southwestern United States

Drawing on McMillan and Chavis's psychological sense of community framework among southwestern community coalition members (N = 18), data were examined for narratives of how psychological sense of community and experiences of community manifest among coalition members. We were also interested in knowing how coalition members make meaning of social change. Findings illustrate that dimensions of psychological sense of community (e.g., membership, emotional connection, needs' fulfillment, and influence) are important in how members made meaning of community needs and their own participation in the coalition. Implications are put forward for theory and community programming.

Strengthening Our Collaborative Approaches for Advancing Equity and Justice

The Principles for Collaborating for Equity and Justice are explicit about addressing social and economic injustice, structural racism, and community organizing to facilitate resident power and ownership. They also focus on structural change, an acknowledgment of complexity, and the need to thoughtfully build on decades of practice and scholarship on collaborating for community change. This special theme issue of Health Education & Behavior includes 10 articles that highlight these principles and provide insight into the complexities, challenges, and rewards of collaborating in ways that are intentional about advancing health equity through inclusive processes and shared goals to address social determinants of health. We provide a brief overview of the articles and identify community organizing and building resident power as possible strategies that should be combined with, complement, or in some cases replace, our more commonplace multisectoral coalitions if we hope to reduce health inequities through community collaboration.

Quality of collaboration within health promotion partnerships: Impact on sense of community, empowerment, and perceived projects' outcomes

Community coalitions or intersectoral partnerships have long been advocated for the promotion of population health. In the present study, we assessed the quality of the functioning of health promotion partnerships created within a large community health promotion program implemented by the Emilia-Romagna region located in the north-east of Italy (2014-2016). In particular, we aimed to test the effectiveness of partnership working in strengthening participants' empowerment, sense of community and ultimately, the outcomes of a well-functioning partnership, conceptualized as including perceived effectiveness of health promotion interventions developed by the partnership, trust in their implementation and personal commitment in health promotion in the future. Participants were 238 stakeholders (e.g., health professionals, representatives of local administrations, teachers, representative of community and volunteer organizations, and citizens) formally included in six partnerships lead by six major local health services. Using Bayesian structural equation modeling, we found that a higher perceived quality of collaboration within the partnership enhances the outcomes of a well-functioning partnership, by strengthening their sense of a health-promoting community and empowerment. Sense of community responsibility did not predict future commitment in health promotion. The study findings suggest that community members' ownership and feeling of responsibility, as well as empowerment constitute positive partnership processes.

Prioritizing Equity: Exploring Conditions Impacting Community Coalition Efforts

Purpose: There is a critical push toward addressing equity in health care. Community coalitions are uniquely situated to heed this call by tackling issues of equity and well-being that are the most relevant for their local context. This article analyzes internal and external contextual factors that may affect coalitions' prioritization of equity.

Methods: Data were collected from 18 coalitions participating in a national, U.S.-based initiative aimed at strengthening community coalition work through the principles of equity and inclusion. A hybrid qualitative–quantitative method (qualitative comparative analysis [QCA]) was conducted using the direct method of calibration and fuzzy set QCA and to obtain casual sufficiency results.

Results: Coalitions located in states that did not expand Medicaid after the Affordable Care Act were most likely to prioritize equity, as were coalitions who were both working with marginalized populations and had low organizational readiness for the initiative. However, only one case demonstrated the latter causal solution; the former accounts for greater coverage of the outcome.

Conclusion: This study illustrates the use of QCA for evaluation and underscores the critical role of contextual factors for affecting meaningful community-level change. Coalitions are willing and able to prioritize tackling health inequities across settings, but those in settings with low state-level support may be more likely to emphasize inequities in their work.

Integrated Programs for Early Recognition of Severe Mental Disorders: Recommendations From an Italian Multicenter Project

The onset of mental disorders often occurs in adolescence or young adulthood, but the process of early diagnosis and access to timely effective and appropriate services can still be a challenge. The goal of this paper is to describe a pilot case of implementation of the ultra-high-risk (UHR) paradigm in six Italian departments of mental health employing an integrated approach to address clinical practice and service organization for youth in a broader preventive perspective. This approach entailed the integration of the UHR paradigm with a service provision model which prioritizes prevention and the promotion of local community coalitions to improve youth service accessibility. The multicenter Italian project "Integrated programs for recognition and early treatment of severe mental disorders in youths" funded by the National Centre for Disease Prevention and Control (CCM2013 Project) implemented in three Italian regions will be described. As a result of synergic actions targeting accessibility of young individuals to innovative youth mental health teams, a total of 376 subjects aged 15-24 years were recruited by integrated youth services within 12 months. Subjects have been screened by integrated multidisciplinary mental health youth teams employing standardized procedure and evidence-based clinical assessment instruments for at-risk mental states in young subjects [e.g., Comprehensive Assessment of At-Risk Mental States (CAARMS)]. Considering the three UHR categories included in CAARMS, the percentage of UHR subjects was 35% (n = 127) of the sample. In conclusion, future strategies to improve the organization of youth mental health services from a wider preventive perspective will be proposed.

Engaging Coalitions in Community-Based Childhood Obesity Prevention Interventions: A Mixed Methods Assessment

BACKGROUND

Childhood obesity prevention interventions have engaged coalitions in study design, implementation, and/or evaluation to improve research outcomes; yet, no systematic reviews have been conducted on this topic. This mixed methods review aims to characterize the processes and dynamics of coalition engagement in community-based childhood obesity prevention interventions.

METHODS

Data Sources: Studies extracted from Ovid MEDLINE, PubMed, and Web of Science; complementary original survey and interview data among researchers of included studies. Eligible Studies: Multisetting community-based obesity prevention interventions in high-income countries targeting children 0-12 years with anthropometric, behavioral, or environmental/policy outcomes. The Community-Based Participatory Research (CBPR) Conceptual Model was used as an overarching framework.

RESULTS

Thirteen studies met inclusion criteria. Elements of CBPR were evident across all studies with community engagement in problem identification (n = 7), design/planning (n = 11), implementation (n = 12), evaluation (n = 4), dissemination (n = 2), and sustainability (n = 10) phases. Five studies reported favorable intervention effects on anthropometric (n = 4), behavioral (n = 1), and/or policy (n = 1) outcomes; descriptive associations suggested that these studies tended to engage community members in a greater number of research phases. Researchers involved in 7 of 13 included studies completed a survey and interview. Respondents recalled the importance of group facilitation, leadership, and shared understanding to multisector coalition work. Perceived coalition impacts included community capacity building and intervention sustainability.

CONCLUSIONS

This review contributes to a deeper understanding of intervention processes and dynamics within communities engaged in childhood obesity prevention. Future research should more rigorously assess and report on coalition involvement to assess the influence of coalitions on multiple outcomes, including child weight status.

Establishing a local coalition for addressing social determinants of hypertension in Quibdó (Colombia): a description and reflection on the process

One-fourth of the adult population of Colombia is estimated to have hypertension. However, there has been relatively little attention to participatory approaches that address the social determinants of hypertension at the local level in Colombia. Early stages of a coalition for addressing hypertension in Quibdó (Colombia) included a stakeholder analysis and engagement of local organizations. This was followed by defining mutual goals, agreement of rules for decision making, and refining a shared vision. Based on a unified understanding of factors influencing hypertension risk, 12 organizations joined the local coalition. They developed an action plan for preventing hypertension and eliminating social disparities in its distribution. Lessons learned during this process suggest that, in marginalized urban areas of middle- and low-income countries, particular attention should be paid, at early implementation stages of coalition, to context specific challenges and opportunities, coalition membership and structure, reframing health, and strengthening capacity.

Evaluating Community Partnerships Addressing Community Resilience in Los Angeles, California

Community resilience has grown in importance in national disaster response and recovery efforts. However, measurement of community resilience, particularly the content and quality of relationships aimed at improving resilience, is lacking. To address this gap, we used a social network survey to measure the number, type, and quality of relationships among organizations participating in 16 coalitions brought together to address community resilience in the Los Angeles Community Disaster Resilience project. These coalitions were randomized to one of two approaches (community resilience or preparedness). Resilience coalitions received training and support to develop these partnerships and implement new activities. Both coalition types received expert facilitation by a public health nurse or community educator. We also measured the activities each coalition engaged in and the extent to which partners participated in these activities at two time points. We found that the community resilience coalitions were initially larger and had lower trust among members than the preparedness communities. Over time, these trust differences dissipated. While both coalitions grew, the resilience community coalitions maintained their size difference throughout the project. We also found differences in the types of activities implemented by the resilience communities; these differences were directly related to the trainings provided. This information is useful to organizations seeking guidance on expanding the network of community-based organizations that participate in community resilience activities.

How Do Communities Use a Participatory Public Health Approach to Build Resilience? The Los Angeles County Community Disaster Resilience Project

Community resilience is a key concept in the National Health Security Strategy that emphasizes development of multi-sector partnerships and equity through community engagement. Here, we describe the advancement of CR principles through community participatory methods in the Los Angeles County Community Disaster Resilience (LACCDR) initiative. LACCDR, an initiative led by the Los Angeles County Department of Public Health with academic partners, randomized 16 community coalitions to implement either an Enhanced Standard Preparedness or Community Resilience approach over 24 months. Facilitated by a public health nurse or community educator, coalitions comprised government agencies, community-focused organizations and community members. We used thematic analysis of data from focus groups (n = 5) and interviews (n = 6 coalition members; n = 16 facilitators) to compare coalitions’ strategies for operationalizing community resilience levers of change (engagement, partnership, self-sufficiency, education). We find that strategies that included bidirectional learning helped coalitions understand and adopt resilience principles. Strategies that operationalized community resilience levers in mutually reinforcing ways (e.g., disseminating information while strengthening partnerships) also secured commitment to resilience principles. We review additional challenges and successes in achieving cross-sector collaboration and engaging at-risk groups in the resilience versus preparedness coalitions. The LACCDR example can inform strategies for uptake and implementation of community resilience and uptake of the resilience concept and methods.

The influence of community context on how coalitions achieve HIV-preventive structural change

Community coalition action theory (CCAT) depicts the processes and factors that affect coalition formation, maintenance, institutionalization, actions, and outcomes. CCAT proposes that community context affects coalitions at every phase of development and operation. We analyzed data from 12 Connect to Protect coalitions using inductive content analysis to examine how contextual factors (e.g., economics, collaboration, history, norms, and politics) enhance or impede coalitions' success in achieving outcomes. Consistent with CCAT, context affected the objectives that coalitions developed and those they completed. Results suggest that local prevention history and political support have particular impact on coalitions' success in creating structural changes. These data underscore the heuristic value of CCAT, yet also imply that the contextual constructs that affect outcomes are issue specific.

Sustaining the utilization and high quality implementation of tested and effective prevention programs using the communities that care prevention system

This paper describes the extent to which communities implementing the Communities That Care (CTC) prevention system adopt, replicate with fidelity, and sustain programs shown to be effective in reducing adolescent drug use, delinquency, and other problem behaviors. Data were collected from directors of community-based agencies and coalitions, school principals, service providers, and teachers, all of whom participated in a randomized, controlled evaluation of CTC in 24 communities. The results indicated significantly increased use and sustainability of tested, effective prevention programs in the 12 CTC intervention communities compared to the 12 control communities, during the active phase of the research project when training, technical assistance, and funding were provided to intervention sites, and 2 years following provision of such resources. At both time points, intervention communities also delivered prevention services to a significantly greater number of children and parents. The quality of implementation was high in both conditions, with only one significant difference: CTC sites were significantly more likely than control sites to monitor the quality of implementation during the sustainability phase of the project.

Implementation of the Communities That Care Prevention System by Coalitions in the Community Youth Development Study

While advances in prevention science over the past 2 decades have produced a growing list of tested and effective programs and policies for preventing adolescent delinquency and drug use, widespread dissemination and high-quality implementation of effective programs and policies in communities has not been achieved. The Community Youth Development Study (CYDS) is a randomized, community-level trial of the Communities That Care (CTC) system for promoting science-based prevention in communities. This paper compares 12 community prevention coalitions implementing the CTC system in 12 intervention communities as part of the CYDS to prevention coalitions located in the 12 control communities. As hypothesized, the CYDS coalitions implemented significantly more of the CTC core intervention elements, and also implemented significantly greater numbers of tested, effective prevention programs than the prevention coalitions in the control communities. Implications of the findings for efforts to achieve widespread dissemination of effective prevention programs, policies, and practices are discussed.

Promoting sustainable community change in support of older adult physical activity: evaluation findings from the Southeast Seattle Senior Physical Activity Network (SESPAN)

Researchers have identified as effective and worthy of broader dissemination a variety of intervention strategies to promote physical activity among older adults. This paper reports results of a community-organizing approach to disseminating evidence-based interventions in a sustainable way: The Southeast Seattle Senior Physical Activity Network (SESPAN). SESPAN was implemented in Southeast Seattle, a group of multicultural neighborhoods extending 8 miles southeast of downtown Seattle, with a population of 56,469 in 2000, with 12% (7,041) aged 65 and older. The SESPAN organizing strategy involved networking to: (1) make connections between two or more community organizations to create new senior physical activity programs; and (2) build coalitions of community groups and organizations to assist in making larger scale environmental and policy changes to increase senior physical activity. The SESPAN evaluation used an uncontrolled prospective design focusing on sustainable community changes, including new or modified programs, policies, and practices. Networking among organizations led to the creation of 16 ongoing exercise classes and walking groups, serving approximately 200 older adults in previously underserved Southeast Seattle communities. In addition, the project's health coalition is sustaining current activities and generating new programs and environmental changes. The success of the SESPAN organizing model depended on identifying and involving champions in partner organizations who provided support and resources for implementing programs.

Using correlational analyses to improve prevention strategies based on survey data from youth

Community coalition prevention models often select interventions based on the types of risk factors (outcome predictors) that are elevated. Variances and correlations between predictors and targeted behaviors also may vary between communities and provide information to improve the selection of interventions. Community differences in risk factor levels and correlations between predictors and problem behaviors were examined using a child self-report computer assessment (ALEXSA); prevention.psu.edu/people/ALEXSA.htm). Three school-based subsamples of children were studied. Means, prevalences, and correlations differed significantly between samples. Discussion addresses developmental considerations and illustrates how correlations between predictors and problem behaviors might improve the selection of interventions. This study is preliminary and should be replicated with larger community samples, more indicated/selected sample, and in more communities.

A national program for injury prevention in children and adolescents: the injury free coalition for kids

Injury is the leading cause of death and a major source of preventable disability in children. Mechanisms of injury are rooted in a complex web of social, economic, environmental, criminal, and behavioral factors that necessitate a multifaceted, systematic injury prevention approach. This article describes the injury burden and the way physicians, community coalitions, and a private foundation teamed to impact the problem first in an urban minority community and then through a national program. Through our injury prevention work in a resource-limited neighborhood, a national model evolved that provides a systematic framework through which education and other interventions are implemented. Interventions are aimed at changing the community and home environments physically (safe play areas and elimination of community and home hazards) and socially (education and supervised extracurricular activities with mentors). This program, based on physician-community partnerships and private foundation financial support, expanded to 40 sites in 37 cities, representing all 10 US trauma regions. Each site is a local adaptation of the Injury Free Coalition model also referred to as the ABC's of injury prevention: A, "analyze injury data through local injury surveillance"; B, "build a local coalition"; C, "communicate the problem and raise awareness that injuries are a preventable public health problem"; D, "develop interventions and injury prevention activities to create safer environments and activities for children"; and E, "evaluate the interventions with ongoing surveillance." It is feasible to develop a comprehensive injury prevention program of national scope using a voluntary coalition of trauma centers, private foundation financial and technical support, and a local injury prevention model with a well-established record of reducing and sustaining lower injury rates for inner-city children and adolescents.