PLANNED APPROACH TO COMMUNITY

HEALTH (PATCH)
The Planned Approach to Community Health (PATCH) was developed in 1983
by the United States Centers for Disease Control (CDC) in partnership with state
and local health departments and community groups. It was designed to provide
a model to assist state and local public health agencies, in their partnerships with
local communities, to plan, conduct, and evaluate health promotion and disease
prevention programs. PATCH was also intended to serve as a mechanism to
improve links both within communities and between communities and state
health departments, universities, and other agencies and organizations. PATCH
combines the principles of community participation with the diagnostic steps of
applied community-level epidemiology. The development of PATCH was
influenced by the theoretical assumptions underlying the PRECEDE model, by
the literature on community organization and development, and by CDC's
tradition of working through state health agencies in the application of health
promotion and disease prevention programs.

The PATCH process guides users through five phases: (1) mobilizing the
community, (2) collecting and organizing data, (3) choosing health priorities, (4)
developing a comprehensive intervention plan, and (5) evaluation. Moving from
the initiation to the full implementation of PATCH can take can up to a year or
more. Successful implementation depends upon actively engaging community
members in the process, having adequate time and resources to gather and
interpret data to guide program development, and developing cohesion among
stakeholder organizations. PATCH is an example of a model that has not only
tested the application of theory, but has also facilitated the link between research
and practice in community health education and health promotion.

PATCH is widely recognized as a practical and user-friendly model for

community health promotion and disease prevention planning. It has been used
in combination with other community-based planning frameworks such as
Assessment Protocol for Excellence in Public Health (APEXPH) and Healthy
Cities.
Public health staff in over forty states have received training in the PATCH
process and it has been applied in over three hundred local communities in the
United States, as well as several communities in Canada, Australia, and in the
Panama Canal region by the United States military. It has also been applied in a
wide variety of settings, including hospitals, managed care organizations,
universities, voluntary health agencies, local health departments, agricultural
extension services, and work sites. PATCH has also been employed to focus on
the health needs of diverse populations to address such topics as cardiovascular
disease, injury prevention, HIV/AIDS (human immunodeficiency virus/acquired
immunodeficiency syndrome), teen pregnancy, and tobacco use.

Although no longer directly funded by the CDC, the PATCH process continues
to be referenced and used by many organizations and agencies for community
planning and for the training of new public health and health promotion
professionals. Further discussion of theory, applications, and evaluation of
PATCH can be found in many publications, some of which are included in the
bibliography below.

Brick Lancaster

Marshall Kreuter

(see also: Centers for Disease Control and Prevention; Community Health;
Community Organization; Epidemiology; Health Promotion and Education;
Mobilizing for Action through Planning and Partnerships; PRECEDE-
PROCEED Model )
PATCH: Its Origin, Basic Concepts, and Links to Contemporary Public Health
Policy

PATCH, the acronym for Planned Approach to Community Health, is a

cooperative program of technical assistance managed and supported by the
Centers for Disease Control (CDC). PATCH is designed to strengthen state and
local health departments' capacities to plan, implement, and evaluate community-
based health promotion activities targeted toward priority health problems.

The PATCH concept emerged in 1983 primarily as a CDC response to the shift
in federal policy regarding categorical grants to states. One of those categorical
grant programs was the Health Education-Risk Reduction (HERR) Grants
Program.

In 1979, the HERR program was created under the authority of Public Law 94-
317, The Health Information and Health Promotion Act of 1976. Through this
program, a modest amount of resources helped local, state, and federal health
agencies take an organized, planned approach to community-based interventions.
Agencies were urged to make maximum use of existing resources and to monitor
and evaluate progress.

This unprecedented federal effort was designed to provide five years of economic
support for state health agencies to establish (1) a focal point for health education
(staff and organizational infrastructure) to carry out and manage state-level risk
reduction programs, and (2) a program of local grants program, managed by the
state health education focal point, to support tobacco and alcohol abuse
prevention and education programs for youth (HERR funds required applicants
to demonstrate that their programs placed primary emphasis on tobacco and
alcohol abuse among youth. Also, some portion of program activity had to be
directed toward minority populations).

The local intervention grants required grantees to submit proposals that:

documented state or territorial and Iocal health needs;

revealed detailed plans for the inclusion or development of a health promotion,

disease prevention network;
included evidence of either the existence or development of a statewide
mechanism to provide and maintain a data base for monitoring prevalence of
selected risk factors;

demonstrated that the proposed intervention was part of an "organized approach"

within the target community.

secured program evaluation assistance from appropriate university programs.

At the midpoint in the five-year HERR program, federal policy shifted. The
economic philosophy of President Reagan's administration held that states should
assume greater responsibility for the manner in which federal resources were to
be spent. The Administration accordingly determined that categorical grants to
states, managed by federal agencies, should be combined into more generic
"blocks" under the management control of the states. As a result, the HERR grants
program was consolidated into the "Prevention Block" with seven other
categorical grant programs: emergency medical services, health incentive grants,
hypertension control, rodent control, community and school-based fluoridation,
home health services, and rape prevention and services (Brandt, 1981)

For the first year of the new block grants, the formula for determining the level
of money available for the entire block was the sum of the previous year's
allocation for each of the programs within the block, less 25 percent.

Even though the block grant approach evoked the principle of local control and
reduced the federal prevention expenditure, the blow it dealt to the HERR
program was especially severe. The key concept in the HERR program was to
strengthen the health education capacity at the state and local levels. The federal
policy decision to create block grants immediately eliminated the CDC support
function, and shifted the management function of the program from the federal
level to the state. In most instances, this shift occurred before the state focal point
was fully in place, thus weakening the attempt to strengthen the federal, state, and
local level health education infrastructure.

So, halfway through the HERR program, health education units in each state and
territory had to compete for resources from a pool that already had been reduced
by 25 percent. In the aftermath of the block grant policy, a few HERR programs
continued to prosper, most continued amid severe economic cuts, and a few were
discontinued (Kreuter, Christensen, & DiVincenzo, 1982).

Despite these difficulties, experiences from the first two years of the HERR
program convinced staff in CDC's Center for Health Promotion and Education
that the capacity-building and community intervention principles of the HERR
program should remain a priority in their overall prevention mission. As a result,
two key components of the HERR program became institutionalized at CDC: (1)
the monitoring and assessment dimension of the program was formally developed
into what is known now as the Behavioral Risk Factor Surveillance System
(BRFSS), and (2) PATCH.

Basic Concept: Diffuse Effective Strategies

From its inception, the primary goal of PATCH was to create a practical
mechanism through which effective community health education action could be
targeted to address local-level health priorities. A secondary goal was to offer a
practical, skills-based program of technical assistance wherein health education
leaders in state health agencies would work with their local level counterparts to
establish community health education programs. (Kreuter, 1984; Nelson, Kreuter,
Watkins, & Stoddard, 1987).

During the formative stages of PATCH, knowledge of what constituted effective

community-based health education interventions was by no means complete and,
of course, remains in a continuous state of development. However, as
investigators directing community-based cardiovascular disease intervention
programs began to describe results of their work in the literature, it became
evident that there was a consistent pattern across successful interventions
(Farquhar, Fortmann, Wood, & Haskell, 1983; Carlaw, R.W, Mittlemark, M,
Bracht, N., & Lupker, R. (1984); Puska, P, Nissinen, J., Tuomilehto, J., &
Salonen, T., 1985). Those interventions included:

a strong core of representative local support and participation in the process;

the collection and analysis of local data and health issues;

setting objectives and standards to denote progress and success;

the design and implementation of multiple intervention strategies to meet
objectives including strategic application of behavioral sciences, community
mobilization, health education, and mass media;

continuous monitoring of problems and intervention strategies to evaluate

progress and detect the need for change;

securing support of a public health infrastructure (system) either nationally,

within the target community, or both.

While providing clear details on research methods and initial results, the literature
reporting the findings from community intervention studies provided only
superficial descriptions of the intervention's methods and strategies. State and
local level health education specialists encouraged their CDC counterparts to
develop a means by which details of intervention innovations could be shared
with them.

These community intervention elements described above, organized within the

context of the PRECEDE model (Green, Kreuter, Deeds, & Partridge, 1980;
Green, & Kreuter, 1991), became essential components of the PATCH program.

Basic Concept: Local Ownership

The most effective center of gravity for health promotion is the community.
Governments can and should exercise their responsibilities for formulating
policies, providing leadership, and allocating funding in support of prevention
programs. Individuals can govern their own behaviors and control the
determinants of their own health up to a point, but the decisions for social change
affecting the more complicated lifestyle issues can be made best collectively, as
close as possible to the homes and workplaces of those affected. Relevant and
appropriate programs are more likely to result in such a context, since those for
whom the program is intended will be engaged in all phases of the program.
Accordingly, PATCH has been influenced greatly by the literature on community
organization and community development (Minkler, 1980; Green, 1986; Bracht,
& Tsouros, 1990) and the Model Standards: A Guide for Community Preventive
Services (1985).
The principle of community participation also embodies the often used, but rarely
defined, concept of empowerment. Cuoto (1990) describes empowerment as a
process wherein information, skills and resources are transferred to "improve the
decision making power of individuals and groups...empowerment begins with the
realization that a condition, problem, or need is not theirs only, but that of others
as well" (pp. 145-146).

Ironically, the element of the PATCH process that usually is identified as the most
demanding for all parties turns out to be the primary source of local
empowerment: gathering and analysis of local area data to facilitate program
planning and evaluation. On average, communities spend about a year collecting
and analyzing data. This energy appears to be well spent, however. With
information to document the magnitude and extent of their health problems and
to set measurable health priorities for health promotion and disease prevention,
communities have additional leverage to strengthen their requests for resources.

In 1987, 25 PATCH projects were underway in 12 states. A survey of those 25

projects revealed that a total of $564,000 had been secured by localities for
program support beyond the resources invested in PATCH by CDC or the states.
For every dollar invested in PATCH in 1987, the community generated an
additional $9 for program implementation (J. Belloni and C.F. Nelson, personal
commumcation).

Basic Concept: Vertical and Horizontal Networks

Although PATCH is applied at the local level, the total process is designed to
operate within an interdependent system that connects local, state, and federal
public health agencies. This process addresses a priority concern voiced by public
health leaders: the need to strengthen the infrastructure and system of public
health (National Academy of Sciences, 1988; Roper, 1990). The arrangement also
makes PATCH unique among other community intervention efforts.

As has been mentioned previously, PATCH was envisioned as a means to

strengthen existing communication channels among state health agencies, their
local counterparts, and CDC. These agencies, which share a common mission,
constitute the vertical chain of public health. The effectiveness of PATCH largely
depends on the chain's functional capacity.
The PATCH program also requires horizontal collaboration and partnerships at
each of the three vertical levels. For example, at the national level, CDC has
gained support for PATCH by engaging cooperative efforts of national voluntary
agencies, foundations, other agencies within the Public Health Service, and other
federal agencies, including the Department of Transportation and the Cooperative
Extension Service of the Department of Agriculture (Figure 1).

Similarly, state health agencies have leveraged support of public, private, and
voluntary sector organizations to support PATCH. In the spirit of communuty
participation, PATCH programs at the local level are required to bring together
representatives of the community not only to maximize the probability that
existing health-related resources will be put to use, but also to ensure that the
interests, wants, and needs of the community are fairly represented throughout
the process.

Positioning PATCH within the context of a functional vertical and horizontal

system builds in the opportunity to provide technical assistance and training, so
essential for effective execution of complicated community intervention
programs. As a part of an established infrastructure, this support can be sustained
over time and thus provide continuity throughout the system.

Although PATCH operates within the existing system of official public health
agencies, its intention has been and continues to be the nurturing of prevention
leadership wherever it might be found at any of the three levels. For a variety of
reasons - political, economic, or financial - the local health agency may not
always be the most appropriate and/or effective focal point for PATCH; primary
care clinics, university groups, businesses, and other nongovernmental
organizations may be in a better position to exercise leadership for a PATCH
program. However, at a minimum, the local health agency should be engaged
actively in the process; it should serve as facilitator to nurture and support the
effort and as the key communication link both to sectors at the local level and to
the state health agency and CDC.

PATCH and Contemporary Health Promotion/Disease Prevention Policy

PATCH citizens provide a democratic mechanism to become either equal or

senior partners in determining the quality of life and health in their communities.
This approach is consistent with contemporary public health policy. Healthy
People 2000: National Health Promotion and Disease Prevention Objectives is a
comprehensive report that outlines the national strategy for improving the nation's
health in the decade from 1990 to 2000. The report calls upon communities to
translate national objectives into state and local action. To facilitate that
translation, Healthy Communities 2000: Model Standards provides a flexible
planning tool to enable communities to share in various efforts necessary to attain
these objectives; specifically, the document offers community implementation
strategies for putting the objectives of Healthy People 2000 into practice (Health
Communities 2000: Model Standards, 1991).

In discussing his vision for implementing these national health objectives, James
O. Mason, M.D., Assistant Secretary for Health, U.S. Department of Health and
Human Services, citing the importance of state and local participation,
specifically calls attention to the role PATCH can play as a critical part of the
nation's overall prevention strategy (Mason, 1990): "States and communities
must make their own decisions, based on assessments of health needs and
resources at their own levels. Using the national objectives as a template, they
can select priorities, objectives, and implementation plans to guide their efforts.
CDC's Planned Approach to Community Health (PATCH) program can be used
to define and refine those priorities into community action and public health
activities."

Comment: The Future of PATCH

One of the lessons learned from implementing PATCH reinforces the

"assessment" recommendations in the Institute of Medicine's Future of Public
Health (1988), and has important implications for health policy makers: none of
the communities participating in the program had any system or capacity to
collect data routinely that is adequate for planning and evaluating health
promotion programs. As a result, considerable time and effort go into gathering
those data.

Because of limited resources for the overall PATCH effort, data collection is
often carried out by persons who have little or no experience and only marginal
interest in the process; further, resources spent on data collection cannot be used
to implement the program. Communities need systems that can routinely and
efficiently gather data relevant to their prevention status. Such systems would not
only facilitate but also would help to establish standard databases, thus enabling
collection of comparable small-area data across divergent populations.

Although PATCH continues to have broad intellectual support, its future will be
dependent upon allocation of economic resources sufficient to support the
management, developmental, and technical assistance aspects of the program.
Economic support necessary to stimulate expansion has been problematic, largely
because government funding tends to target categorical problems, such as HIV/
AIDS, heart disease, unintentional and intentional injuries, and women's cancers.
Within these and other problem categories, one can find varying levels of support
for basic research, applied research and demonstration projects, and program
implementation and diffusion.

With a focus on transfer of community intervention technology through states to

localities, community PATCH applications do not start with an a priori health
problem; they begin with community members trying to understand what their
particular health problems are. Economic support is problematic in the absence
of a discernable problem up front.

In some cases, PATCH planning leads to a priority problem for which resources
are available; in others, where the indicated problem is not a priority of the
government, the community may have to choose between shifting focus to a
health issue for which there are available resources, or go without. This has been
a long standing problem with PATCH -- indeed, all community-based health
promotion programs that require extensive technical assistance face this dilemma.

If public health commitment to strengthening community competence is to go

beyond words, public health leaders must work with elected officials at all levels
to find a mechanism that will allocate health promotion resources equitably
without compromising the need to respond to categorical priorities.
References
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community participation. Health Promotion International, 5, 199-208.

Brandt, E.N. (1981). Block grants and the resurgence of federalism. Public Health
Reports, 96, 495-497.

Carlaw, R.W., Mittlemark, M., Bracht, N., & Lupker, R. (1984). Organization for
a community cardiovascuiar health program: Experiences from the Minnesota
Heart Health Program. Health Education Quarterly, 11, 243-252.

Cuoto, RA. (1990). Promoting health at the grass roots. Health Affairs, 9, 144-
151.

Farquhar, J.W., Fortmann, S.T., Wood, P.D., & Haskell, W.L.,. (1983).
Community studies of cardiovascuiar disease prevention. In N.M. Kaplan and J.
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Green, L.W. (1986). The theory of participation: A qualitative analysis of its

expression in national and international health policies. In W.B. Ward (Ed.),
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Green, L.W., & Kreuter, M.W. (1991). Health promotion planning: An

educational and environmental approach (2nd ed.). Mt. View, CA Mayfield
Publishing.

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Nelson, C.F., Kreuter, M.W., Watkins, N.B. & Stoddard, R.R. (1987). Planned
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Puska, P., Nissinen, J., Tuomilehto, J., & Salonen, T. (1985). The community
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