Applied community health

Kruger, D.J., Aiyer, S.M., Caldwell, C.H., & Zimmerman, M.A. (2013). Local scarcity of adult men predicts youth assault rates. Journal of Community Psychology, 42, 119-125..

Father involvement reduces risky youth behavior at the individual level. We examine the association between the scarcity of adult men and youth violence at the Census Tract level across a small Midwestern city experiencing decades of economic adversity and high rates of violence. We calculated the ratio of men to women aged 25-64 and indicators of concentrated disadvantage across residential Census Tracts with 2000 US Decennial Census data and the average monthly assault rates for those aged 10-24 between June 2006 and December 2008 with data from the local police department. Adult male scarcity and the proportion of individuals 25 or older who had less than a high school degree were the two unique predictors of youth assault rates, together explaining 69% of the variance. Interventions promoting effective social, material, and protective support from fathers and other adult male role models may ameliorate risk for youth violence.


Kruger, D.J., Greenberg, E., Murphy, J.B, DiFazio, D.A., & Youra, K.R. (in press). Local concentration of fast food outlets is associated with poor nutrition and obesity. American Journal of Health Promotion.

Purpose: We investigated the relationship of the local availability of fast food restaurant locations with diet and obesity.

Design: We geocoded addresses of survey respondents and fast food restaurant locations to assess the association between the local concentration of fast food outlets, BMI, and fruit and vegetable consumption.

Setting: Genesee County, Michigan.

Subjects: 1345 individuals were included in this analysis, the response rate was 25%.

Measures: The Speak to Your Health! Community Survey included fruit and vegetable consumption items from the Behavioral Risk Factor Surveillance System, height, weight, and demographics. We used ArcGIS to map fast food outlets and survey respondents.

Analysis: Stepwise linear regressions identified unique predictors of BMI and fruit and vegetable consumption.

Results: Survey respondents had 8 +/- 7 fast food outlets within 2 miles of their home. Individuals living in close proximity to fast food restaurants had higher BMIs t(1342) = 3.21, p < .001, and lower fruit and vegetable consumption, t(1342) = 2.67, p = .008.

Conclusion: Individuals may be at greater risk for adverse consequences of poor nutrition because of the patterns in local food availability, which may constrain the success of nutrition promotion efforts. Efforts to decrease the local availability of unhealthy foods as well as programs to help consumers identify strategies for obtaining healthy meals at fast food outlets may improve health outcomes.


Kruger, D.J., French-Turner, T.M., & Brownlee, S. (2013). Genesee County REACH windshield tours: Enhancing health professionals understanding of community conditions that influence infant mortality. Journal of Primary Prevention, 34, 163-172.

The Genesee County Racial and Ethnic Approaches to Community Health (REACH) program is a community-based program designed to reduce African American infant mortality rates in Flint, Michigan. Genesee County REACH activities address three core themes: fostering community mobilization, reducing racism, and enhancing the maternal infant health care system. The REACH Community Action Plan was generated using a community based participatory approach, and is based on a socio-ecological model with interventions focused at the individual, organizational, health system, and community levels. Genesee County REACH's Community Windshield Tours were developed to raise awareness of social and environmental barriers to health promotion among health care system staff in Flint, Michigan. These tours provide a close-up examination of the community's environmental conditions and the experiences of mothers, children, and families at risk for poor birth outcomes. In this article, we report our findings from pre-/post-tour surveys, as well as long-term follow-up surveys, to assess the impact of this REACH activity on participants' knowledge and beliefs about Genesee County residents, and to determine any resultant individual, policy, system, or environmental changes. We used t tests to compare participants' responses before and after the tours. We found that several individual- and systems-level changes have resulted from these tours, reflecting greater cultural sensitivity and increased understanding of patients' circumstances. African American infant mortality rates in Genesee County declined to a historic lowin 2005, and they remain lower than in previous years. Although REACH coalition partners recognize that this reduction cannot be attributed to a single intervention or activity, REACH activities such as the Community Windshield Tours addressingmultiple levels of the socio-ecologicalmodel may have had a synergistic effect.


Kruger, D.J., Shirey, L.A., Taylor, S. (2012). GIS facilitates community-based child lead screening efforts. Michigan Journal of Public Health, 6 (1), 32-50.

Background: Children at the highest risk for lead poisoning are African American, living in families with low incomes, or are living in housing built prior to 1946. The Greater Flint Lead Safe Children Program (GFLSCP) was designed to increase the proportion of African Americans under 6 years of age who are tested for lead in a State-designated high risk area for childhood lead poisoning.

Objective: We used Geographical Information Systems to create maps that facilitate program process and evaluation.

Methods: We created maps of neighborhood outreach coverage and lead screening results. We identified areas with higher concentrations of African American children under 6 years of age and housing units constructed prior to 1940.

Results: Digital maps organize program information and facilitate program process. Maps visually demonstrate the association between older housing stock and elevated blood lead levels, and assist GFLSCP staff in prioritizing areas at highest risk of lead poisoning. Analyses indicated that the proportion of houses built prior to 1940 predicted blood lead levels.

Conclusions: Geographic Information Systems provide an intuitive, visual means of tracking program progress and correspondence of intervention activities within the focus demographic and identified areas of concentrated risk.


Kruger, D. J., Turbeville, A. R., Greenberg, E.C., & Zimmerman, M.A. (2012). An increase in economic adversity is associated with poorer self-reported physical and mental health. Journal of Behavioral Health, 1, 134-137.

Numerous studies document the inverse relationship between socioeconomic status and health. The recent economic recession provides an opportunity to examine the relationship between temporal declines in financial status and health outcomes. We assessed the association of economic decline with health indicators at the individual level with data from 733 adult participants in a countywide survey conducted in Spring 2009. We included general health and mental health items from the Behavioral Risk Factor Surveillance System (BRFSS), Brief Symptom Inventory (BSI-18) depression subscale,(13) and Perceived Stress Scale. Analysis was conducted in 2011. The degree to which an individual's financial situation declined over the past year was associated with worse self-reported general and mental health, increased number of days that poor general and mental health interfered with daily activities in the past month, as well as higher levels of self-reported stress and depressive symptoms. These relationships were independent of education, income, age, gender and minority status. Our results indicate that a decline in financial status is associated with a decline in self-reported physical and mental health quality independent of traditional demographic and socioeconomic indicators.


Kruger, D. J., Munsell, M.A., & French-Turner, T. (2011). Using a life history framework to understand the relationship between neighborhood structural deterioration and adverse birth outcomes. Journal of Social, Evolutionary, and Cultural Psychology, 5, 260-274.

The physical deterioration of neighborhood buildings has physiological consequences. The local density of highly dilapidated residential structures was associated with the concentration of premature births and low birth weight births. Previous research has shown the consequences of the physical deterioration of neighborhoods for individuals' mental health and their perceptions of neighborhood social conditions; this is the first study to demonstrate a relationship with birth outcomes. Adverse birth outcomes and demographic disparities persist despite decades of clinical, scientific, and legislative efforts. The authors propose that community environments influence birth outcomes beyond associations with traditional socio-economic factors. The statistical relationship was not due to parental education, access to health insurance, or race. In fact, the effect was stronger within the African-American population and African American births were overrepresented in areas with high structural deterioration, suggesting that this phenomenon could partially underlie racial health disparities.


Kruger, D.J., Hamacher, L., Strugar-Fritsch, D., Shirey, L., Renda, E., & Zimmerman, M.A. (2010). Facilitating the development of a county health coverage plan with data from a community based health survey. Journal of Public Health Policy, 31, 199-211.

Community-Based Participatory Research (CBPR) includes the goals of generating data and shaping policy decisions, yet examples combining these goals are scarce in the literature. Data can be a powerful tool in advocating for policy change. This paper describes the use of a community-based survey to facilitate the development of a county health plan. The Genesee Health Plan (GHP) is a community-initiated non-profit organization that provides primary care, prescription drugs, and specialty care to uninsured, low-income adults through a network of independent physicians, clinics, and hospital systems. GHP advocates presented results from the Speak to Your Health! Community Survey, a study generated by a collaboration of community and university partners following CBPR principles, and other pertinent data to three local foundations and obtained $1.7M in grants to support infrastructure development. Two years later, GHP representatives presented survey results and other pertinent data to Genesee County Commissioners, who placed a property tax millage on the ballot to fund the health plan. The ballot initiative was successful, making Genesee County among the first counties in the nation to make basic health care available to nearly all of its uninsured, low-income adults. Our example fulfils an important component of the vision for CBPR, a substantial contribution to an emerging area of public health practice that is data driven, policy focused, and involves members of the community that are affected by the policy.


Kruger, D.J., Lewis, Y., & Schlemmer, E. (2010). Mapping a message for faith leaders: Encouraging community health promotion with local health data. Health Promotion Practice, 11, 837-844.

We used a community based health survey to share local health information with faith leaders. Geographical Information Systems identified survey respondents within two kilometers of places of worship. Results were tabulated for the community surrounding each place of worship and were compared to city and county level data. Faith leaders were presented with community-specific reports describing the health attributes of residents who lived in the surrounding area, in order to assist with the identification issues of concern and opportunities to develop health ministries to address these issues. Faith leaders were encouraged to share this information with members of their faith community and develop means of obtaining additional information on the subjects of interest. We believe that engaging faith leaders with neighborhood specific health information will be critical in providing an understanding of the importance of their voice in improving health outcomes of their faith community, the surrounding neighborhood, and the community at large. Our goal is to empower faith leaders to understand personal and community health issues and to act as a conduit for health related information and health promotion at a local level. Church health teams developed a HIV and STI prevention program for African American adolescents and young adults.


Kruger, D.J., Morrel-Samuels, S., Davis-Satterla, L., Harris-Ellis, B.J. & Slonim, A. (2010). Developing a Cross-Site Evaluation Tool for Diverse Health Interventions. Health Promotion Practice, 11, 555-561.

The Prevention Research Center of Michigan provided technical assistance for the evaluation of 10 projects funded by the Michigan Department of Community Health's (MDCH) Health Disparities Reduction Program. These projects varied considerably in focus, methodology, geographical coverage, and populations served. The authors developed a cross-site evaluation tool to complement the internal evaluations of the projects. The tool contains four sections based on priorities identified by MDCH: evidence-based practice, research-based learning/evaluation (including process, impact, and outcomes indicators), cultural competence, and sustainability. Recognizing the diversity of programmatic efforts and organizational evaluation capacity, the authors sought to enable each project to create the best evaluation possible given the resources and data available. Each section contains a range of components from basic questions to more advanced evaluation techniques. The instrument attempts to use the highest quality of information available for each project. This evaluation tool can be used by programs with diverse goals and methodology.


Kruger, D.J., & Valerio, M. A. (2009). Association between psychosocial factors and asthma in a demographically representative adult sample. Journal of Asthma, 46,708-711.

We conducted an analysis of a demographically representative community health survey to examine the association between psychosocial factors and asthma. Data from the Speak to Your Health! Community Survey, a community-based survey designed and implemented by university and community partners using Community Based Public Health (CBPH) principles to investigate health and social issues in Genesee County, Michigan was used in the analysis presented. The survey gathered information on self-reported mental and physical health status, disease diagnoses, health access and utilization, health promoting and health adverse behaviors, neighborhood conditions, and other topics. We sampled households in all residential census tracts in Genesee County, Michigan. One resident over 18 years of age was randomly selected within each household and participated in a telephone interview. The total sample size for the telephone survey in 2007 was 1748. The mean age of the participants was 54.7 (SD=15.69); 66% of participants were White, 26% African American, and 7% other race/ethnicity; and 15% of the population reported being diagnosed with asthma. Adults with asthma had significantly higher Body Mass Index, higher levels of social support, and higher levels of stress than adults without asthma. Clinicians and researchers should be aware of psychosocial factors impacting their adult patient populations and tailor patient care, communication, and community-based educational interventions to specifically address these.


Kruger, D.J., & De Loney, E. H. (2009). The association of incarceration with community health and racial health disparities. Progress in Community Health Partnerships: Research, Education, and Action, 3, 109-117.

Background: Bureau of Justice Statistics data indicate that the United States has the highest incarceration rate in the world, and substantial disparities exist between incarceration rates for Whites and minorities. Research on the impact of incarceration usually focuses on the sentenced individual and occasionally on the children of incarcerated parents. The health consequences of incarceration may also extend to other family members and friends left behind in the community, exacerbating racial disparities in physical and mental health.

Objectives: We used a community-based public health survey to assess how incarceration of a friend or family member was associated with physical and mental health status.

Methods: Participants provided information on physical and mental health status in a county- wide telephone health interview.

Results: Controlling for demographics and health-related behaviors, individuals knowing someone who was recently incarcerated reported worse mental and physical health. Blacks were more likely to report knowing someone who was incarcerated and also felt closer to the incarcerated individuals. The degree of felt closeness with someone incarcerated was positively correlated with worse physical health (Pearson r = 0.14; P < .01) and mental health (Pearson r = 0.09; P < .05).

Conclusions: Our results indicate that the incarceration of close others influences mental and physical health and the health disparities between Blacks and Whites. More attention should be given to the potential effects of incarceration on the people closest to those incarcerated.


Kruger, D.J., Shirey, L.A., Morrel-Samuels, S., Skorcz, S., & Brady, J.S. (2009). Using a community-based health survey as a tool for informing local health policy. Journal of Public Health Management and Practice, 15, 47-53.

Background. The Speak to Your Health! Community Survey is a biennial community-based survey designed and implemented by the Prevention Research Center of Michigan, whose central mission is to strengthen the capacity of the community to improve health.

Method. The survey was developed collaboratively by the university and community partners that comprise the Prevention Research Center of Michigan and focuses on health and social issues at the heart of the community of Genesee County, Michigan.

Findings. The results of this survey have been used to shape policy changes and strategic planning at the county health department and in local health intervention programs.

Conclusions. This project has demonstrated that useful quantitative data for addressing local public health policy and planning can be collected using the principles of community-based research.


Shirey, L.A., Griffith, D.M., Brady, J., Kruger, D.J., Morrel-Samuels, S., Greene-Moton, E. (2008). Challenges and lessons learned in developing a community-based health survey. Progress in Community Health Partnerships: Research, Education, and Action, 2, 99-104.

Background: Collecting community-level data to inform interventions and document change is critical to improving community health and eliminating health disparities. Ideally the process for designing the data collection tools will include representation from community, service, and academic institutions; yet the process for incorporating these diverse needs and perspectives can be challenging.

Objectives: This paper describes how a community-academic partnership designed a survey in 2003 and 2005 to examine proximal and distal factors influencing the health of residents in an urban community and surrounding county area.

Methods: The partnership used community-based public health research principles to guide the development of the telephone surveys, though to varying degrees.

Lessons Learned: Through these two iterations of developing the community survey, we learned to regularly clarify and revisit the purpose and goals of the survey; to communicate directly with and obtain the support of each individual partner; and to focus on building the capacity of the partners and partnership.


Kruger, D.J. (2008). Verifying the operational definition of neighborhood for the psycho-social impact of structural deterioration. Journal of Community Psychology, 36, 53-60.

The physical decay of neighborhoods is associated with social conditions such as disease risk, poor mental health, and fear of crime. Researchers assessing neighborhood effects commonly operationalize neighborhoods via municipal boundaries such as U.S. Census Tracts, although more sophisticated analyses examine structures within a defined radius of respondents, typically .25 mile. This study verifies the .25 mile heuristic as a sound operational definition for neighborhood residential structures consequential to social conditions with measures of social contact with neighbors, perceptions of social capital, fear of neighborhood crime, and satisfaction with neighborhood quality of life. Deteriorating commercial structures cluster in smaller areas than deteriorating residential structures, however the peak consequential radius appears to occur at four times the distance of residential structures.


Kruger, D.J., Reischl, T.M., & Gee, G.C. (2008). Neighborhood social conditions mediate the association between physical deterioration and mental health. American Journal of Community Psychology, 40, 261-271.

This study investigates how neighborhood deterioration is associated with stress and depressive symptoms and the mediating effects of perceived neighborhood social conditions. Data come from a community survey of 801 respondents geocoded and linked to a systematic on-site assessment of the physical characteristics of nearly all residential and commercial structures around respondents' homes. Structural equation models controlling for demographic effects indicate that the association between neighborhood deterioration and well-being appear to be mediated through social contact, social capital, and perceptions of crime, but not through neighborhood satisfaction. Specifically, residential deterioration was mediated by social contact, then, social capital and fear of crime. Commercial deterioration, on the other hand, was mediated only through fear of crime. Additionally, data indicate that the functional definition of a “neighborhood” depends on the characteristics measured. These findings suggest that upstream interventions designed to improve neighborhood conditions as well as proximal interventions focused on social relationships, may promote well-being.


Kruger, D.J., Brady, J.S., & Shirey, L.A. (2008). Using GIS to facilitate community-based public health planning of diabetes intervention efforts. Health Promotion Practice, 9, 76-81.

Data from a community survey were analyzed geographically to help facilitate local diabetes prevention efforts. Data were available from the Speak to Your Health! Community Survey, a community-based survey designed and implemented by The Prevention Research Center of Michigan (PRC/MI), whose central mission is to strengthen the capacity of the community to improve health. This survey was developed collaboratively by the university and community partners that comprise the PRC/MI and focuses on health and social issues at the heart of the community of Genesee County, Michigan. We used survey data matching U.S. DHHS criteria to calculate and geographically map diabetes risk scores and also mapped diabetes screening rates. These maps indicated that those areas where the estimated risk of diabetes was the highest had only moderate rates of diabetes screening relative to other areas. We have presented these results to those involved in local diabetes intervention programs with the intent that the data will be used in planning local prevention and intervention efforts.


Alaimo, K., Packnett, E., Miles, R., & Kruger, D.J. (2008). Fruit and Vegetable Intake Among Urban Community Gardeners. Journal of Nutrition Education and Behavior, 40, 94-101.

Objective: To determine the association between household participation in a community garden, and fruit and vegetable consumption among urban adults.

Design: Data were analyzed from a cross-sectional random phone survey conducted in 2003. A quota sampling strategy was utilized to ensure that all census tracts within the city were represented.

Setting: Flint, MI

Participants: 766 adults

Variables Measured: Fruit and vegetable intake was measured using questionnaire items from the Behavioral Risk Factor Surveillance System. Household participation in a community gardens was assessed by asking the respondent if they or any member of their household had participated in a community garden project in the last year.

Analysis: Generalized linear models and logistic regression models assessed the association between household participation in a community garden and fruit and vegetable intake, controlling for demographic, neighborhood participation, and health variables.

Results: Adults with a household member who participated in a community garden consumed 1.4 servings more of fruits and vegetables per day than those who did not participate, and were 3.5 times more likely to meet the "5 a day" dietary recommendation.

Conclusions and Implications: Intervention studies are needed to test the hypothesis that participation in a community garden will lead to an increase in fruit and vegetable consumption.


Kruger, D.J., Hutchison, P., Monroe, M.G., Reischl, T. & Morrel-Samuels, S. (2007). Assault Injury Rates, Social Capital, and Fear of Neighborhood Crime. Journal of Community Psychology, 35, 1-16.

This study develops an explanatory framework for fear of neighborhood crime based on respondents' social context and local rates of assault injuries. Rates of assault injuries within zip codes are based on hospital discharge records. We find that only four variables have a significant unique contribution to fear of crime; respondent's sex, perceptions of neighborhood social capital, and the rates of struck by/against assault injuries for the 10-24 and 50+ age groups. We also find that the perception of neighborhood social capital moderates the impact of assault injury rates on fear of crime; those who perceive a high level of neighborhood social capital exhibit less sensitivity to assault injury rates. We include a map of assault injury rates and fear of crime by ZIP Code and describe the community context related to our results.


Kruger, D. J. (2003). Integrating quantitative and qualitative methods in community research. The Community Psychologist, 36, 18-19.

There is a false dichotomy between using either quantitative or qualitative methods. Our research projects would be strengthened by making use of the range of available methods. Quantitative methods facilitate an understanding of the distribution of views in the population, which would be quite useful in a needs assessment of a community. These techniques are invaluable in evaluations of interventions and other types of comparisons. Qualitative methods allow one to capture the subtle nuances of a situation and present information in a way that the general population can relate to. Combining quantitative and qualitative techniques would provide a comprehensive description of an issue in a format that can easily be digested by a diverse body of stakeholders.