Journal Reflection � Strategic Planning for Chronic Disease Prevention in Rural America: Looking Through a PRISM Lens Amanda A. Honeycutt, PhD; Kristi

Strategic Planning for Chronic Disease Prevention
in Rural America: Looking Through a PRISM Lens

Amanda A. Honeycutt, PhD; Kristina Wile, MS; Cassandra Dove, MPH; Jackie Hawkins, MS;
Diane Orenstein, PhD
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Context: Community-level strategic planning for chronic disease
prevention. Objective: To share the outcomes of the strategic
planning process used by Mississippi Delta stakeholders to

prevent and reduce the negative impacts of chronic disease in

their communities. A key component of strategic planning was

participants’ use of the Prevention Impacts Simulation Model

(PRISM) to project the reduction, compared with the status quo,

in deaths and costs from implementing interventions in

Mississippi Delta communities. Design: Participants in
Mississippi Delta strategic planning meetings used PRISM, a

user-friendly, evidence-based simulation tool that includes 22

categories of policy, systems, and environmental change

interventions, to pose what-if questions that explore the likely

short- and long-term effects of an intervention or any desired

combination of the 22 categories of chronic disease intervention

programs and policies captured in PRISM. These categories

address smoking, air pollution, poor nutrition, and lack of

physical activity. Strategic planning participants used PRISM

outputs to inform their decisions and actions to implement

interventions. Setting: Rural communities in the Mississippi
Delta. Participants: A diverse group of 29 to 34 local chronic
disease prevention stakeholders, known as the Mississippi Delta

Strategic Alliance. Main Outcome Measure(s): Community
plans and actions that were developed and implemented as a

result of local strategic planning. Results: Existing strategic
planning efforts were complemented by the use of PRISM. The

Mississippi Delta Strategic Alliance decided to implement new

interventions to improve air quality and transportation and to

expand existing interventions to reduce tobacco use and

increase access to healthy foods. They also collaborated with the

J Public Health Management Practice, 2015, 21(4), 392–399
Copyright C 2015 Wolters Kluwer Health, Inc. All rights reserved.

Department of Transportation to raise awareness and use of the

current transportation network. Conclusions: The Mississippi
Delta Strategic Alliance strategic planning process was

complemented by the use of PRISM as a tool for strategic

planning, which led to the implementation of new and

strengthened chronic disease prevention interventions and

policies in the Mississippi Delta.

KEY WORDS: chronic disease, prevention, strategic planning,
systems modeling

Mississippi has the highest heart disease death rate
of any state in the nation.1 In 2007, 28.4% of all deaths
in Mississippi were attributable to cardiovascular dis-
ease (CVD).2 Mississippi also has correspondingly high
rates of risk factors and risk behaviors known to con-
tribute to the development of CVD. In 2009, 35% of
Mississippi adults were obese—the highest obesity rate
in the nation. Approximately 32% reported not partici-
pating in physical activity for the past 30 days; 17% con-
sumed 5 or more fruits or vegetables daily; 23% were
smokers, 37% had high blood pressure, and 41% had
high blood cholesterol.3 The Mississippi Delta (MSD)

Author Affiliations: Public Health Economics Program, RTI International,
Research Triangle Park, North Carolina (Dr Honeycutt); Systems Thinking
Collaborative, Stow, Massachusetts (Ms Wile); Mississippi Delta Health
Collaborative, Chronic Disease Bureau of the Offce of Preventive Health,
Mississippi State Department of Health, Jackson (Mss Dove and Hawkins); and
Division of Community Health, Centers for Disease Control and Prevention,
Atlanta, Georgia (Dr Orenstein).

The fndings and conclusions in this report are those of the authors and do not
necessarily represent the offcial position of the Centers for Disease Control and
Prevention. The authors declare no conficts of interest.

Correspondence: Amanda A. Honeycutt, PhD, Public Health Economics Pro-
gram, RTI International, 3040 Cornwallis Rd, PO Box 12194, Research Triangle
Park, NC 27709 (honeycutt@rti.org).

DOI: 10.1097/PHH.0000000000000062

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392

Strategic Planning for Disease Prevention ❘ 393

region has even higher rates of these CVD risk factors
and death rates than the state of Mississippi as a whole.

Federal, state, and regional public health advocates
are working together to address heart disease and
its risk factors in Mississippi. In 2008, in partnership
with the Centers for Disease Control and Prevention’s
Division for Heart Disease and Stroke Prevention, the
Mississippi State Department of Health created the
MSD Health Collaborative to build capacity within the
Delta region’s communities to address risk factors for
heart disease and stroke through policy, systems, and
environmental changes that would increase access to
physical activity, healthy foods, clinically based hyper-
tension management/prevention programs, and qual-
ity health care and increase tobacco prevention efforts.
The Mississippi Delta Strategic Alliance (MDSA) was
formed in 2009 to implement community-based initia-
tives that integrate multiple evidence-based strategies
to reduce CVD risk factors.

This article describes the MDSA strategic planning
process and outcomes. We focus on MDSA’s use of the
Prevention Impacts Simulation Model (PRISM) as an
important tool to support strategic planning, although
as with any strategic planning process, the MDSA syn-
thesized information from a variety of sources, in-
cluding PRISM outputs, community priorities, local
resources, and needs assessments, to decide which
interventions to implement.

● Methods

PRISM is a user-friendly, interactive simulation tool
that estimates the short- and long-term (up to year
2040) impacts of 22 categories of chronic disease inter-
ventions on health outcomes and costs.4 The PRISM
intervention strategies (listed in the Table) range
from individual-level intervention approaches, such
as smoking quit services, to policy and regulatory
changes with population-wide reach, such as local
policies requiring daily physical activity in schools or
statewide workplace smoking bans. The estimated im-
pact of each PRISM intervention on behavior changes
and costs is based on evidence from the peer-reviewed
published literature or on expert opinion when pub-
lished evidence was lacking or inconsistent. Figure 1
shows the PRISM framework; interventions modeled
in PRISM affect CVD risk factors, such as hyperten-
sion, smoking, and obesity, which in turn affect mor-
tality and costs from CVD and associated risk fac-
tors. PRISM allows users to visualize the relationship
between CVD risk factors and outcomes and to ex-
plore the likely impact of various intervention scenar-
ios on risk factor prevalence rates, CVD death rates, and
medical and productivity costs. When using PRISM to

support strategic planning, users frst determine the
current levels of each intervention approach relative to
the maximum possible implementation. For example,
if half of workers are already affected by workplace
smoking bans, then the current level of that interven-
tion is 0.50, or half of the full range between 0 and
the maximum level of 1. Users may then explore al-
ternative scenarios by adjusting the intervention levels
between 0 and 1 to examine the potential impact, rel-
ative to the current baseline, on short- and long-term
health outcomes and costs.

More details on PRISM and its assumptions are pro-
vided elsewhere,5 , 6 but as an example, we describe key
fruit and vegetable access assumptions. Based on ev-
idence in the literature, PRISM assumes that 41.3% of
adults have low fruit and vegetable consumption. At
baseline, 75% are assumed to have access to affordably
priced supermarkets and produce stands.7 Providing
access to affordable fruits and vegetables is assumed to
reduce the likelihood of a diet low in fruits and vegeta-
bles consumption by 40% (based on Morland et al8 and
expert opinion).

The MDSA held 3 strategic planning meetings in
the MSD between July 2009 and April 2010 during
which they used PRISM to inform their decisions.
Meeting participants included representatives from a
variety of state and local agencies (health, education,
transportation, and environmental), local medical
providers, academic leaders, community leaders,
and legislators. These meetings had 34, 31, and 29
participants, respectively, and included interactive,
facilitated discussions. The meeting facilitators con-
tributed to this article. PRISM provided participants
with quantitative information about the likely short-
and long-term impacts of various intervention com-
binations compared with no intervention baseline
forecasts. Strategic planning participants used PRISM
as a tool to inform decisions regarding which chronic
disease prevention activities to pursue.

During the frst meeting in July 2009, participants
discussed what a healthy Delta might look like. Using
PRISM, participants examined several alternative inter-
vention scenarios and identifed interventions with the
highest projected impact. At the second meeting in De-
cember 2009, participants again used PRISM to inform
their strategic planning decisions. Participants identi-
fed existing partners and organizations in their com-
munities and determined which interventions could
feasibly be implemented or enhanced by these part-
ners and organizations to have an impact in the Delta.
At the third meeting in April 2010, a diverse group
of participants (eg, Department of Transportation) was
brought together for an additional round of strategic
planning. Participants described their ongoing disease
prevention activities, which were then entered into

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394 ❘ Journal of Public Health Management and Practice

FIGURE 1 ● PRISM Model Overview
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

CHD indicates coronary heart disease; CHF, congestive heart failure; CV, cardiovascular; CVD, cardiovascular disease; PAD, peripheral artery disease.

PRISM using a facilitated process to reach consensus
on what portion of the maximum possible interven-
tion effort had been achieved. The facilitator led a dis-
cussion of what fraction of the population was being
reached and the intensity of each intervention. For ex-
ample, if 50% of the population was being reached,
and the intervention was being implemented in 50%
of all possible settings, then the intervention was rep-
resented as being at 25% (0.50 × 0.50) of its maximum
level. PRISM outputs demonstrated the expected short-
and long-term health and cost benefts relative to the no
intervention baseline forecasts. Participants then used
a similar process to identify possible incremental gains
in health outcomes from additional preventive inter-
ventions. They committed to implementing a selection
of additional preventive interventions, spending time
in small groups to create action plans for each inter-
vention. Because the locations varied, different groups
of stakeholders participated in each of these meetings,
yet a core group participated in all 3.

A national version of PRISM was developed that re-
fects the average prevalence of chronic disease risk
factors for the US population. To increase buy-in
from strategic planning participants, the version of the
model used in the MSD was calibrated to match the
population size and risk factor prevalence observed
in the Delta. For this calibration, local health depart-

ment partners in the MSD provided pooled census
data for the years 2000 through 2007 from which we
estimated population size by age, sex, and county for
the 11 counties in the Delta. We also used National
Health and Nutrition Examination Survey data for the
years 1999 through 2006 to estimate national risk factor
prevalence for hypertension, high blood cholesterol, di-
abetes, obesity, and smoking. We then used census data
for the 11 Delta counties to reweight risk factor preva-
lence estimates accounting for differences between the
United States as a whole and the Delta region in age,
sex, race/ethnicity, poverty, and prior CVD events. Be-
havioral risk factors for the population, such as lack
of vigorous physical activity and not having a regu-
lar health care provider, were obtained from the 2004
to 2007 Behavioral Risk Factor Surveillance System for
the MSD counties.

Participants in the strategic planning effort were able
to use PRISM to visualize the likely impact of cur-
rent interventions on CVD and non-CVD outcomes
and costs from 2010 through 2040 and then to com-
pare the current interventions trajectory with a base-
line refecting the pre-2009 CVD prevention efforts in
Mississippi that contributed to existing levels of risk
factor and disease prevalence. They also compared
outcomes and costs under several alternative scenar-
ios of adding new or expanding existing interventions.

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Strategic Planning for Disease Prevention ❘ 395

PRISM users can easily add from the menu of inter-
ventions or explore increases in the estimated popula-
tion reach or intensity of existing interventions using
the interactive model features. Users are provided with
graphs for each scenario that show disease prevalence,
deaths, costs, and other projected outcomes for the cur-
rent year and for each successive year through 2040.

● Results

The MDSA’s use of PRISM complemented the strate-
gic planning process already underway in the MSD.
Using PRISM as a tool for strategic planning, partici-
pants identifed specifc actions to reduce the impacts
of chronic disease in the Delta.

Integration of diverse chronic disease
prevention efforts

The strategic planning meetings brought together par-
ticipants from multiple sectors and allowed them to see
how their own sector’s activities were contributing to
improved interventions and outcomes. This shared ex-
perience and learning are important outcomes of strate-
gic planning. The importance of creating a technical
package of a limited number of high priority, evidence-
based interventions and bringing a range of partners
and coalitions together are 2 of 6 components that
have been highlighted for effective public health pro-
gram implementation.9 PRISM may help contribute to
shared learning among a diverse group of planning
participants, because it integrates multiple risk factors
into a single model, enabling discussion about which
organizations are working in each intervention area.
PRISM was used to demonstrate the combined impact
of stakeholders’ efforts on chronic disease prevalence
and cost. Participants planned to align their goals and
reduce program duplication and costs. For example,
participants identifed a shared need to catalog exist-
ing resources, such as preventive care services, farmers’
markets, and recreational facilities, for each geograph-
ical area. Partners would use this resource to identify
where gaps and redundancies existed.

Evaluation of future impact of today’s policies

A goal for the strategic planning group was to ana-
lyze their past investment of resources to determine
expected future trajectories of risk factors, chronic
diseases, and costs if preventive efforts are sustained at
existing levels. Strategic planning facilitators perceived
that participants were encouraged by the simulated
long-term impact of current efforts and motivated
to implement new interventions (described later) to

further reduce chronic disease. Participants also used
the simulated estimates to communicate the potential
benefts of policy change through presentations to
their stakeholders.

Intervention implementation

By using PRISM in small groups, the participants were
able to experiment with different combinations of in-
terventions during their second meeting in December
2009. At the start of the third meeting in April 2010,
the facilitator used PRISM to demonstrate how MDSA
members’ recent efforts were affecting CVD outcomes
and to illustrate the long-term potential impact of sus-
taining those efforts. Participants also committed to
implementing new interventions and expanding sev-
eral existing interventions by increasing the intensity
of intervention efforts and/or the number of people
reached. Their use of PRISM helped inform these deci-
sions because PRISM allowed them to visualize which
intervention options have the greatest impacts in terms
of improving population health. The intervention ap-
proaches that MDSA participants committed to adopt
during the April 2010 meeting are described in the sub-
sections later.

Mississippi Delta strategic planning participants
committed to adopt or expand the following evidence-
based chronic disease prevention efforts: workplace
smoking bans, air pollution restrictions, fruit and
vegetable access, fruit and vegetable promotion,
preventive care for residents who have experienced a
previous CVD event (ie, post-CVD) and those who have
not, and acute care and rehabilitation for post-CVD
residents. Participants were already engaged in chronic
disease prevention efforts that touched on 20 of the
22 CVD prevention interventions included in PRISM
(all except air pollution and physical activity require-
ments in child care). The level of effort for each of these
interventions is shown in the Table as MSD sustained
efforts. After using PRISM in the April 2010 strategic
planning session, participants agreed, at a minimum, to
double existing efforts for 6 interventions and to begin
working on a new intervention, air pollution restric-
tions (see the Table). The levels of increased interven-
tion efforts are shown in the Table as MSD additional
efforts for the following interventions: preventive care
for both pre- and post-CVD events, acute care and
rehabilitation for post-CVD events, fruit and vegetable
access and promotion, and workplace smoking bans.

Figures 2 and 3 show the simulated impacts on
death rates and medical and productivity costs of im-
plementing what participants viewed as feasible lev-
els of the 7 new or expanded interventions. We as-
sumed that all interventions are implemented during a
2-year period and that they are sustained through 2040.

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396 ❘ Journal of Public Health Management and Practice

TABLE ● PRISM Intervention Levels
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Intervention Baseline MSD Sustained MSD Sustained
Category PRISM Interventionsa Levelb Effortsc + Additional Effortsd
Clinical Preventive care precardiovascular event 0 0.25 0.5

Preventive care postcardiovascular event 0 0.3 0.6
Acute care and rehabilitation for cardiovascular events 0 0.25 0.5

Behavioral support Smoking quit services 0 1 1
Weight loss services 0 0.25 0.25
Distress support services precardiovascular event 0 0.25 0.25
Distress support services postcardiovascular event 0 0.25 0.25

Health promotion and access Smoking counter-marketing 0 0.3 0.3
Energy dense (junk) food counter-marketing 0 0.1 0.1
Fruit and vegetable promotion 0 0.1 0.6
Fruit and vegetable access 0 0.25 0.6
Physical activity promotion 0 0.1 0.1
Physical activity facilities access 0 0.25 0.25
Physical activity in schools 0 0.5 0.5
Physical activity in childcare facilities 0 0 0

Taxes and regulation Tobacco taxes 0 0.25 0.25
Tobacco marketing restrictions 0 0.9 0.9
Workplace smoking bans 0 0.1 0.25
Air pollution restrictions 0 0 0.1
Energy dense (junk) food taxes 0 0.1 0.1
Sodium reduction in processed food 0 0.1 0.1
Trans fat reduction in processed food 0 0.1 0.1

Abbreviation: MSD, Mississippi Delta.
aThis manuscript uses a version of PRISM (CVD 09v2q MSD11) that is no longer current.
bBaseline intervention values are normalized to average Mississippi values for 2009.
cRefects intervention levels for the cardiovascular disease prevention efforts that MSD implemented as a result of strategic planning efforts before July 2009. The possible range
is from 0 to 1.
dRefects expansion of 6 intervention levels and the adoption of 1 new intervention (shown in bold) as a result of strategic planning using PRISM. The levels of all other interventions
are maintained at their initial sustained levels. The possible range is from 0 to 1.

The fgures also refect the impacts of demographic
changes, such as population aging as refected in US
Census bureau population forecasts for the Delta coun-
ties, and the combined effects of expected changes in
all of the risk factors. Figure 2 illustrates that sustaining
current efforts and expanding or implementing 7 inter-
ventions are expected to reduce Mississippi death rates
from CVD risk factors by more than 15% in 2040 com-
pared with the baseline. The expected future medical
and productivity net costs of CVD and its risk factors
are projected to decrease by more than 12% in 2040
compared with the baseline, assuming the MDSA fully
sustains 14 existing CVD prevention interventions, ex-
pands 6 existing interventions, and adopts 1 new inter-
vention (Figure 3).

Tobacco and smoking

Participants from Mississippi’s Offce of Tobacco
Control have been pursuing tobacco policy changes,

and the cigarette tax rate increased from $0.18 to
$0.68 per pack in spring 2009—the frst increase in
almost 30 years. Although these efforts were initi-
ated prior to MDSA’s strategic planning meetings,
the PRISM results provided strong verifcation for
the increased tax by showing the future impact on
CVD events, non-CVD events, deaths, and costs.10-12

These efforts are refected in PRISM as sustained
levels through 2040 for the tobacco tax intervention
(Table).

In addition, the Offce of Tobacco Control used
the PRISM results to identify local county clean air
acts as important interventions to reduce CVD events
and deaths.13-16 This led to MDSA’s commitment to
gather signatures for smoking bans at the county level,
and they are now pursuing a state-level smoke-free
policy. A 150% increase in the workplace smoking
bans intervention in PRISM allowed strategic planning
participants to visualize the likely impact of these ef-
forts (see the Table).

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Strategic Planning for Disease Prevention ❘ 397

FIGURE 2 ● Death Rate Comparisons of Cumulative
Simulations for Baseline, Sustained Interventions, and
Additional Interventions for Mississippi Delta
(2000-2040)
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

Fruits and vegetables access and promotion

Limited access to fresh fruits and vegetables in rural
areas has been identifed as a potential barrier to res-
idents’ consumption of a healthy diet,8 and strategic
planning participants described that access is prob-
lematic in the MSD population. To address this issue,
participants decided to implement interventions to in-
crease access to fruits and vegetables. The initial action
was to increase advertising and media efforts to make
residents more aware of locations and times for existing
farmers’ markets. They also formed a 3-organization
collaboration to expand the number of farmers’ mar-
kets to further increase access to all residents within
the MSD region. These efforts are expected to more
than double levels for the PRISM interventions fruit
and vegetable access and fruit and vegetable promo-
tion (see the Table).

FIGURE 3 ● Cost Comparisons of Cumulative Simulations
for Baseline, Sustained Interventions, and Additional
Interventions for Mississippi Delta (2000-2040)
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

Transportation

Even before strategic planning meetings were held,
MDSA identifed low utilization of existing preventive
care and community services as a problem that needed
to be addressed. When MDSA presented the current
conditions to strategic planning participants, the par-
ticipants were interested in how they might improve
access to preventive care, treatment services, and nutri-
tious foods. An important contribution of using PRISM
for strategic planning is that it enabled participants to
think more broadly about the interconnections between
risk behaviors, diseases, and their wider environment.
As a result, discussions among strategic planning
participants highlighted potential actions that might
reduce the barriers and thus increase access to and
utilization of care and services. The MDSA strategic
planning participants identifed the lack of transporta-
tion as a major barrier to obtaining preventive health
care, treatment, and healthy foods.17 Thus, improving
public transportation could have long-term impacts on
disease prevalence and costs. To begin to address the
transportation needs of MSD residents, MDSA mem-
bers invited representatives from the Mississippi De-
partment of Transportation to attend their April 2010
meeting. The MDSA members are now working with
the Department of Transportation to raise awareness
and use of the transportation network presently in
place and have participated in transportation regional
planning meetings. These improvements in transporta-
tion were assumed to double the levels of 3 PRISM in-
terventions: preventive care for the post-CVD event
population, preventive care for the non-CVD event
population, and acute care and rehabilitation for CVD
events.

Air quality

Using PRISM allowed strategic planning participants
to identify potential contributors to chronic disease out-
comes and costs that they were not already addressing
through existing public health intervention efforts. For
example, participants identifed that interventions to
improve local air quality could have a considerable im-
pact on chronic disease outcomes and costs. Air quality
is an important risk factor for heart and respiratory
disease and deaths.18 , 19 Once MDSA participants iden-
tifed poor air quality as an important contributor to
chronic disease in the MSD that they could intervene to
improve, a representative from the Mississippi Depart-
ment of Environmental Quality was invited to attend
the April 2010 MDSA meeting. Following discussion
about specifc intervention efforts that could improve
local air quality, MDSA participants committed to
work toward engine-idling restrictions for schools,
government vehicles, and distribution centers. The

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

398 ❘ Journal of Public Health Management and Practice

Department of Environmental Quality will also work
with other partners to develop alternatives to agricul-
tural burning in the Delta. These efforts are refected in
the Table as the adoption of a new local air pollution
restriction intervention.

● Conclusions

Strategic planning in the MSD was enhanced by the use
of PRISM to examine the potential impact of alternative
chronic disease interventions. PRISM is an evidence-
based simulation tool for strategic planning that can
help organizations examine the potential impacts of
their current and additional intervention efforts over
short and long time horizons. PRISM visually depicts
the causal pathways of many different risk behaviors
and clinical risk factors that lead to CVD and other
chronic diseases.

The MDSA’s use of PRISM complemented the strate-
gic planning process already underway in the MSD.
Strategic planning participants committed to maintain-
ing 14 interventions, expanding 6 interventions, and
adopting 1 new intervention. The MDSA participants
reported that PRISM was especially useful for pictur-
ing the likely impact of interventions that they might
not have considered in the absence of PRISM simu-
lation results (eg, air pollution interventions). PRISM
also helped participants recognize that health and cost
impacts can be greater when organizations that share
overarching goals work together.

Even with its population-specifc calibrations,
PRISM, like any model, incorporates simplifcations
and does not capture the full complexity of chronic
disease. PRISM should not be viewed as an oracle that
provides answers about what to do. Rather, it is a de-
cision support tool that provides diverse stakehold-
ers with an evidence basis to work collectively and
think clearly about chronic disease in the local context.
Users should also consider community priorities exter-
nal to PRISM, such as social justice and health equity,
as well as local resources and context, when deciding
which chronic disease interventions to implement, as
the MDSA did during its strategic planning process. In
addition, there are many assumptions about effect sizes
in PRISM, where each effect has a range of uncertainty.
Sensitivity testing has been done to better character-
ize ranges of results over the long term, and although
not a part of the engagement with Mississippi, results
support the MDSA conclusions about effective inter-
vention options. Another limitation is that the MSD
version of PRISM used national data on the prevalence
of hypertension, high blood cholesterol, diabetes, obe-
sity, and smoking, adjusted to refect the demographic
profle of the MSD population. Even if these adjusted

numbers over- or undercount risk factor prevalence in
the Delta, any bias should affect baseline and postinter-
vention estimates in the same direction and therefore
have little impact on the simulated differences from
baseline. Finally, PRISM assumes that community in-
terventions will have the effect sizes reported in the
published literature and that the interventions will be
implemented over 2 years a

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