Picture a disease map: when a virus spreads, the dots on the map multiply, perhaps even bumping into and overlapping each other until the entire map is covered.

The result may be unsettling, even evoking fear.

But what if the dots on the map represented paying a compliment? Providing a ride home for someone who has had too much to drink? Answering a call for help?

That's the idea behind the Green Dot initiative: to spur the spread of active bystander behaviors, in particular among high school and college students, by educating them on how to prevent violence and shift social and cultural norms.

Since 2013, the CommonSpirit Mission and Ministry Fund, the philanthropic arm of CommonSpirit Health, has provided $6.3 million to support Green Dot programs in eight high schools in three areas of Kentucky. The money goes toward salaries of violence prevention coordinators, training of school personnel, and supplies. The funds also support a program in three middle schools called Sources of Strength. That program promotes mental health care and suicide prevention. The schools work in cooperation with CHI Saint Joseph Health's Flaget Memorial Hospital in Bardstown, Saint Joseph Mount Sterling, and Saint Joseph Berea as part of those three Kentucky hospitals' violence prevention programs.

The Green Dot program is homegrown in Lexington. It got its start there in 2006 at the University of Kentucky. The city has a Green Dot Lexington page on its website encouraging "small, individual and manageable actions and behaviors that express intolerance for violence."

Sherri Craig is market vice president, external relations for Lexington-based CHI Saint Joseph Health, part of CommonSpirit. She points out that while only about 20% of health outcomes are affected by traditional delivery of health care, about 55% can be affected by social determinants of health, including the environment where someone lives, attends school, or works.

"If you look at violence overall across our country, it really is an issue of public health," she said. "I think there's an important role for hospitals to play, to be proactive, rather than just to respond to situations when they occur."

According to the National Center for Education Statistics, one in every five students ages 12-18 experiences bullying. According to the United Health Foundation, Kentucky outpaces the nation in suicide rates for adolescents ages 15-19.

How Green Dot works
In Green Dot terms, each positive, preventative action or interaction is considered a green dot. A harmful, negative action or interaction is considered a red dot. The idea is to cover the participating school and overall community in green dots.

"Every student in the school has an idea of the Green Dot program, and then our students actually use the language, and that's kind of cool," said Brian Hill, a CHI St. Joseph Health violence prevention program manager who oversees initiatives in Madison County, Kentucky. "It's like, 'Hey man, that's a red dot. You need to quit doing that.' Or when we come to schools, we'll see a student that we just trained who will say, 'Hey, I did a green dot the other day. Let me tell you about it.'"

Hill explains to students that there are two types of green dots: reactive and proactive. A reactive dot is when people step in to help. "But we don't want to be in reactive mode all the time," he said. "We want to be proactive, so that these things don't happen to begin with."

For example, if a fight breaks out in a school, it's a common bystander reaction for students to film the fight or encourage it with chants, he said. A green dot move would be to intervene using one of the program's "three D's": distract, delegate or be direct.

Faculty and student ambassadors at schools are trained with the idea of spreading the Green Dot concepts to the rest of the school community. They meet regularly and come up with messaging and activities to draw awareness to Green Dot initiatives, such as a Green Dot Trot 5K hosted by Flaget Memorial Hospital in Bardstown. And, of course, there's Green Dot merch, like sweatshirts and water bottles, to promote the program.

The training covers recognizing problems, identifying barriers to solutions, learning how to intervene, and strengthening positive community norms.

"We train 15% of the student population, and they go out and use their influence within their peer groups to create culture change," explained Hill. "And the whole concept of the culture change is that violence is not OK and will not be tolerated."

Making a change
Communities can tailor the program to meet goals. In Nelson County, Kentucky, about 40 miles southeast of Louisville, the focus of the Green Dot program is to reduce bullying, threats and unwanted sexual advances and assaults. In Berea, about 40 miles south of Lexington, the priority is reducing power-based violence. In Mount Sterling, about 40 miles east of Lexington, the push is to reduce student disciplinary events.

Surveys in Nelson County and Berea from 2021 show about 17% of students in grades 6-12 reported being bullied, a drop from a baseline of 24% from when the programs were first implemented. Results weren't available yet for Mount Sterling programs.

Misty Roller is the CHI St. Joseph Health violence prevention program manager for Nelson County schools. She explained that Green Dot training is meant to help students build a community, so they know they're not alone as trained active bystanders.

Roller says she has more than 250 students on a waiting list to be trained. "And I think that's what we all want," she said. "We want to be part of something bigger, to make a change."

Roller took on her current role in September after serving as the community relations lead for the school system. She'd like to use that background to bring Green Dot training to area businesses as part of onboarding new employees. "The strategies we teach in Green Dot are strategies that all of us adults could use as well," she said.

Struggles and results
Hill and Roller said students today struggle with cyberbullying, the sharing of inappropriate or pornographic pictures on cell phones, and vaping — something they discuss as part of violence prevention because of the link between addiction and the potential for aggression, Roller explained.

Hill, who has worked with the program in schools for 10 years, said he's also seen attitudes of students change since the COVID-19 pandemic.

"It's almost like we've hit a reset button," he said. "We live in a culture where kids are so in their own world and in their own bubble, to where (they) don't care about anybody else: 'I'm gonna do me, and you do you, and if something bad happens to you, so be it.'"

Still, those who oversee Green Dot programs hear about results. Counselors report to them that students are increasingly pointing out other students who are struggling and may need help.

At one school, a student noticed that another student's shoes were worn out, bought a new pair, and asked a faculty member to pass them to the student in need, Hill said.

As to why students participate in Green Dot training, one wrote:

"I have been sexually assaulted, bullied, cyberbullied and mentally abused. I want to be able to do everything in my power to prevent other people from having to go through the gut-wrenching things I've had to experience. If I can help people who have been through those things, it would help heal my heart."

Hill recalled a time when a female student showed up to school feeling upset and was crying in the bathroom, and she told other girls that she wanted to end her life. Those girls told a Green Dot-trained student about the distressed girl. The trained student stayed with the distraught student while another student fetched a counselor. The girl ended up going to therapy and has been doing great since this incident, Hill said.

"To me, the fact that I feel one student's life was saved, everything else is just the cherry on top," said Hill. "You know, we've seen the impact. We've seen students get help. We've seen the culture change at our schools."