Public Health Practice in Communities

26 Public Health Practice in Communities

Chapters 24 and 25 discuss the organization and health of the public health system overall. This chapter discusses the theory and practice of improving community health. Theories are important because a theory-based program is more likely to be effective (see Chapter 15). The technical term for attempts to improve community health is community/program planning.

Community planning is defined as an organized process to design, implement, and evaluate a clinic or community-based project to address the needs of a defined population.1 Community planning is often the province of personnel in a public health agency, such as the commissioner of health or agency staff. However, the principles of community planning and evaluation pertain to any person who has a stake in improving the community (stakeholders, policy makers), including an employee of a foundation, school, mayor’s office, or political party and any interested citizen. Although there are many ideas on how to improve the health of a community, many good ideas fail. Reasons include lack of community or organizational support, lack of coordination, “turf battles,” inefficient and duplicative efforts, and failure to use evidence-based interventions. Careful planning before a project begins can make a significant impact on the success of the project.2

This chapter discusses the steps involved in planning and evaluating a program, highlighting two special applications of community planning: (1) tobacco prevention, as an example of multiple successful community interventions (Box 26-1), and (2) health disparities, one of the greatest public health problems. A community is only as strong as its weakest link. Therefore, public health practitioners should aim not just to raise health overall, but to raise most the health of the vulnerable populations. Box 26-2 lists some examples how health disparities have been successfully addressed.

Box 26-1 Prevention Efforts

Tobacco Use (Cigarette Smoking)

The decrease in tobacco use has been called one of the 10 great public health achievements in the 20th century. This success illustrates what is required to change community health practices. Several historic factors came together to enable significant improvements in this important public health problem.

A. Credible evidence and effective interventions led to medical consensus:

B. Trusted experts and grassroots groups provided effective advocacy:

C. Political will on many levels and available funds led to effective tobacco control.

Because of this high level of attention at all levels and significant funding for community prevention programs, multiple effective interventions to reduce smoking were developed, evaluated, and disseminated. The U.S. Community Preventive Services recommends a three-pronged approach combining strategies to:

Recommended interventions include:

Modified from Institute of Medicine: Ending the tobacco problem: a blueprint for the nation, 2007; Task Force on Community Preventive Services (TFCPS): Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke, Am J Prev Med 20(2 suppl):10–15, 2001; and Tobacco. In Zaza S, Briss PA, Harris KW, editors: The guide to community preventive services: what works to promote health? Atlanta, 2005, Oxford University Press,

Box 26-2 Addressing Health Disparities

Health in the U.S. population is characterized by pervasive and persistent health care disparities, sometimes also called health inequities. Despite the deeply rooted and intractable nature of many health care disparities, many states and communities have successfully implemented intervention to reduce them. Characteristics of successful programs include:

Interventions against health inequities can be successful even on a very small scale. Examples for such successful interventions include librarians who visit schools to give each child a library card; public housing directors who address lead and mold; and safe route to school initiatives with “human school buses” (group of parents who take turns in walking children to school).

Modified from Centers for Disease Control and Prevention: Health disparities and inequalities report (CHDIR), 2011. IOM reports on unequal treatment and reducing healthcare disparities.

Many models and acronyms describe the steps of community planning (Box 26-3). They all have their strengths and weaknesses. We follow mainly the steps outlined in the Centers for Disease Control and Prevention (CDC) model, Community Health Assessment and Group Evaluation (CHANGE).3 Other models are described in the section that addresses their main emphasis. Any other model of community planning likely works equally well as long as planners follow the following basic principles:

Table 26-1 provides an overview of the process and possible resources for each step.

I Theories of Community Change

When behavioral factors are a threat to health, improving health requires behavior change. Unhealthy behaviors (e.g., sedentariness) need to be replaced by healthy ones (e.g., exercise). Individual behavior, however, does not occur in a vacuum; it is strongly influenced by group norms and environmental cues. Practitioners aiming to change group norms and environmental cues should be aware of theories of community changes. This is because, as with any behavior change, practitioners will have a higher chance of success if they intervene in accordance with a valid theory of behavior change (see Chapter 15 for theories of individual behavior change.) A number of theories have been developed to describe how individual change is brought about through interpersonal interactions and community interventions. These theories can be broadly characterized as cognitive-behavioral theories and share the following key concepts:

Some well-known theories governing social change are social cognitive theory, community organization and other participatory approaches, diffusion of innovations, and communication theory. Taken together, these theories can be used to influence factors within a social-ecological framework, as follows:

Although behavior can be changed directly through any of these levels, the physical, regulatory, and political environments also have a powerful impact on behavior.

A Social Cognitive Theory

Social cognitive theory (SCT) is one of the most frequently used and robust health behavior theories.4 It explores the reciprocal interactions of people and their environments and the psychosocial determinants of health behavior (see Chapter 15).

Environment, people, and their behavior constantly influence each other (reciprocal determinism). Behavior is not simply the result of the environment and the person, just as the environment is not simply the result of the person and behavior.5 According to SCT, three main factors affect the likelihood that a person will change a health behavior: (1) self-efficacy (see Chapter 15), (2) goals, and (3) outcome expectancies, in which people form new norms or new expectations from observing others (observational learning).

B Community Organization

A heterogeneous mix of various theories covers community organization. The social action theory describes how to increase the problem-solving ability of entire communities through achieving concrete changes towards social cause. The theory includes several key concepts. Empowerment is a social action process that improves community’s confidence and life skills beyond the topic addressed. Empowerment is any social process that allows people to gain mastery over their life and their community. For example, individuals in a community may feel more empowered as they work together to strengthen their cultural identity and their community assets. Empowerment builds community capacity.

Community capacity is the unique ability of a community to mobilize, identify, and solve social problems. It requires the presence of leadership, participation, skills, and sense of community. Community capacity can be enhanced in many ways, such as through skill-building workshops that allow members of the community to become more effective leaders.

Critical consciousness is a mental state by which members in a community recognize the need for social change and are ready to work to achieve those changes. Critical consciousness can be built by engaging individuals in dialogues, forums, and discussions that clearly relate how problems and their root causes can be solved through social action.

Social capital refers to social resources such as trust, reciprocity, and civic engagement that exist as a result of network between community members. Social capital can connect individuals in a fragmented community across social boundaries and power hierarchies and can facilitate community building and organization. Social networking techniques and increasing the social support are vital methods that build social capital.6

Media advocacy is an essential component of community organizing. It aims to change the way community members look at various problems and to motivate community members and policy makers to become involved. This occurs through a reliable, consistent stream of publicity about an organization’s mission and activities, including articles and news items about public health issues. Media advocacy relies on mass media, which make it expensive. In the 21st century, social media and games can generate extensive publicity with minimal investment. Table 26-2 summarizes how social marketing, public relations, and media advocacy complement each other.

1 Participatory Research

Immigrants and racial or ethnic minorities often distrust the health care system, making it more difficult for researchers and health practitioners to identify and address the health needs of these communities. For these groups, as well as for building community capacity in general, various participatory research methods have been proposed. Participatory efforts combine community capacity–building strategies with research to bridge the gap between the knowledge produced and its translation into interventions and policies.7

Participatory action research (PAR) and community-based participatory research (CBPR) are two participatory research approaches that have gained increasing popularity since the late 1980s.8 Both PAR and CBPR conceptualize community members and researchers working together to generate hypotheses, conduct research, take action, and learn together. PAR focuses on the researcher’s direct actions within a participatory community and aims to improve the performance quality of the community or an area of concern.912 In contrast, CBPR strives for an action-oriented approach to research as an equal partnership between traditionally trained experts and members of a community. The community members are partners in the research, not subjects.13 Both approaches give voice to disadvantaged communities and increase their control and ownership of community improvement activities.10,13,14

The guidelines for participatory research in health promotion15 describe seven stages in participation, from passive or no participation to self-mobilization. For both approaches, the process is more important than the output, goals and methods are determined collaboratively, and findings and knowledge are disseminated to all partners.10,13 Participatory research is more difficult to execute because of greater time demands and challenges in complying with external funding requirements.1618 For example, if actions require a negotiated process with the community, they may divert from a project plan previously submitted to a funder.

Engaging the community in research efforts is essential in translating research into practice. However, there are still large gaps in translating conclusions from well-conducted randomized trials into community practice. The Multisite Translational Community Trial is a research tool designed to bridge the gap. This trial type explores what is needed to make results from trials workable and effective in real-world settings and is particularly suited to practice-based research networks such as the Prevention Research Centers.19

C Diffusion of Innovations Theory

To be successful, a community strategy needs to be disseminated. Successful dissemination is called diffusion. Diffusion of innovations (DOI) theory is characterized by four elements: innovations, communication channels, social systems (the individuals who adopt the innovation), and diffusion time. The DOI literature is replete with examples of successful diffusion of health behaviors and programs, including condom use, smoking cessation, and use of new tests and technologies by health practitioners.20 Although DOI theory can be applied to behaviors, it is most closely associated with devices or products.

Groups are segmented by the speed with which they will adopt innovations. Innovators are eager to embrace new concepts. Next, early adopters will try out innovations, followed by members of the early majority and late majority. Laggards are the last to accept an innovation. Consequently, innovations need to be marketed initially to innovators and early adopters, then need to address each segment in sequence. The relevant population segments are generally referred to as innovators 2.5% of the overall population), early adopters (13.5%), early majority (34%), late majority (34%), and laggards (16%).20

The speed of adoption by any group depends on the perceived characteristics of the innovations themselves. Relative advantage, the degree to which an innovation is perceived as being better than the idea it supersedes, is a consequence of the following:

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Aug 27, 2016 | Posted by in PUBLIC HEALTH AND EPIDEMIOLOGY | Comments Off on Public Health Practice in Communities

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