Public health practice in Communities WITH THIRUVENGADAM MUNIRAI CHAPTER OUTLINE a public health agency, such as the commissioner of health THEORIES OF COMMUNITY CHANGE 318 or agency staff. However, the principles of community plan A. Social Cognitive Theory 321 ning and evaluation pertain to B. Community Organization 321 in improving the community(stakeholders, policy cipatory Resea including an employee of a foundation, schoo C. Diffusion of Innovations Theory 322 office, or political party and any interested citizen. Social Marketing in Public Health 322 there are many ideas on how to improve the health of a com- D. Communication Theory 323 munity, many good ideas fail. Reasons include lack of com- Delphi Technique 323 munity or organizational support, lack of coordination, 2. Role of Media Communication 323 turf battles, inefficient and duplicative efforts, and failure E. Environmental Influences on Behavior 323 to use evidence-based interventions. Careful planning before II. STEPS IN DEVELOPING A HEALTH PROMOTION a project begins can make a significant impact on the success PROGRAM 325 of the pre A. Define Strategy and Assemble Team 325 This chapter discusses the steps involved in planning and B. Identify Primary Health Issues 325 evaluating a program, highlighting two special applications PRECEDE/PROCEED Model of community planning:(1) tobacco prevention, as ar 2. Planned Approach to Community Health 326 example of multiple successful community interventions 3. Mobilizing for Action through Planning and Partnerships 32 (Box 26-1), and(2) health disparities, one of the greatest C. Develop Objectives to Measure Progress 3 ublic health problems. a community is only as strong as its Healthy People 2020 327 weakest link. Therefore, public health practitioners shoul D. Select Effective Interventions 328 aim not just to raise health overall, but to raise most the Community Preventive Services 328 health of the vulnerable populations. Box 26-2 lists some 2. Cultural Congruence of Interventions 329 examples how health disparities have been successfully ddressed mplement Innovations 329 Many models and acronyms describe the steps of co munity planning(Box 26-3). They all have their strengths III. FUTURE CHALLENGES 330 and weaknesses. We follow mainly the steps outlined in the A. Integrating CLinical Care and Prevention 330 Centers for Disease Control and Prevention(CDC) model B. Integrating Community-Based Prevention with Other Community Health Assessment and Group Evaluation Community Services 330 (CHANGE). Other models are described in the section that C. E-Health 331 addresses their main emphasis. Any other model of com- IV. SUMMARY 331 munity planning likely works equally well as long as planners REVIEW QUESTIONS, ANSWERS, AND EXPLANATIONS follow the following basic principles Assemble community stakeholders and, in collaboration with them, define the agend nd pri Perform a needs assessment a Design measurable objectives and interventions Chapters 24 and 25 discuss the organization and health of the public health system overall. This chapter discusses the Build evaluation into the entire process theory and practice of improving community health. Theo Table 26-1 provides an overview of the process and pos ries are important because a theory-based program is more ible resources for each step. likely to be effective(see Chapter 15). The technical term for attempts to improve community health is community/ program planning . THEORIES OF COMMUNITY CHANGE Community planning is defined nized proces to design, implement, and evaluate a When behavioral factors are a threat to health, improving based project to address the needs of a health requires behavior change, Unhealthy behaviors(e.g Community planning is often the prov personnel in sedentariness) need to be replaced by healthy ones(e.g 318
CHAPTER 26 Public Health Practice in Communities Box 26-1 Prevention Efforts: Tobacco use(Cigarette Smoking) The decrease in tobacco use has been called one of the 10 great public airlines and buses, and changes to FDA rules for more oversight health achievements in the 20th century. This success illustrates what tobacco production and marketing is required to change community health practices. Several historic 6. States action States used excise tax on tobacco to fund factors came together to enable significant improvements in this smoking control programs, which led to the development important public health problem. and evaluation of community-level approaches to tobacco A. Credible evidence and effective interventions led to medical control 7. New litigation strategies opened up even more monies and created willingness in industry to agree to changes 1. Changes in understanding of the genesis of tobacco addiction eframed the problem as not one of individual control and choice Because of this high level of attention at all levels and significant but of addiction. Evidence for harm to nonsmokers(secondary unding for community prevention programs, multiple tobacco exposure)strengthened the case for regulation interventions to reduce smoking were developed, evaluated, 2. Behavioral and pharmacologic treatments became available, seminated. The U.S. Community Preventive Services recor making it easier to support smokers desiring to quit. combining strategies to B. Trusted experts and grassroots groups provided effective a Reduce exposure to environmental tobacco smoke. a Reduce tobacco use initiation, especially among adolescents, Increase tobacco use cessation 3. The American Cancer Society, American Association, and American Heart Association were each ating against Recommended interventions include tobacco independent from each other. I they formed a Smoking bans and restrictions in public areas, workplaces, and alition on smoking, which was later by the American Medical Association. This broad coalition led legitimacy to the a Increasing the unit price for tobacco produ a Mass media campaigns of extended duration using brief, 4. Grassroots efforts in many communities and from many sources recurring messages to motivate children and adolescents to ang king. Examples include fligh emain tobacco free pendants advocating for their right for a smoke-free workplace Provider reminders to counsel patients about tobaco d the Reader's Digest series educating its readers. The grassroots groups framed their issues as part of the broader Provider education combined with such reminders environmental protection movement and increased consumer a Reducing out-of-pocket expenses for effective cessation health consciousness C. Political will on many levels and available funds led to effective Multicomponent patient telephone support through a state quit 5. On a federal level, Congress passed several laws addressing tobacco labeling, advertising on TV and radio, smoking bans on odified from Institute of Medicine: Ending the tobacco problem: a blueprint for the nation, 2007: Task Force on Community Preventive Services S): Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke, Am/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,OxfordUniversityPress,http:/www.thecommunityguide.org/tobacco/tobacco.pd Box 26-2 Addressing Health Disparities Health in the U.S. population is characterized by pervasive and per- Empowering communities to a sense of increased ownership sistent health care disparities, sometimes also called health inequities. Despite the deeply rooted and intractable nature of many health care Ity participation parities,many states and communities have successfully imp a Addressing environmental factors such as safe walkabilit mented intervention to reduce them. Characteristics of successful bikeability of environment, and access to high-quality food programs include: n Making health equity a component of all policies, including a Strong data skills with geographic mapping of premature death clusters and other determinants of healtl Interventions against health inequities can be successful even on a a Strong coalitions among agencies, community leaders, and other ery small scale. Examples for such successful interventions include stakeholders librarians who visit schools to give each child a library card; public a Assessment of the community environment as a whole and housing directors who address lead and mold; and safe route to addressing the social determinants at the root of health school initiatives with "human school buses"(group of parents whe equities(e.g,, poverty, low rates for high school graduation take turns in walking children to school) ModifiedfromCentersforDiseaseControlandprEvention:hEalthdisparitiesandinequalitiesreport(chdir),2011.http://www.cdc minorityhealth/chdireport.html#execsummarY.IoMreportsonunequaltreatmentandreducinghealthcaredisparitieshttp://www.iom.edu/ Reports/201 1/State-and-Local-Policy-Initiatives-To-Reduce-Health-Disparities-Workshop-Summary asp
320 SECTION 4 Public Health Box 26-3 Frequently used Acronyms in Program Plannin CBPR Community-Based Participatory Research Community Health Assessment and Group Evaluation Diffusion of effective behavioral Interventions DOI Diffusion of innovations HEDIS Healthcare Effectiv Data and Information Set IOM Institute of Medicine MAP-II Mobilize, Assess, Plan, Implement, Track Mobilizing for Action through Planning and Partnerships NACCHO National Association of County and City Health Officials National Committee for Quality Assurance NPHPSP National Public Health Performance Standards Program PLANEI Plan, Link, Act, Network with Evidence-based Tools PAR CH Planned Approach to Community Health PRECEDE Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation PROCEED Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development RTIP Research Tested Intervention Program RE-AIM Reach, Effcacy, Adoption, Implementation, Maintenance SCT Social Cognitive Theory Specific, Measurable, Attainable, Relevant, and Timely ickness Prevention Achieved through Regional Collaborat lot an acronym, but a program emphasizing verb as a part of speech, meaning an action word Table 26- Overview of Steps for Community Program Design, Implementation, and Evaluation Step/Description Suggested resources 1. Create strategy and elicit COmmunityheAlthAssessmentandGroupEvaluation(change)http://www.cdc.gov/ 2. Identify primary health issues in CountyHealthRankingshttp://www.countyl National Public Health Performance Standar Mobilizing for Action through Planning and 3, Develop measurable process and People2020leadinghealthindicatorshttp://www.healthy gov/2020/default. aspx outcome objectives to assess progress HEDIS(Healthcare Effectiveness Data and Information Set) performance measures 4, Select effective interventions to help ide to Community Preventive Services achieve these objectives Guide to Clinical Preventive services Research-testedInterventionpRogramshttp://rtips.cancergow/rtips/index.do 5. Implement selected interventions. PartnershipforPrevention:http://preventioninfo.org/ CdcyNergYhttp://www.cdc.gov/healthcommunication/cdcynergy/ //rtips cancer. gov/rtip 6. Evaluate selected interventions Framework for program evaluation in public health based on objectives; use this http://www.cdc.gov/mmwr/preview/mmwrhtml/rr481lal.htmCdcyNergy www.re-alm.org Guides/ The-Community CancerControlP.l.A.N.e.t:http://cancercontrolplanet.cancergov/;Communitytoolboxhttp://ctb.ku.edu/en/defaultaspx:Debl:http:// exercise). Individual behavior, however, does not occur in a behavior change( see Chapter 15 for theories of individual vacuum; it is strongly influenced by group norms and behavior change. )A number of theories have been devel environmental cues. Practitioners aiming to change group oped to describe how individual change is brought about norms and environmental cues should be aware of theories through interpersonal interactions and community inter- of community changes. This is because, as with any behavior ventions. These theories can be broadly characterized change, practitioners will have a higher chance of success cognitive-behavioral theories and share the following key if they intervene in accordance with a valid theory of concepts
CHAPTER 26 Public Health Practice in Co a Knowledge is necessary, but is not in itself sufficient increase the problem-solving ability of entire communities produce behavior changes through achieving concrete changes towards social cause. Perceptions, motivations, skills, and social environment The theory includes several key concepts. Empowerment is are key influences on behavior a social action process that improves community's confi dence and life skills beyond the topic addressed. Empower Some well-known theories governing social change are ment is any social process that allows people to gain mastery social cognitive theory, community organization and other over their life and their community. For example, individual participatory approaches, diffusion of innovations, and in a community may feel more empowered as they work ommunication theory, Taken together, these theories can be together to strengthen their cultural identity and their com- ed to influence factors within a social-ecological frame- munity assets. Empowerment builds community capacity work, as follows: Interpersonal: Family, friends, and peers provide role nity to mobilize, identify, and solve social problems. It models, social identity, and support. Organizations: Organizations influence behavior through sen rganizational change, diffusion of innovation, and social many wavs such as through skill-building workshops that marketing strategies allow members of the community to become more effective Community: Social marketing and community organizing leaders n change community norms on behavior Critical consciousness is a mental state by which members Public policy: Public opinion process and policy changes a community recognIze the need for social change and are can change the incentives for certain behaviors and make ready to work to achieve those changes. Critical conscious them easier or more difficult (e ., taxes on high-sugar ness can be built by engaging individuals in dialogues, thei Although behavior can be changed directly through any Social capital refers to social resources such as trust, reci- ments also have a powerful impact on behaviorenviron of these levels, the physical, regulatory, and political procity, and civic engagement that exist as a result of network between community members. Social capital can connect individuals in a fragmented community across social bound A. Social Cognitive Theory aries and power hierarchies and can facilitate community building and organization. Social networking techniques Social cognitive theory(SCT) is one of the most frequently and increasing the social support are vital methods that Ised and robust health behavior theories, It explores the build social capital reciprocal interactions of people and their environments and Media advocacy is an essential component of community the psychosocial determinants of health behavior(see organizing. It aims to change the way community members look at various problems and to motivate community Environment, people, and their behavior constantly influ- members and policy makers to become involved. This occurs ence each other (reciprocal determinism). Behavior is not hrough a reliable, consistent stream of publicity about an mply the result of the environment and the person, just as organizations mission and activities, including articles and the environment is not simply the result of the person and news items about public health issues. Media advocacy relies behavior. According to SCT, three main factors affect the on mass media, which make it expensive. In the 21st centur likelihood that a person will change a health behavior: (1) social media and games can generate extensive publicity with self-efficacy(see Chapter 15),(2) goals, and(3)outcome minimal investment. Table 26-2 summarizes how social expectancies, in which people form new norms or new expec- marketing, public relations, and media advocacy comple- tations from observing others(observatic ment each ot B. Community Organization I. Participatory Research A heterogeneous mix of various theories covers community Immigrants and racial or ethnic minorities often distrust the organization. The social action theory describes how to health care system, making it more difficult for researchers able 26-2 Relationship of Social Marketing, Public Relations, and Media Advocacy Social Marketing Public Relations Media Advocacy Message focus Look at me Enhance image and Change your behavior relationship with public Individuals at risk General public Effect Individuals Social Benefits Motivates individual Develops strategic relationships Community change through policy Generates support for cause ModifiedfromMediaAdvocacytoAdvancePublicHealthPolicyUclaCenterforHealthpOlicyResearch2002.http://www.healthpolicy.uclaedu/healthdata/tw_media2.pdf
SECTION 4 Public Health and health practitioners to identify and address the health concepts. Next, early adopters will try out innovations, fol needs of these communities. For these groups, as well as lowed by members of the early majority and late majority. for building community capacity in general, various par Laggards are the last to accept an innovation. Consequently, ticipatory research methods have been proposed. Parti innovations need to be marketed initially to innovators cipatory efforts combine community capacity-building and early adopters, then need to address each segment in strategies with research to bridge the gap between the sequence. The relevant population segments are generall knowledge produced and its translation into interventions referred to as innovators 2.5% of the overall population) and policies early adopters(13.5%), early majority(34%), late majority Participatory action research(PAR)and communit (34%), and laggards(16%). based participatory research( CBPR)are two participatory The speed of adoption by any group depends on research approaches that have gained increasing popularity ceived characteristics of the innovations themselves. since the late 1980s. Both PAR and CBPR conceptualize advantage, the degree to which an innovation is perceived ommunity members and researchers working together to as being better than the idea it supersedes, is a consequence generate hypotheses, conduct research, take action, and learn of the following ogether. PAR focuses on the researcher's direct action within a participatory community and aims to improve Compatibility, the degree to which an innovation the performance quality of the community or an area of eived to be consistent with the existing values, current concern. In contrast, CBPR strives for an action-oriented processes, past experiences, and needs of potential pproach to research as an equal partnership between tradi tionally trained experts and members of a community. The a Low complexity, the degree to which an innovation is per- ommunity members are partners in the research, not sub ceived as easy to use cts. Both approaches give voice to disadvantaged com a Trialability, the opportunity to experiment with the inno munities and increase their control ar vation on a limited basis community improvement activities. d a Observability, the degree to which the results of an inno- vation are visible to others The guidelines for participatory research in health promotion describe seven stages in participation, from passive or no participation to self-mobilization. For both I. Social Marketing in Public Health goals and methods determined collaboratively, and Social marketing is typically defined as a program-planning findings and knowledge are disseminated to all partners. process that applies commercial marketing concepts and Participatory research is more difficult to execute because techniques to promote behavior change in a target audience. of greater time demands and challenges in complying Social marketing has also been used to analyze the social with external funding requirements. For example, if consequences of commercial marketing policies and activi actions require a negotiated process with the community, ties, such as monitoring the effects of the tobacco and food they may divert from a project plan previously submitted industries'marketing practices. As in commercial market- to a funder ing, social marketing depends on the following: Engaging the community in research efforts is essential in Audience segmentation. Dividing markets into small seg- translating research into practice. However, there are still large gaps in translating conclusions from well-conducted ments based on sociodemographic, cultural, or behav randomized trials into community practice. The Multisite ral characteristics anslational Community Trial is a research tool designed to bridge the gap. This trial type explores what is needed to address specific cognitive and behavioral patterns as well make results from trials workable and effective in real-world individual demographic characteristics. Therefore, tai settings and is particularly suited to practice-based research lored materials are more precise, but also more limited in such as the pre population reach and more expensive. For example, the CDCs VERB campaign(It's what you do")specially pro moted the benefits of daily physical activity to children 9to13 C. Diffusion of Innovations Theory Branding. Public health branding is the application of com To be successful, a community strategy needs to be dissemi mercial branding strategies to promote health behavior nated. Successful dissemination is called diffusion. Diffusion change. For example, a study recruited highly regarded of innovations(DOI) theory is characterized by four ele peers to make condom use"cool"among a group of men ments: innovations, communication channels, social systems t risk for hur (HIV) infec the individuals who adopt the innovation), and diffus ime. The DOI literature is replete with examples of success- Marketing mix. Addressing the four Ps of marketing ful diffusion of health behaviors and programs, including (product, price, place, promotion) and redefining them condom use, smoking cessation, and use of new tests and for social marketing(see next) echnologies by health practitioners. Although DOI theory can be applied to behaviors, it is most closely associated with inclue devices or products benefits that go with it. Price is an exchange of benefits and Groups are segmented by the speed with which they will costs and refers to barriers or costs involved in adopting the adopt innovations. Innovators are eager to embrace new behavior (e. g, money, time, effort), Place (making new