Community-Based Health Interventions E-Book

Sally Guttmacher

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 384

Veröffentlichungsjahr: 2010

Beschreibung

Community-Based Health Interventions covers the skills necessary to change health in a community setting through the reduction of disease, disease conditions, and risks to health, as well as create a supportive environment for the maintenance of the behavior changes. The first section provides background information about why interventions in communities are important, the history of several major community interventions, ethical issues in the design and implementation of interventions and the different types of interventions. The second section covers planning and activities needed to complete an intervention, along with the theoretical basis of interventions. The third section shows how to assess the needs and strengths of a particular community, gain community support, define the goals of an intervention and get started. This section also contains information on obtaining material and financial support and on strategies for continuing the intervention beyond its initial phase. The final section examines current work and problems encountered as well as projecting future trends. Each chapter includes practice exercises or activities useful to students learning to develop interventions at the population or community level, such as public health, social work and nursing.

Leseprobe

Table of Contents

Cover

Title

Copyright

Table of Exhibits

PREFACE

ACKNOWLEDGEMENTS

THE AUTHORS

PART 1: INTRODUCING COMMUNITY-BASED INTERVENTIONS

CHAPTER 1: IMPROVING HEALTH IN COMMUNITY SETTINGS

LEARNING OBJECTIVES

OVERVIEW

DEFINING COMMUNITY

ECOLOGICAL THEORY AND LEVELS OF PREVENTION

SUMMARY

KEY TERMS

ACTIVITY

DISCUSSION QUESTIONS

CHAPTER 2: A BRIEF HISTORY OF COMMUNITY-BASED HEALTH INTERVENTIONS

LEARNING OBJECTIVES

OVERVIEW

COMMUNITY-BASED HEALTH INTERVENTIONS: AN INSTRUMENT FOR CHANGE

EARLY COMMUNITY-BASED HEALTH INTERVENTIONS

ASSESSING THE EVIDENCE FROM EARLY COMMUNITY-BASED HEALTH INTERVENTIONS

THE EVOLUTION OF COMMUNITY-BASED HEALTH INTERVENTIONS

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTIONS

CHAPTER 3: ETHICAL ISSUES IN COMMUNITY INTERVENTIONS

LEARNING OBJECTIVES

OVERVIEW

THE INTEGRATION OF ETHICS INTO PUBLIC HEALTH PRACTICE

INSTITUTIONAL REVIEW BOARDS

VULNERABLE POPULATIONS

PERMISSION AND CONSENT

PROTECTION FOR RESEARCH PARTICIPANTS

ENSURING RESEARCH QUALITY

MAINTAINING THE INTEGRITY OF RESEARCH

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTION

CHAPTER 4: LEVELS AND TYPES OF COMMUNITY-BASED INTERVENTIONS

LEARNING OBJECTIVES

OVERVIEW

AN ECOLOGICAL FOCUS ON TYPES OF PREVENTION

SELECTING A GOAL FOR THE INTERVENTION

EXAMPLES OF INTERVENTIONS AT DIFFERENT LEVELS OF PREVENTION

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTIONS

PART 2: DEVELOPING THE INTERVENTION

CHAPTER 5: A FRAMEWORK FOR DESIGNING COMMUNITY-BASED INTERVENTIONS

LEARNING OBJECTIVES

OVERVIEW

THEORETICAL GUIDANCE FOR HEALTH INTERVENTIONS

EXAMPLES OF THEORIES USED AT THE FOUR ECOLOGICAL LEVELS

SUMMARY

KEY TERMS

ACTIVITY

DISCUSSION QUESTIONS

CHAPTER 6: COLLECTING AND MANAGING DATA

LEARNING OBJECTIVES

OVERVIEW

DATA: A CRUCIAL COMPONENT OF RESEARCH

COLLECTING QUANTITATIVE DATA

COLLECTING QUALITATIVE DATA

AFTER DATA COLLECTION

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTIONS

PART 3: WORKING THROUGH THE INTERVENTION

CHAPTER 7: ASSESSING COMMUNITY NEEDS

LEARNING OBJECTIVES

OVERVIEW

BASIC COMPONENTS OF A COMMUNITY ASSESSMENT

STRENGTHENING YOUR FINDINGS

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTIONS

CHAPTER 8: PLANNING A COMMUNITY-BASED INTERVENTION

LEARNING OBJECTIVES

OVERVIEW

INTERVENTION CONTENT AND FORMAT

A LOGIC MODEL AS AN ORGANIZING STRATEGY

A FICTIONAL COMMUNITY ASSESSMENT: ADOLESCENT TOBACCO USE

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTIONS

CHAPTER 9: IMPLEMENTING A COMMUNITY-BASED INTERVENTION

LEARNING OBJECTIVES

OVERVIEW

IMPLEMENTATION AT THE FOUR ECOLOGICAL LEVELS

INTERVENTIONS AT THE COMMUNITY OR POLICY LEVEL

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTIONS

CHAPTER 10: EVALUATING A COMMUNITY-BASED INTERVENTION

LEARNING OBJECTIVES

OVERVIEW

REASONS FOR EVALUATION

PREPARING FOR AN EVALUATION

DESIGNING THE EVALUATION

FLEXIBILITY: AN ESSENTIAL SKILL IN EVALUATION

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTION

PART 4: LEARNING FROM THE PAST AND ADAPTING TO THE FUTURE

CHAPTER 11: FUNDING AND SUSTAINABILITY

LEARNING OBJECTIVES

OVERVIEW

FINANCING COMMUNITY-BASED HEALTH INTERVENTIONS

COMPONENTS OF THE PROPOSAL FOR FUNDING

COMPONENTS OF THE BUDGET

CONTINUING AND SUSTAINING AN INTERVENTION

SUMMARY

KEY TERMS

ACTIVITIES

DISCUSSION QUESTIONS

CHAPTER 12: IMPLEMENTATION PITFALLS

LEARNING OBJECTIVES

OVERVIEW

THINGS HAPPEN

SUMMARY

ACTIVITY

DISCUSSION QUESTIONS

CHAPTER 13 - THE FUTURE OF COMMUNITY-BASED HEALTH INTERVENTIONS

LEARNING OBJECTIVES

OVERVIEW

ADAPTING METHODS OF INTERVENTION TO TWENTY-FIRST-CENTURY COMMUNITIES

A CHALLENGE AND AN OPPORTUNITY FOR PUBLIC HEALTH PRACTITIONERS

A LIMITATION OF THE NEW TECHNOLOGIES

SUMMARY

ACTIVITIES

DISCUSSION QUESTIONS

CHAPTER 14: COMMUNITY-BASED HEALTH INTERVENTIONS IN PRACTICE

OVERVIEW

ARTHRITIS

REFERENCE

ASTHMA

REFERENCES

ADULT VACCINATIONS

REFERENCE

ALCOHOL USE

REFERENCE

CARDIOVASCULAR DISEASE

REFERENCE

CHILDHOOD VACCINATIONS

REFERENCE

INJURIES FROM MOTOR VEHICLE ACCIDENTS

REFERENCE

SEXUAL ASSAULT AND RELATIONSHIP VIOLENCE

REFERENCE

SMOKING

REFERENCES

SUMMARY

GLOSSARY

REFERENCES

INDEX

End User License Agreement

List of Tables

CHAPTER 1: IMPROVING HEALTH IN COMMUNITY SETTINGS

TABLE 1.1 Examples of community-based health interventions by levels of prevention

CHAPTER 4: LEVELS AND TYPES OF COMMUNITY-BASED INTERVENTIONS

TABLE 4.1 Health problem #1: adults and type 2 diabetes

TABLE 4.2 Health problem #2: preventing asthma attacks among children

CHAPTER 5: A FRAMEWORK FOR DESIGNING COMMUNITY-BASED INTERVENTIONS

TABLE 5.1 Key constructs and intervention activities

TABLE 5.2 Six key concepts of social cognitive theory

CHAPTER 8: PLANNING A COMMUNITY-BASED INTERVENTION

TABLE 8.1 Components of a logic model

TABLE 8.2 Logic Model: Group-level domain

TABLE 8.3 Logic Model: Organization-level domain

TABLE 8.4 Logic Model Community-level domain

TABLE 8.5 Logic Model: Policy-level domain

CHAPTER 9: IMPLEMENTING A COMMUNITY-BASED INTERVENTION

TABLE 9.1 Interventions to decrease obesity at four ecological levels

TABLE 9.2 One-year implementation timeline

TABLE 9.3 Content and schedule for dance class

TABLE 9.4 Staff training schedule

CHAPTER 10: EVALUATING A COMMUNITY-BASED INTERVENTION

TABLE 10.1 Sample evaluation timeline

CHAPTER 11: FUNDING AND SUSTAINABILITY

TABLE 11.1 Example of budget justification for HIV prevention intervention: twelve-month period

List of Illustrations

CHAPTER 5: A FRAMEWORK FOR DESIGNING COMMUNITY-BASED INTERVENTIONS

FIGURE 5.1

The advocacy coalition framework

CHAPTER 6: COLLECTING AND MANAGING DATA

EXHIBIT 6.1 Sample survey with data entry codes

Guide

Cover

Table of Contents

Begin Reading

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COMMUNITY-BASED HEALTH INTERVENTIONS

Principles and Applications

SALLY GUTTMACHER

PATRICIA J. KELLY

YUMARY RUIZ-JANECKO

Copyright © 2010 by John Wiley & Sons, Inc. All rights reserved.

Published by Jossey-BassA Wiley Imprint989 Market Street, San Francisco, CA 94103-1741—www.josseybass.com

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Library of Congress Cataloging-in-Publication Data

eISBN : 978-0-470-57508-6

1. Primary health care. 2. Community health services—United States. I. Kelly, Patricia J. (Patricia Jane) II. Ruiz-Janecko, Yumary, 1969- III. Title. [DNLM: 1. Health Promotion—methods. 2. Community Health Services. WA 590 G985c 2010]

RA427.9.G88 2010

362.12—dc22

2009041344

Table of Exhibits

EXHIBIT 6.1 Sample survey with data entry codes

PREFACE

As instructors to students who ventured into the community, we could not find a text that covered the entire process of doing a community-based health intervention. This book is designed for these students and practitioners who are untrained in conducting such fieldwork. This book will review the skills necessary to implement a community-based health intervention to change health in a community setting. Community-based health interventions (referred to below and in future chapters as community interventions) differ from those undertaken by health care providers in the clinical setting, which involve a one-on-one interaction. Health interventions in a community setting involve groups of individuals and take place in any of the diverse venues that make up community—schools, churches, libraries, community centers, and public health departments with Women, Infants, and Children (WIC) programs. Community-based health interventions are important because they aim both to reduce the impact of disease, health-related conditions like obesity, and health-related risk taking such as cigarette smoking and to create a supportive environment for the maintenance of the behavior changes. To implement such interventions does not require a medical background; however, a specific set of skills is needed. To successfully implement community interventions, practitioners and researchers must have good communication skills, especially with people who come from backgrounds different from their own. They must feel comfortable talking to groups. Most important, practitioners and researchers should be able to think on their feet—that is, to be able to make decisions and keep an intervention going in an environment that may have limited resources and is complex and often unfamiliar. Such an environment differs from that of a clinic or hospital, which has clearly defined resources present in very controlled settings. This difference in environments can make clinicians uncomfortable at first, but is less problematic for public health practitioners if they have never been exposed to a clinical environment and do not have to make the transition from a patient or client focus to targeting a group or community. The frequent surprises and adaptations that come with working in community settings provide a rich sense of satisfaction and connection to those willing to engage in this work. We wrote this book because we have participated in a variety of community-level health interventions and have experienced such satisfaction. We hope to pass on to students the skills and the satisfaction that we have been privileged to experience in our work.

This book is intended as an introduction to the field of community-based health interventions and is not meant to be a comprehensive manual of all nuances and facets of developing interventions. The chapters review and summarize topics that could each easily be a book in itself. Students and practitioners who are not experienced in community work can progress through the various steps necessary to acquire the skills to complete, evaluate, disseminate, and sustain a community-based health intervention.

The text is set within the context of ecological theory. This theory posits an approach to health problems at different social levels starting with a group, moving to the organizational level, and finally to a policy level, where the entire community may be involved. This theory is used by public health practitioners and clearly distinguishes health programs taking place at the community level from those implemented at the clinical or individual level. The text will provide examples of community-based health interventions at each of the four ecological levels. The group level focuses on individuals who share a health risk or some other characteristic. The organization level includes interventions that take place throughout an individual school or all the schools in a district. For students using this book, interventions at the group or organizational level will probably be most appropriate. Community-level interventions work to change the total environmental or social structure of a geographic community, usually through a social marketing campaign. Policy-level interventions are the fourth ecological level and include changes in laws or regulations such as communitywide no-smoking policies.

The book is organized into four sections. The first section provides background information about why interventions in communities are important, the history of several major community interventions, ethical issues important to keep in mind during the design and implementation of interventions, and the different types of interventions that might be implemented. The second section covers the thinking and activities that must be completed to develop an intervention and helps students understand the theoretical basis of their intervention and how data will be managed. The third section projects the student into the field, assessing the needs and strengths of a particular community, gaining community support, defining the goals of an intervention, and actually getting started. This section also contains information on obtaining material and financial support and on strategies for continuing the intervention beyond its initial phase. The final section examines current work and problems encountered, as well as projecting how the field may change and expand in the near future. Each chapter of the book contains a number of practice exercises or activities to help students develop the skills they will need as practitioners. We hope these exercises will prove useful to students in the many professions that develop interventions at the population or community level, such as public health, social work, and nursing. Discussion issues are also raised at the end of each chapter. Additional readings and references are provided at the end of each chapter so that students who are interested in the particular areas covered can explore them in greater depth. Finally, the book contains a glossary defining words or phrases that may be unfamiliar to students who are just being introduced to the field.

ACKNOWLEDGMENTS

We have many people to thank, starting with the students we have taught, including graduate students Amarilis Cespedes, Jaugha Nielsen-Bobbit, and Jennifer Mills, who helped us by critically reading the text. We would also like to thank Benjamin Alan Holtzman for providing us a window into the future. We could not have written this book without our very supportive partners, William R. Breen, Joshua Freeman, and Gerald Andrew Janecko, who willingly held down the forts when we took off without them for a book-writing retreat in Tucson.

THE AUTHORS

Sally Guttmacher, PhD, is professor of public health at New York University, where she directs the MPH Program in Community Public Health. She is also a Visiting Professor in Public Health at the University of Cape Town. Her doctorate in sociomedical sciences is from Columbia University. She has been involved in community-based health interventions and evaluation research in New York City and in Cape Town, South Africa, and is coauthor of the book Community-Based Health Organizations (Jossey-Bass, 2005). She has been the president of the Public Health Association of New York City, the chair of the Medical Care Section of the American Public Health Association, the chair of the Council of Public Health Programs, and is on the National Board of Public Health Examiners. Her recent research interests include program evaluation, the prevention and treatment of HIV/AIDS, and the reduction of sexual risk behavior in refugee populations.

Patricia J. Kelly, PhD, MPH, APRN, is professor at the University of Missouri-Kansas City, School of Nursing. Her PhD in Public Health is from the University of Illinois at Chicago. Her clinical and research work has focused on improving the conditions of health for women and children in underserved populations. Kelly has conducted a number of NIH-, state-, and foundation-funded community-based research studies in Hispanic and African American communities. Her work has focused on reproductive health and violence prevention and has used a variety of research and evaluation methodologies, including community-based participatory action research.

Yumary Ruiz-Janecko is clinical assistant professor of public health and the Public Health Internship Director in the Department of Nutrition, Food Studies, and Public Health at New York University (NYU). She earned her PhD in health promotion and disease prevention, with a focus on health policy and health advocacy, from Purdue University in 2006. Her research interests include the links between migration and health and the impact of empowerment on health outcomes at individual, community, and system levels. Her current research focuses on examining HIV risk behaviors among recent Mexican immigrants residing in New York City. Prior to joining NYU, her research investigated the use of the Internet by nonprofit organizations, specifically advocacy organizations, and its association to sociopolitical empowerment. She has taught and developed numerous graduate and undergraduate courses, and as a public health practitioner she has coordinated and implemented health programs using multicomponent, multisectoral, and multisetting approaches.

Diana Silver, PhD, MPH, is an assistant professor of public health at the New York University’s Steinhardt School of Culture, Education and Human Development. She has been working in the field of public health for more than two decades. Silver’s research explores the ways in which local government policies and programs can be used to more effectively address those needs. She began her career focused on the developing policies and programs that could address the epidemics of AIDS, substance abuse, and violence in New York City in such settings as schools, workplaces, jails, and through community-based organizations. For the past decade, she served as the project director of the national evaluation of the Robert Wood Johnson Foundation ’s Urban Health Initiative, which aimed to improve health and safety outcomes for children and youth in some of America’s most distressed cities.

PART 1INTRODUCING COMMUNITY-BASED INTERVENTIONS

CHAPTER 1IMPROVING HEALTH IN COMMUNITY SETTINGS

LEARNING OBJECTIVES

Explain the components of an ecological approach to health

Distinguish an ecological from an individual approach to health interventions

Recognize different ways in which community can be defined

OVERVIEW

Ecological theory provides an overview to understanding interventions that take place in community settings. This chapter will explain the differences between interventions taking place in community settings and those taking place in clinical settings. Examples of community interventions will be provided.

DEFINING COMMUNITY

A community is a group of people connected by visible and invisible links. Communities are defined in different ways. Geographic communities have geographic, physical, or political boundaries, whereas communities of interest are connected not by physical space but by the sharing of an interest, behavior, risk, or characteristic, and professional communities share knowledge and skills as well as interests.

Place Can Define a Community

Geographic communities can have political boundaries such as municipal lines that may be more or less arbitrary, but provide residents with a sense of identity that is generally distinct from the adjacent area—such as Center City, as opposed to South Center City. Geographic communities can also be defined by geographic or physical boundaries that unite people inside the boundaries (north of the river) or make them distinct and separate from adjacent groups (the other side of the railroad tracks). The use of geographic features to define communities is necessary for the work of policy makers and planners who use, for example, census tracks, health districts, or hospital catchment areas for planning purposes. While these boundaries may or may not indicate differences between people who live in these areas, they provide a useful delineation in which to conduct interventions.

Communities Defined by a Shared Concern

Communities of shared concerns or interest can be linked by something as inherent as racial, ethnic, or national background and the history, values, culture, and customs that are part of that background. The social units that structure people’s work, school, or other daily activities provide another form of community. These units can generally be broken down further by age (third-grade class as distinct from the sixth-grade class in a suburban elementary school), by role (nurses as distinct from physicians in a public hospital), or by status (students as distinct from teachers in the suburban elementary school; patients as distinct from providers in the hospital). An important community of shared interest for students and practitioners concerned with health issues is the groups of people with potential, current, or past shared disease and behavior or health risk. Women with a positive BRCA gene (indicating a higher-than-average risk for breast cancer), women receiving radiation treatment for breast cancer (current disease), and women in a cancer survivors support group (past disease) are all part of a potential or real community of interest.

The definition of community is important for public health practitioners because health interventions must target a specific community. How a target community is defined determines how resources will be allocated, how an intervention will be delivered, and how a message will be framed.

An example of the importance of defining a target community can be seen in designing a smoking cessation intervention. If the target audience is undergraduate students, focusing on the long-term health effects of tobacco use is unlikely to be an effective strategy because this population is in an adolescent phase of development, believing that “it won’t happen to me” and focusing on today rather than the future. A more successful strategy for smoking cessation with this population would be an intervention demonstrating ways to resist social pressures while gaining peer acceptance. If the target population of a smoking cessation intervention is pregnant women, however, a message about the impact of cigarette smoking on healthy pregnancy outcomes will be more effective than one that stresses prevention of lung cancer and chronic obstructive pulmonary disease.

Demographic variables such as race, ethnicity, education level, age, gender, and class describe both geographic and common-interest communities. Many interventions will have a target community arising from more than one of these variables. A breast cancer survivor group for women in their sixties will have different issues from women in their thirties; an intervention to increase mammogram screening among African American women will need to incorporate different cultural strategies from one aimed at Latinas. Educational messages on mammogram screening for middle-class women with private health insurance may differ from messages with the same goal designed for women relying on public hospitals and clinics. Knowledge of the cultural background, health beliefs, developmental stage, socioeconomic status, and literacy levels must all be incorporated into the content of any health intervention.

ECOLOGICAL THEORY AND LEVELS OF PREVENTION

Ecological theory postulates health to be the result of a dynamic interplay between demographic variables and the physical and social environment. It expands on the model of living organisms as self-regulating systems by including the families, organizations, and communities in which we interact on a daily basis; a disturbance in any part of the system has an effect on the other parts (Bronfenbrenner, 1979). Individuals, families, and communities are not isolated entities, but rather an interrelated ecological system with each adapting to changes that occur in other parts of the organization. Each component of the system participates in determining health. Key factors in ecological theory that have a disproportionate influence on health include socioeconomic status, family, work (for adults), and school (for children) (Grzywacz & Fuqua, 2000). Consideration and integration of one or more of these factors cannot be considered in isolation from the others.

Ecological Theory Applied to Community-Based Intervention

Applying ecological theory to community-based health interventions requires an understanding of these three principles:

Health is the result of a fit between individuals and their environment

Environmental and social conditions interact with an individual to exert an important influence on health

A multidisciplinary approach to health is necessary (Grzywacz & Fuqua, 2000)

This appreciation of health as influenced by other than individual behavior has important implications for health promotion interventions. Community-based health interventions move beyond a focus on changing the behavior of individuals and instead acknowledge the importance of interpersonal or group behavior, institutional climate, community resources, and policy effects. Community-based interventions therefore work with groups such as women over age fifty in a church, institutions such as all teachers in a district’s school system, communities with geographic or political boundaries, and large populations covered by specific policies.

Prevention Efforts Focused on the Community

The influence of social and environmental factors on health behaviors and outcomes occurred around the same time as an understanding of the limitations of the individualistic medical model in changing health behaviors and outcomes. While health care technologies such as angioplasty and bone marrow transplants are now commonplace in the USA, many of the health status indicators lag behind those of other industrialized countries (Central Intelligence Agency, 2008). The overall U.S. infant mortality rate is higher than most similarly developed countries because significant areas of the United States lack access to good preventive services. Although highly trained and skilled physicians and nurses work in neonatal nurseries to save the lives of premature babies, prenatal and other preventive care is not available to many pregnant women, resulting in high rates of preterm labor, which ensure fully occupied neonatal nurseries. Dialysis programs are available for people with diabetes who experience kidney failure, but many afflicted with diabetes are unaware of their disease or unable to manage it through diet and exercise. While sophisticated regimens of antiretroviral drug treatment are available for those with HIV infection, many others with HIV/AIDS are undiagnosed and spread the infection through unprotected sex or sharing needles. Twenty-first-century medical technology that is largely confined to health care settings cannot optimize health or prevent disease. This is the role of community-based health promotion.

Focusing health and disease prevention at the community level can be successful only if the community is involved. The World Health Organization recognized the importance of community participation in its definitions of health and health promotion. For example, the definition of primary health care in the Alma Ata Declarationreads: “Primary health care is essential health care based on practical, scientifically sound and acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (Mahler, 1981, p. 7).

This understanding of the limitations of the health care system to maintain a healthy population and the contributions to health of the psychosocial and physical environment in which we live has resulted in a shift to a broader community focus (McLeroy, Bibeau, Steckler, & Glanz, 1988). Interventions in community settings differ from individual clinical interventions in their focus on the health of a target population or community. In the targeting of communities for health interventions, community can be considered in one of the two following ways:

Community as setting, which uses any of the above definitions of community and focuses on changing individual behaviors as a way to lower a population ’s risk of disease. In this type of intervention, population change is considered as the aggregate of individual, interpersonal, or institutional change.

Community as target, in which the goal is changing policy or community institutions, such as the development of walking trails, the availability of smoke-free facilities, or the overall rate of a disease.

Whatever the focus, the goal of almost all community interventions is to have an impact on morbidity and mortality factors that occur outside of health care settings. These interventions can be contrasted with clinical interventions, which are individually focused and usually involve diagnosis with physical exam and laboratory tests. This is usually followed by treatment with drugs or procedures, with a goal to prevent an existing harmful condition from becoming worse.

Examples of Community-Based Interventions by Levels of Prevention

Since community interventions involve a vast array of topics, one way of organizing them is by levels of prevention. Interventions that focus on primary prevention have a goal of avoiding or preventing a disease or condition before it begins. Secondary prevention efforts focus on screening and the early diagnosis of a disease or condition. Tertiary prevention interventions aim to prevent disease progression after a risk factor or disease has been identified. Table 1.1 provides some initial examples to assist students in identifying a topic area and type of intervention for implementation.

Developing walking can be considered an intervention at both the primary and the tertiary prevention levels because they can be important components in preventing obesity and cardiac disease. They can also be used by people who already have these conditions to help in preventing additional weight gain or further deterioration of cardiac functioning. A school system intervention that seeks to remove soda vending machines from schools is likewise both primary and tertiary in its focus on initially preventing childhood obesity, an important risk factor for the future development of Type 2 diabetes (James, Thomas, Cavan, & Kerr, 2004). Support groups for women with breast cancer have been shown to be effective in decreasing stress and improving coping and overall mental health (Winzelberg et al., 2003). Because the support groups help women to be proactive about potential future complications of the disease process, they are tertiary prevention. The Back to Sleep campaign, jointly sponsored by the National Institutes of Health and the American Academy of Pediatrics, is a social marketing campaign that recommends that infants be placed on their backs to sleep to reduce the incidence of sudden infant death syndrome (SIDS) (Havens & Zink, 1994). This successful primary prevention campaign is credited with reducing the incidence of SIDS 50 percent since its inception in the mid -1990s (National Institute of Child Health and Human Development, 2008).

TABLE 1.1Examples of community-based health interventions by levels of prevention

Needle exchange interventions are a primary preventive measure that can prevent the spread of HIV infection among injecting drug users (Des Jarlais et al., 1996). Campaigns to increase HIV tests and learn about one’s HIV status are considered secondary prevention because of their goals of early detection of HIV infection. They are also a form of primary prevention because of their focus on decreasing the risk of HIV transmission to unknowing sexual partners (Varghese, Maher, Peterman, Branson, & Steketee, 2002). Interventions to increase access to mammograms are secondary prevention because mammograms are an important source of screening for breast cancer (Humphrey, Helfand, Chan, & Woolf, 2002). Women who have their healthy breasts removed because they carry the bracia (SP) gene that puts them at much higher risk of developing breast cancer are practicing primary prevention.

Now that there is a vaccine to prevent the spread of the human papillomavirus, there is a method for the primary prevention of cervical cancer. A campaign to get young women vaccinated is a primary prevention method. Secondary prevention would be a campaign to encourage women to get Pap smears. A tertiary preventive measure is a colposcopy for women who have some abnormal cells (Franco, Duarte-Franco, & Ferenczy, 2001). A buckle-up publicity campaign can be designed to increase seat belt use among the community as a whole, or it can be focused on a target population such as Hispanics or adolescents. Either way, such a campaign is a form of primary prevention against unintentional injuries from motor vehicle accidents (Evans, 1990).

Each of these examples has a citation—that is, each has been shown to be effective in achieving its goals. These interventions are examples of evidence-based practice, in which public health practitioners actually go to the literature and learn if an intervention has been shown to be effective. Such a citation does not guarantee positive results in a given community or population, but the chances of success are much higher than simply making up an intervention de novo or relying on anecdotal experience.

SUMMARY

Public health interventions have a community focus, rather than an individual focus. One of the tasks of public health practitioners is to understand both the composition of the community in which they are trying to make an impact and the level of prevention at which they want to intervene. In the following chapters, readers will be exposed to all the steps necessary to develop a community-based intervention.

KEY TERMS

Alma Ata DeclarationCommunityCommunity-based health interventions Demographic variables Ecological theory Levels of prevention Primary prevention Secondary prevention Target community Tertiary prevention

ACTIVITY

As discussed in this chapter, communities are not defined solely by geographic boundaries.

Identify two examples of nongeographic communities in which you are involved. Describe the commonalities that tie the communities together—such as interests, behaviors, or characteristics.

DISCUSSION QUESTIONS

In the United States, the shift of emphasis from infectious to chronic disease has frequently been cited as one of the main reasons for the growing interest in community health interventions. Are chronic diseases better suited to community-based health interventions than other illnesses?

Many of the interventions for infectious diseases use strategies involving community networks and organizing. Are these types of community intervention particularly well suited to infectious diseases? What factors influence your response (economics, target population, geography, or others)?

How would you identify and define a community in which to conduct an intervention for teen pregnancy? Breastfeeding? Early child development? How would the approach differ between these communities? What are the potential problems that might emerge, depending on the different definitions of the community?

CHAPTER 2A BRIEF HISTORY OF COMMUNITY-BASED HEALTH INTERVENTIONS

DIANA SILVER

LEARNING OBJECTIVES

Recognize the aims and objectives of some of the pioneer community-based health interventions

Relate how the problems in evaluating the impact of large-scale interventions may extend to small-scale interventions

Understand important issues that can arise in implementing current community-based health interventions

OVERVIEW

This chapter will review the experience of community-based health interventions planned and implemented in the last forty years. It examines the principles and assumptions that underlay early community-based health interventions and discusses some of the problems encountered when measuring their impact.

COMMUNITY-BASED HEALTH INTERVENTIONS: AN INSTRUMENT FOR CHANGE

Community-based health intervention is a relatively recent idea dating to the early 1960s. The phrase refers to the set of interventions designed to create changes in community infrastructure and services, norms, attitudes, beliefs, and policies that would result in improved health status for community residents. While the term is relatively new, the approach is not, and indeed it has guided much of the progress in public health since the nineteenth century. When John Snow removed the handle of the pump from a contaminated well in London in 1849, he was engaged in a community-based health intervention. Faced with recurrent cholera epidemics, Snow was less focused on extending medical care to those who were sickened with cholera and more concerned with addressing the source of the problem.

The planning and implementing of community-based interventions that this volume addresses build on some of the experience of community-based health interventions planned and implemented in the last forty years. Community-based health interventions are concerned with health at the community level—that is, they are designed to create improvements in the overall health status of the community. Their success or failure is measured at the community level, in the average change in individuals’ health status within a community.

The Rationale for Developing Community-Based Interventions

The rationale for such interventions echoes Snow’s orientation. By the 1960s, the dramatic improvements in the health status of populations in industrialized nations had begun to level off, and chronic disease posed a greater threat to health and well-being than infectious disease. Much of the gains in the earlier part of the twentieth century had been due to improvements in sanitation, water, access to food and medicine, and important medical and scientific achievements such as the discovery of penicillin or the polio vaccine. At least in Europe, access to national health care had been established for the vast majority of the population. By the end of the 1960s, Medicare and Medicaid in the United States had established programs that would also extend health care to large portions of the population that had not previously had access. Regulations on chemicals, equipment, and workplace hazards demanded largely by trade unions had reduced health threats to workers. Along with environmental improvements, more consistent access to treatment of both minor and complex health problems had extended life expectancy for men and women of all racial groups, and gaps in life expectancy among racial groups had even begun to narrow.

In the last half of the twentieth century, the leading causes of mortality shifted from infectious diseases to chronic illness, and progress in reducing its impact had begun to slow by the mid-1960s, even as greater understanding of the risk factors for chronic diseases had improved. Considerable resources and attention focused on improving care for those suffering from chronic diseases, with sophisticated technology addressing catastrophic medical events such as heart attacks and strokes. Yet addressing the leading causes of death, especially cardiovascular and respiratory diseases, was seen by the medical community as requiring a change in individual lifestyle and behavior that technology could not address. In contrast, public health practitioners and researchers, in partnership with those in the medical community, began to look to intervening at a community level to address such lifestyle factors.

This chapter reviews the principles and assumptions that underlay five early exemplar community-based health interventions: North Karelia, Stanford Three-Community, Stanford Five-City, Pawtucket Heart Health, and Minnesota Heart Health, all of which addressed some aspect of cardiovascular disease. The major findings of these interventions are reviewed, as well as some of the concerns raised about their implementation and evaluation. The chapter concludes with a discussion of some of the key issues that subsequent interventions have focused on and some that remain for further consideration.

Principles and Assumptions of Early Community-Based Health Interventions

The initial community-based health interventions shared some common assumptions and principles that informed their rationale and design, as well as assumptions about the ways such interventions should work. Following are some of the principles and assumptions that guided the individuals who planned, implemented, and evaluated these interventions.

The focus is on changing

risk behaviors,

not providing treatment

. Although these interventions employed an “upstream” approach, seeking to change norms and behaviors before they resulted in morbidity, they also sought to improve the health of those already diagnosed with chronic health conditions related to heart disease and myocardial infarction. And while they employed various strategies to increase screening and referrals for disease, they were not concerned with developing new treatment or increasing access to health care.

A

population-based approach

is required to address health behaviors

. These interventions embraced the idea that risk behaviors were distributed across the population, with some people at higher or lower risk. Because of the size of the population targeted, even small improvements in risk behaviors could provide big payoffs (Rose, 2001).

“Community” has geographic boundaries

. The early community-based health interventions defined community as a geographic entity or political jurisdiction. While these communities varied in size, membership was defined as residence within the community. The implementation of community-based health interventions led scholars and practitioners to question and broaden this definition of community, pointing to other meanings of the word (see Chapter One).

Improved

case finding

of those at high risk in the population is important

. A goal of community-based health interventions was to extend the reach of the medical community by identifying those at highest risk. These interventions looked for opportunities to screen for risk factors and ensure that those identified as high risk were attached to a health care provider.

Individuals are embedded in families

. Some of the strategies these interventions employed were focused on families and aimed to change or reinforce changes in risk behavior on the part of those at risk by enlisting family members in making changes within the household.

Families are embedded in larger communities that share context and culture, which in turn influence behavior

. Interventions must focus on creating social norms related to health behavior. In addition to seeing individuals as embedded in their families, practitioners also looked beyond the family for other influences on risk behavior and health conditions. They viewed aspects of the physical and social environment as reasonable targets for interventions that would facilitate and reinforce behavior change by changing or shaping norms, values, and attitudes of community members.

It is possible and necessary to work in many settings at once

. Embracing this assessment of the influences on individual health, the designers of the early community-based health interventions were convinced that programs should be situated within the institutions and other structures in communities. Thus, the early community-based health interventions developed programs in schools, churches, community organizations, health care settings, parks, worksites, stores, and other venues.

Multiple programs and activities may have a synergistic effect

. While each of these interventions involved multiple strategies and projects, the designers of early community-based health interventions were as interested in the cumulative impact of multiple interventions on an individual’s or household’s risk behaviors as they were in the ways specific efforts contributed to the overall effect. The interventions, in embracing social context as a determinant of behavior, were intent on working in many arenas—churches, media, health care settings, worksites—with the idea that the interaction of the different interventions would spur new activities and add to the impact of each specific one.

Interventions can be successfully evaluated to capture the processes and impacts of behavior change

. These early interventions were rigorously evaluated, using

quasi-experimental designs

and employing multiple methods of data collection. Evaluators believed that both

process indicators

and

outcome indicators

could be identified and assessed and that evaluations could provide information on how the intervention worked and what its impact was.

These principles informed the direction and implementation of the set of community-based health interventions initiated in the 1970s and 1980s. Lessons learned from the design, implementation, and evaluation of these interventions laid the groundwork for much of our current thinking about the promise and challenges of community-based health interventions.

EARLY COMMUNITY-BASED HEALTH INTERVENTIONS

The North Karelia Project responded to community concern about the high mortality rate from cardiovascular heart disease in this largely rural area of Finland. In 1971, the governor and all parliament members of North Karelia, together with the directors of many voluntary and official organizations, petitioned the Finnish government for funding and assistance to reduce the burden of disease and mortality from cardiovascular disease. In 1972, a new Public Health Act was passed to reorganize primary care in Finland, and leaders from the North Karelia area met with government officials and representatives from the World Health Organization to develop a plan of action (Puska et al., 1985).

The North Karelia Project envisioned a complete community mobilization to alter norms and behaviors that contributed to early mortality of middle-aged men from cardiovascular disease. To achieve their goals, the researchers used varied strategies that combined efforts to inform the public, build skills among women and men, and reorganize the delivery of health care services. They mobilized both health and nonhealth sectors and looked for opinion leaders both in the medical community and outside it to serve as public ambassadors for the program. Following are some of the activities they undertook:

Use of mass media (television and print) campaigns to increase awareness and provide information

Community organizing and mobilization to identify and alter norms and provide support for behavior change

Mobilization of multiple sectors of society, including health and nonhealth sectors

Aiming a variety of activities at high-risk and low-risk people, such as smoking reduction support groups, cooking classes, and agreements with local businesses

Encouraging women to make household changes in the purchasing and cooking of food

Training of influential leaders whose opinions would permeate down through different levels of society

Changing the delivery of health care services, which included some formal changes in training and the reorganization of guidelines and materials