Community-Based Health Interventions

Sally Guttmacher, Patricia J. Kelly, Yumary Ruiz-Janecko, Patricia Kelly Vana

• Publisher: Jossey-Bass
• Year: 2010
• Print ISBN: 9780787983116
• eBook ISBN: 9780470575086
• Edition: 3
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

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.

PART 1
INTRODUCING COMMUNITY-BASED INTERVENTIONS

CHAPTER 1
IMPROVING 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 Declaration reads: “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 whi...

Table of contents

• Cover
• Table of Contents
• Title
• Copyright
• Table of Exhibits
• PREFACE
• ACKNOWLEDGEMENTS
• THE AUTHORS
• PART 1: INTRODUCING COMMUNITY-BASED INTERVENTIONS
• PART 2: DEVELOPING THE INTERVENTION
• PART 3: WORKING THROUGH THE INTERVENTION
• PART 4: LEARNING FROM THE PAST AND ADAPTING TO THE FUTURE
• GLOSSARY
• REFERENCES
• INDEX
• End User License Agreement