Organisations, Communities, and Society: Models and Interventions
Individuals and families are embedded within social, political, and economic systems that shape behaviors and constrain access to resources necessary to maintain health (Brown, 1991; Gottlieb and McLeroy, 1994; Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; McKinlay, 1993; Sorensen et al., 1998a; Stokols, 1992, 1996; Susser and Susser, 1996a, b; Williams and Collins, 1995; WHO, 1986). The impact of social and environmental conditions is most visible in the growing gap between the health behaviors and health status of rich and poor, white and non-white (Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; Lillie-Blanton and LaVeist, 1996; Lynch et al., 1997; Williams and Collins, 1995). There is a need to better understand the role of organizational, community, and societal factors in determining health. This chapter continues to explore the ecologic framework, describing theoretical concepts and sample interventions at the organizational, community, and societal levels.
ORGANIZATIONS AND HEALTH
Formal and informal organizations constitute another framework for describing interactions between behavior and health. Organizations are important components of social and physical environments, and they exert considerable influence over the choices people make, the resources they have to aid them in those choices, and the factors in the workplace
that could influence health status (e.g., work overload, exposure to toxic chemicals). As employees, consumers, customers, clients, and patients, people are influenced by the organizations to which they belong.
Porras (1987) and Porras and Robertson (1992) suggest four major categories of work settings that are targets for change: organizing arrangements, social factors, technology, and physical settings. Organizing arrangements include organizational goals and strategies for progressing toward them, organizational structure (e.g., formal division of labor, authority relationships, lines of communication), policies and procedures (the formal rules that govern the organization), and reward systems. Social factors include management style, informal social networks, and interaction processes (e.g., problem-solving, decision-making, conflict resolution). The technology category includes job design factors, work flow design, and technical systems. Physical settings include spatial configuration, interior design, and physical ambiance factors such as temperature, lighting, and noise. In their original typology, Porras and Robertson (1992) included individual attributes under the social factors umbrella. However, given the emphasis placed on individual beliefs, attitudes, and skills in health behavior research, those individual factors are suggested as a fifth category in the work setting for targeting change interventions.
Organizational Culture and Change
Organizational culture is the base upon which organizational and related individual behavior change occurs. The culture prescribes the “right way” to do things (Schein, 1990). An organizational culture that supports health is likely to adopt policies, procedures, and priorities that facilitate the healthy behaviors of employees; enhance employee health by reducing environmental risk factors; facilitate healthy behavior on the part of clients, customers, or members; and facilitate linkages to other organizations for health-enhancing purposes. The more health-enhancing policies an organization adopts, the more likely it is to be perceived as having a health-conscious culture (Basen-Enquist et al., 1998).
Organizational development (OD) is a set of behavioral-science-based theories, values, strategies, and techniques aimed at planned change in the organizational work setting (Porras and Robertson, 1992). Three important foundations are briefly described here: systems theory, employee participation in change efforts, and action research. Systems theory (Katz and Kahn, 1978) says that a change in one part of the system will influence
other parts, and so there is a need to vigilantly monitor unexpected (and often undesired) changes. Increased involvement and participation of organizational members in decision-making and problem-solving processes enhances the quality of decisions and solutions, increases members’ commitment to following through on plans, reduces organizational stress, and enhances employee well-being (Cotton et al., 1988; Ganster, 1995). The action research involves outside change agents working with organization members in a cyclical process of diagnosing problems, planning, implementing plans, monitoring, and evaluating progress (Argyris and Schon, 1989).
Lewin (1951) developed an early and influential model for conceptualizing the change process. He posited three stages: first is unfreezing the old behavior, second is moving to a new behavior, and third is refreezing or stabilizing the new behavior. Thus, change was conceptualized as moving from one equilibrium point to another. To begin the process, the balance between opposing forces (those that facilitate and those that hinder change) must change, Lewin’s “force field analysis” was instrumental in the development of subsequent models of change. For example, organizational theorists such as Lippitt and co-workers (1958) and Schein (1987) built on Lewin’s three stages and linked them to psychological mechanisms for change and to action steps that change agents should take to facilitate progress through the stages.
INTERVENTIONS TARGETED AT ORGANIZATIONS
Organizational change is an integral component of a comprehensive ecologic approach to health behavior change that emphasizes how individual decisions and behaviors are influenced by the multiple layers of systems within which individuals are embedded (Stokols, 1996). As important components of the social and physical environments, organizations exert considerable influence over the choices people make, the resources they have to aid them in those choices, and the factors in the workplace that could affect health status (e.g., work overload, exposure to toxic chemicals). People are influenced by organizations as employees, consumers, customers, clients, and patients.
Changing Employee Health Behaviors
National surveys of work organizations clearly document a burgeoning interest in worksite health promotion programs (see McGinnis, 1993). These programs focus either on a single behavioral risk factor (e.g., smoking) or on multiple risk factors (e.g., behavioral risk factors associated with cardiovascular disease). Because many of these interventions are aimed primarily at individual behaviors, they are reviewed in Chapter 5. Here the organizational context for these programs is addressed.
In a review of 47 studies of health promotion programs that addressed multiple risk factors, Heaney and Goetzal (1997) found that almost all provided health education to employees. A smaller number of the programs (25%) incorporated modifications in organizational policy or the work environment to facilitate employee behavior changes. Such modifications included policies restricting or banning smoking on the premises, removing cigarette-vending machines, providing on-site exercise facilities, and providing healthier cafeteria food. A survey of health promotion programs funded by the Canadian Ministry of Health showed that more than half the programs reviewed reported modifications of health-compromising aspects of the organization (Richard et al., 1996). Most of the organization-level interventions addressed organizing arrangements. With the exception of providing on-site fitness facilities, few programs attempted to change physical settings, social factors, or technologies. Programs integrated into the culture of the organization were more likely to have multiple components and last longer than did those that had less support from top management and were less a part of the underlying fabric and culture of the organization (Heaney and Goetzal, 1997). Heaney and Goetzal (1997) concluded that providing opportunities for individual risk reduction counseling was necessary but not sufficient for effective worksite health promotion programs.
Studies of programs aimed at individual risk factors also provide some support for the importance of changing the organizational context to support employee health behavior change (Glanz et al., 1996; Hennrikus and Jeffery, 1996). The example of smoking-control efforts at the workplace is illustrative. In their review, Eriksen and Gottlieb (1998) concluded that there is consistent evidence that smoking-control policies reduce cigarette consumption at work among smokers and reduce all employees’ exposure to second-hand smoke. However, they found mixed evidence for policies aimed at prevalence of smoking and overall consumption of cigarettes (including during non-work hours). They also point out that many
evaluation studies lacked the methodologic rigor necessary to permit confident causal inferences. And although several investigators have suggested the importance of looking at the degree of management support for smoking-control programs, the extent to which the organizational climate is consistent with control efforts, and the design and implementation of programs, few studies have done so.
Some worksite health promotion programs use organizational change theory to inform their strategies. More specifically, current standards of practice include employee participation in planning the efforts. This ranges from incorporating employee input into the assessment of employee health needs (e.g., through surveys or focus groups), to having employee advisory boards guide the planning process, to having employee groups take full responsibility for implementation. Although several large, randomized trials incorporated at least one strategy (Glasgow et al., 1995; Sorensen et al., 1996), a direct comparison of health promotion programs with and without planned employee involvement has not been made. In addition, results from randomized trials that incorporate employee involvement have been mixed.
Another strategy for incorporating organizational change into health promotion programming relies on training key figures in the organizations in methods for creating a supportive organizational culture and developing a comprehensive health promotion program. For example, Golaszewski and colleagues (1998) devised a seven-session curriculum for human resource managers who wanted to develop programs for employee heart health. The training addressed such issues as how to generate support among senior management; how to develop employee wellness committees; and how to conduct needs and resource assessments, diagnose organizational culture, and use employee benefits plans to support health promotion. Student interns were provided to the organizations, faculty from an academic medical center were available for consulting, and potential vendors for health promotion services were identified. Evaluated with a quasi-experimental design, the intervention organizations exhibited a significantly greater increase in organizational support for employee heart health than did the comparison organizations.
Reducing Environmental Risk Factors
Traditional worksite health promotion programs focus on individual change of personal risk factors. Occupational safety and health (OSH)
programs address the influence of physical (e.g., noise, extreme temperatures), chemical, ergonomic, and psychosocial work hazards on employee health. According to Goldenhar and Schulte (1994), OSH programs can involve three strategies: engineering, administrative, and behavior change, used to address the different targets for organizational change presented in Figure 6-1. Engineering strategies modify technology or physical setting; administrative strategies modify the organizing arrangements or social factors; and behavior change strategies target beliefs, attitudes, and skills.
Examples of behavior change interventions in OSH include training to increase compliance with safety practices (Parkinson et al., 1989), use of personal protective equipment (Ewigman et al., 1990), and exercise to prevent occupationally related back injuries (Silverstein et al., 1988). Those interventions tend to focus almost exclusively on individual-level change (Goldenhar and Schulte, 1994). Strategies to enhance compliance with universal precautions among health care workers provide a case in point. Although descriptive research clearly indicates the influence of organizational safety climate and work task design on compliance rates, most interventions have targeted only individual employee knowledge, attitudes, and behaviors for change (DeJoy et al., 1995; Gershon et al., 1995).
Few OSH interventions address more than a single type of environmental exposure or use more than a single intervention strategy. However, no matter the exposure or strategy used, organizational change principles are needed to initiate, implement, and maintain OSH programs. Programs oriented to reducing adverse psychosocial work exposures illustrate that point. A voluminous literature documents the consequences of occupational psychosocial stressors such as work overload, role conflict, job insecurity, unpredictability, ambiguity, responsibility for the work of others, and poor relationships with supervisors and co-workers (Hurrell and Murphy, 1992). Much research supports the benefits of psychosocial resources, such as social support and control or decision latitude over how one’s job is done (Baker et al., 1996; House, 1981; Israel et al., 1989; Karasek and Theorell, 1990). These psychosocial resources can directly affect employee well-being, and they can buffer employees from the negative effects of stress. Baker et al. (1996) give a comprehensive presentation of the stress process in occupational settings.
Strategies for reducing the harm caused by psychosocial stressors most often entail individual behavior change strategies or administrative change strategies. Those efforts focus either on developing personal strat-
egies for alleviating stress-related symptoms (e.g., relaxation techniques, biofeedback, exercise) or on increasing employees’ coping capacity (e.g., cognitive restructuring, problem-solving skill building, stressor recognition). (See Murphy  for a review of these strategies.) Administrative strategies involve changing the way work is organized, distributed, supervised, and rewarded, for example by using clear job descriptions (to reduce uncertainty or unnecessary conflict), providing for flexible scheduling, and holding regular work team meetings so that employees can voice concerns and engage in group problem solving. Members of work teams that meet regularly or that have leaders trained in facilitating group problem solving report receiving more social support from their supervisors and experiencing less role ambiguity and higher job satisfaction (Heaney, 1991; Jackson, 1983).
In addition to these behavior change and administrative strategies, environmental psychologists suggest that changes in the physical setting can reduce occupational stressors and enhance psychosocial resources (Sundstrom and Altman, 1989). For example, the physical proximity of employee work stations and the presence of “gathering places,” such as mailrooms or lunchrooms, have been associated with the quantity and quality of employee social interactions.
Behavior change strategies are usually “expert guided” (Karasek, 1992) in that they depend on health professionals or other outside consultants to counsel, train, or educate employees. The administrative strategies described here either were expert guided or were guided by the employees themselves. An example of the latter was the formation of an agency-wide labor/management stress committee in a study of stress among social workers in a child protective services agency (Cahill, 1992; Cahill and Feldman, 1993). Working with outside researchers, this committee developed goals to reduce sources of worksite stress, such as poor communication, and strengthen psychosocial resources, such as decision-making latitude over job tasks. Workers, management, and researchers then collaborated to develop, implement, and evaluate different interventions. For example, a computerized information system was introduced to reduce the workload and frustration associated with intake and tracking of clients. Economically correct computer workstations were provided. All employees were trained to use the new system and had easy access to technical assistance. Evaluation of the project suggested that the staff who were most involved in the intervention experienced gains in job decision latitude, productivity, and job satisfaction.
Karasek (1992) reviewed 19 case studies of occupational stress reduction programs gathered from countries around the world. He concluded that the programs that focused solely on individual-level coping enhancement—even when they involved substantial resources—were not effective. Programs that attempted to change work organization, task structure, or communication patterns in worksites were more likely to be effective. Karasek (1992) concluded that this was particularly true when participatory strategies (e.g., worker discussions in quality circles or “health circles” to identify stressors and develop plans to reduce them) were used.
Several intervention studies attempting to increase employee participation in and influence over work-related decisions have shown positive effects on employee stress and well-being (e.g., Israel et al., 1992; Jackson, 1983; Landsbergis and Vivona-Vaughan, 1995; Schurman and Israel, 1995; Terra, 1995; Wall and Clegg, 1981). Participatory action research (PAR) has been proposed as a promising approach to occupational health interventions (see Israel et al., 1992; Schurman, 1996; Schurman and Israel, 1995). PAR entails collaboration between researchers and members of an organization in a data-guided, problem-solving approach to enhance an organization’s ability to provide a safe and healthy work environment. PAR builds on many of the tenets of organizational development and it has been used as a stress reduction intervention with some success, particularly in Scandinavia (DiMartino, 1992; Israel et al., 1992; Lindstrom, 1995; Schurman and Israel, 1995; Terra, 1995).
No direct empirical comparisons of individual behavior change approaches with organizational-level change approaches to stress reduction have been conducted. Indeed, an either/or approach is not likely to enhance understanding of the stress reduction process. The ecologic approach, models of the stress process, systems theory, and the organizational development literature suggest that stress reduction approaches that use several points of intervention are likely to be most effective. Thus, comprehensive programs that address both changing the organizational processes that are causing stress and strengthening employees’ skills and resources for coping with stress could be most promoting of employee health. Some efforts along these lines are promising (see Monroy et al., 1998), but more research is needed to elucidate fully the potential of these interventions.
Lessons From Organizational Change Interventions
In 1988, the observation was made that the “most striking feature” of studies examining the effects of organizational-level interventions to enhance worker control is “the sheer lack of them” (Murphy, 1988). This observation still applies today to the broader arena of organizational change strategies intended to enhance health. Although more studies are being done now, the scarcity of well-evaluated interventions is still apparent.
A few recurring themes emerge from the findings of existing studies. First, they address a relatively narrow set of organizational targets. Few interventions attempt to modify social factors, technology, or physical setting. The results of studies that do address these factors (see, e.g., Cahill, 1992; Heaney, 1991; Sundstrom and Altman, 1989) have been encouraging. Second, many studies did not consider the organizational culture of their participants. Given the potential importance of organizational culture to the success of change efforts (Schein, 1990), future studies should routinely assess and diagnose this factor. Several validated instruments for measuring organizational climate (the more superficial manifestation of organizational culture) and its receptivity to health innovations are available (Basen-Engquist et al., 1998; Steckler et al., 1992). Third, many studies found that when the external change agents terminated their involvement with the target organizations, intervention benefits quickly dissipated. Efforts to build capacity for sustaining organizational changes among organization members can address this problem.
The same critique applies to the areas of worksite health promotion and occupational health and safety programs. Over the past decade, it has become clear that generic programs are not likely to be optimally effective because they do not consider organizational culture or the beliefs, attitudes, needs, and resources of organization members. The prescription for this challenge is two-fold: strong formative research, and participation of all relevant stakeholders in the planning and conduct of health-promoting activities. Careful formative research is likely to illuminate important local issues and challenges, and stakeholders’ participation is likely to enhance the program quality and increase commitment to follow through with the program activities.
COMMUNITIES AND HEALTH
Individual-level risk factors, families, and organizations influence health behavior and health status, and so do social and environmental
conditions. This phenomenon is most visible in the growing gap between the health behaviors and health status of rich and poor, White and non-White (Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; Lillie-Blanton and LaVeist, 1996; Lynch et al, 1997; Williams and Collins, 1995). There is a need to better explain how the broader community and societal factors help determine the health status of individuals and groups. Some important conceptual constructs regarding the nature of communities as they relate to health outcomes are discussed below.
Communities of Identity
There are numerous definitions for and considerable confusion about what is meant by “community” (Heller, 1989; Klein, 1968; Rogers-Warren and Warren, 1977; Sarason, 1984; Steuart, 1993; Warren, 1975). Particularly important for this discussion of community-level change is the recognition that a “catchment area” or “population” is not a community but a geographic entity (e.g., city, county) that has a population aggregate with numerical but not a functional meaning (Steuart, 1993). Here, community means “unit of identity” created and recreated through social interactions (Hatch et al., 1993; Steckler et al., 1993; Steuart, 1993). A community in this sense is characterized by the following elements (Israel et al., 1994):
Its membership has a sense of identity and belonging.
It has common symbol systems: similar language, rituals, and ceremonies.
It has shared values and norms.
It offers mutual influence—community members have influence and are influenced by one another.
It has shared needs and a shared commitment to meeting them.
It has a shared emotional connection—members share common history, experiences, and support.
Thus, a community of identity can exist within a defined geographic neighborhood or as a geographically dispersed group among whose members there is a sense of common identity. A city or catchment area might not be a community as defined here, or it might include numerous different and overlapping communities of identity (Israel et al., 1998).
Communities as units of identity are also indigenous “units of solution” that include members with the knowledge, skills, and expertise necessary to solve problems at the community level (Steuart, 1993). Community-level change can reduce the numerous social, structural, and environmental stressors that affect health but that are beyond the ability of any one person to control or change (e.g., poverty, discrimination, income inequalities, crime, inadequate housing). Community-level change also can strengthen the situational factors (e.g., social support, community empowerment, community capacity, community cohesion) that protect against the effects of stress on health. Community-level change involves bringing together the skills and resources within a community to collectively identify stressors and protective factors and implement ways to promote good health. Although it often is possible to affect the stressors and protective factors within a given community of identity, it also is frequently necessary to bring together several communities of identity to extend the units of solution to address more complex issues (Steuart, 1993).
Geography versus Identity and Action
It is important to recognize the distinction between population-based, community-wide interventions (which have for the most part defined community as a geographic place within which to carry out interventions that usually are focused on individual behavior change) and community-level change interventions (in which the emphasis is on working with and strengthening communities of identity to foster social and structural changes that are associated with the health status of the community as a whole).
There are numerous community-level constructs to help inform the role of the community as a unit of identity and solution, such as “sense of community” (Parker et al., in press; McMillan and Chavis, 1986), “community competence” (Cottrell, 1976; Eng and Parker, 1994), “community capacity” (Goodman et al., 1998), and “community empowerment” (Israel et al., 1994; Wallerstein, 1992).
Theories of Change for Community-Level Interventions
Interventions at the community level pose many challenges. Unlike clinical trials, it is usually impossible to have randomized control groups;
even finding comparison communities is frequently unrealistic. Interventions at the community level are often dynamic and change with the interactions. The interventions can be complex, working toward change in social, economic, physical, and/or political factors among individuals, organizations, families, as well as the community itself (Kubisch et al., 1998). A number of useful conceptual constructs and typologies provide frameworks for thinking about community-level interventions, as described below.
Chin and Benne (1969) explicate three different theoretical assumptions regarding changes in human systems, each of which has different implications for conducting community-level interventions. First, the “rational-empirical” construct assumes that humans are rational and that they will follow their self-interest once it is made clear to them, and that a person or community will adopt a proposed change if it is rationally justified. Second, the “normative-re-educative” construct assumes that actions are supported by socio-cultural norms, values, attitudes, and significant relationships, and the commitments on the part of individuals and communities to these norms; and that change will occur only as those involved are brought to change their normative orientations. This is similar to Lewin’s (1951) model, presented earlier, for conceptualizing change as a continuous process that involves an unfreezing, a changing, and a refreezing phase. Third, the “power-coercive” construct assumes that the change or influence process will either occur through compliance of those with less power to the ideas, direction and leadership of those with greater power (i.e., power over); or when that power is questioned or in conflict that there is collective power (i.e., power with) in which change occurs when those with less power come together to transform power relations from one group to another (Minkler and Wallerstein, 1997).
Warren (1975) conceptualizes purposive change in communities as being based on different configurations with respect to the agreement-disagreement dimensions of an issue, as well as other intervening variables. He posits three situations on a continuum that have different implications for community-level purposive change: (1) “issue consensus” —where there is basic agreement within the community on an issue and how it should be resolved; (2) “issue difference” —where no agreement yet exists on the issue, but there is the possibility that the community will reach issue consensus; and (3) “issue dissensus” —where members of the community either refuse to recognize the issue or are in strong disagreement with the change being proposed and there is little likelihood of achieving issue consensus.
Minkler and Wallerstein (1997), in their typology of community organization and community building, posit a two-by-two figure that is anchored on the horizontal axis by the constructs of “consensus” and “conflict,” and on the vertical axis the constructs of “needs-based” and “strengths-based”. Thus, different models or approaches to community change are based on different assumptions regarding the issues being addressed and the relationships that exist within the community (i.e., consensus or conflict), and the assessment of the community that drives the change process (i.e., needs-based or strengths-based).
Recently, Weiss (1995) proposed “theory-based evaluation,” or the theory of change, challenging program planners to assess “how and why the program will work.” In the theory of change approach, the first step is to articulate clearly the goals of the intervention and specific pathways to attain them (hypotheses). Consensus among the key participants about the goals is important. Agreement on the desired final outcome provides clarity on what to measure in the beginning and over the long term. Evidence from previous interventions is useful in identifying any weak assumptions in the hypotheses that might need rethinking. The pathways are likely to be a sequence of activities and their expected outcomes that lay out the key steps to the anticipated change. Specific interim outcomes provide options for measurements that can be used to see if the changes are occurring according to the original hypotheses. In this way, theory of change can help to guide decisions about what to measure and when to expect the change. Multiple theories of change can be applied simultaneously within a program with multiple pathways leading to the goal of the intervention (Weiss, 1995). Effective implementation of the theory of change approach does not ensure that the goals will be attained, but does provide the framework for evaluating the success of the intervention. Furthermore, by tracking progress with interim goals, it can help to distinguish problems with the hypotheses from problems with the implementation of the intervention and thereby allow midcourse corrections in the interventions (Milligan et al., 1998).
It is beyond the scope of this chapter to provide an exhaustive review of the various approaches to community change interventions. Within the community-organizing literature there is extensive discussion of change models, such as community development, social action, commu-
nity building, and empowerment-oriented social action. There is also a long history of community organizing for health (see Clark and Gakuru, 1982; el-Askari et al., 1998; Eng and Parker, 1994; Friedman, 1997; Freudenberg, 1984; Fullilove, 1998; Gibbs, 1983; Hofrichter, 1993; Kass and Freudenberg, 1997; Medoff and Sklar, 1994; Minkler, 1997; Minkler and Wallerstein, 1997; Nash, 1993; Newman, 1993; Wallerstein et al., 1997; Young and Padilla, 1990). However, as discussed throughout this report, within the field of public health per se, considerably less emphasis and fewer resources have been placed on conducting and evaluating community-level interventions in the United States (Israel et al., 1998; Lomas, 1998). The very nature of these interventions— with their emphasis on the social, cultural, economic, and political context of communities of identity, and on the role of community involvement in and control of an evolving process for which full specification of goals and objectives is not possible at the beginning—and the necessary commitment to the long time frame required to bring about major community-level changes preclude application of traditional evaluation designs and methods to assess effectiveness (Israel et al., 1998; Minkler and Wallerstein, 1997; Patrick and Wickizer, 1995; Wallerstein and Sanchez-Merki, 1994). Therefore, for the purposes of this section, a brief description is provided of two key studies of community-level interventions. In keeping with an ecologic framework, it is important to recognize that these interventions also targeted individual-level factors, although they are not discussed here.
Tenderloin Senior Organizing Project
Over a 16-year period, the Tenderloin Senior Organizing Project (TSOP) involved community members in the Tenderloin district of San Francisco, focusing on low-income elderly residents in single-room occupancy hotels. TSOP was established in 1979 by faculty and graduate students at the School of Public Health, University of California, Berkeley, with the initial goals of enhancing mental and physical health by reducing social isolation and providing health education, and of bringing together local residents to identify common problems and solutions for addressing those shared concerns (Minkler, 1992, 1997).
TSOP drew on four conceptual domains—social support, critical consciousness, social action, and democratic citizenship—to foster community empowerment and competence (Minkler, 1997). TSOP’s interven-
tion strategies evolved, including problem-posing discussions, support groups, leadership training, organizing tenants’ associations, and the formation of interhotel groups and coalitions. Its accomplishments included establishment of hotel-based minimarkets, reduction of the neighborhood crime rate, improved pest control, upgrading of substandard plumbing and wiring, agreements for the removal of lead-based paint, cleanup of a vacant lot used as an illegal dump, recognition by hotel management of the tenants’ associations as the organized voice of residents in the buildings, and the successful diffusion and replication of the TSOP model in other cities (Minkler, 1997).
Minkler (1997) offers several lessons from the TSOP experience for those interested in community organizing in the health field:
the importance of the community, rather than an outside organizer, in defining needs and priorities;
the need for an initial and continuing community diagnosis and assessment to identify and build on community strengths and resources;
the flexible implementation of theories and methodologies, tailoring them to a particular community context;
the importance of using participatory and empowering approaches to evaluate community-level change interventions;
the necessity of long-range planning and developing diversified bases of funding.
East Side Village Health Worker Partnership
The East Side Village Health Worker Partnership (ESVHWP) is a project of the Detroit Community-Academic Urban Research Center, funded in 1995 through a cooperative agreement with the Centers for Disease Control and Prevention (Parker et al, 1998; Schulz et al, 1998). The project is a partnership between the University of Michigan School of Public Health, the Detroit Health Department, seven community-based organizations (Butzel Family Center, Friends of Parkside, Kettering Butzel Health Initiative, Warren/Conner Development Coalition, Islandview Development Coalition, V.I.S.I.O.N., East Side Parish Nurse Network), and the Henry Ford Health System. The partnership involves community-based participatory research with two broad goals: identifying and explaining the intrapersonal, interpersonal, organizational, community, and public policy factors in the stress model associated with poor health
outcomes on Detroit’s east side; and designing, implementing, and evaluating a collaborative lay health advisor intervention aimed at reducing stressors and strengthening protective factors associated with health, as identified by members of the community.
The objectives of this intervention incorporate change at several levels. Of particular importance is having lay health advisors (Village Health Workers [VHWs]) assist community residents in identifying and solving problems that affect the health of the community. More than 40 VHWs have completed an initial eight-session training program. They meet monthly to share experiences and skills and to participate in additional training in grant writing and community organizing, for example. The results of a random-sample community survey and in-depth interviews and focus group discussions with VHWs, steering committee members (representatives from each partner organization) and key community members identified four priority areas: parenting, support of women, crime and relationships with the police, and community organizing (Parker et al., 1998; Schulz et al., 1998). VHWs participated in monthly meetings at the police precincts, assisted in arson prevention (Maciak et al., 1998), organized neighborhood block clubs, established a fresh fruit and vegetable minimarket for neighborhood residents, and developed support mechanisms for women who have child care responsibilities.
The ESVHWP is using quantitative and qualitative data collection methods for several purposes. For example, a group interview with the Steering Committee developed a local stress model and guided the design of items on a community survey (Parker et al., 1998; Schulz et al., 1998). The survey is being used for basic research (e.g., to test the relationships of the variables in the stress model, see Schulz et al., 2000a,b; Parker et al., 2001) and evaluation purposes (e.g., to examine the effect of the intervention on reducing such stressors as crime and on strengthening such protective factors as social support and perceived control). One aim of the evaluation is to assess the extent to which the intervention has changed community-level factors, including the community’s sense of competence, empowerment, and cohesion (Eng and Parker, 1994; Fullilove, 1998; Goodman et al., 1998; Israel et al., 1994; Lomas, 1998).
Lessons from Community Change Interventions
Many social, economic, and environmental factors that affect health are disproportionately represented in minority communities and among
women. Therefore, greater emphasis is needed on public health interventions that involve communities of identity with the goal of collectively identifying resources, needs, and solutions that can influence community-level variables. There are several challenges and barriers to this approach and several factors that facilitate intervention effectiveness (e.g., Israel et al., 1998; Patrick and Wickizer, 1995). More resources are needed to support such community change efforts, as is an expanded set of methodologic tools to evaluate program success (Chapter 7). The Theory of Change for communities may help in developing evaluation approaches. In addition, the limits of community change interventions and the need to engage in broader policy programs that can affect social and structural factors must be recognized.
SOCIETY AND HEALTH
Research consistently reveals an inverse relationship between social class and a variety of diseases (Feinleib, 1996; Haan et al., 1987; Kaplan, 1989; Kitagawa and Hauser, 1973; Tomatis, 1992). In addition, these differentials are also increasingly prominent in the prevalence of health behaviors (Moss, in press; Winkleby et al., 1990). Studies have similarly reported that people with low incomes or minimal education levels are especially likely to exhibit multiple risk-related behaviors (Emmons et al., 1994). Interventions are needed to address the “pockets of prevalence” of risk-related behaviors to reduce the social inequalities of risk. The structure and function of society per se thus constitute the final framework within which interactions between behavior and health should be considered.
Interventions designed for low-income populations also must consider the social context that influences health behaviors and health status. Socioeconomic class affects the availability of an array of social and material resources that ultimately have profound effects on health (Aday, 1993; Graham, 1994a; Kaplan, 1995). For example, the Alameda County (California) Study (Berkman and Syme, 1979) identified multiple risk factors associated with low income, including smoking, obesity, unmet needs for food and medical care, unsafe neighborhoods, and lack of social supports (Kaplan, 1995). Graham (1994a,b) demonstrated the relevance of these socioeconomic factors for one risk-related behavior, smoking. Based on a qualitative study, she found that low-income women used smoking as a means of coping with economic pressure and the resulting demands placed
on them to care for others. Indeed, spending on cigarettes appears to be protected because it is viewed as a necessary luxury. Using survey data, Graham (1994b) found that, compared with their nonsmoking counterparts, working-class mothers who smoke generally care for more children and for children in poorer health, and are more likely to be providing that care alone. A larger proportion of smokers had insufficient resources to meet the basic needs of their families, and they lived in less desirable neighborhoods than did women with higher incomes. She concluded that smoking among working-class women was linked to the caring responsibilities and material circumstances that shape their lives (Graham, 1994b). Similarly, Romano and colleagues (1991) found that African American individuals who reported experiencing high levels of stress associated with their socioeconomic circumstances—such as being out of work or not having enough money to meet basic needs—were more likely to smoke than were those reporting better circumstances.
Even beyond the stressors associated with low income, social structure clearly shapes people’s daily lives (Amick et al., 1995; Kaplan, 1995; Wilkinson, 1996). For example, there are many ways the effects of income extend beyond purchasing power to influence daily life. Middle-class neighborhoods have proportionally more pharmacies, restaurants, banks, and specialty stores; low-income areas have more fast food restaurants, check cashing stores, liquor stores, and laundromats. Typical food purchases cost approximately 15% more in poor neighborhoods, and fresh produce can cost as much as 22% more than in higher income areas. In addition, the quality of the food on average is poorer in low-income areas (Trout, 1993). Relatively higher food costs in low-income neighborhoods could be associated with their relatively fewer supermarkets and with greater reliance on small and medium-sized stores (Crockett et al., 1992) in which the quality, quantity, and variety of fresh fruits and vegetables and meats is limited (Morris et al., 1992). As a result, people living in low-income areas often are much less able to meet their needs for healthful foods.
The public health response to social class differences in health behaviors must extend to changes in social structure to improve the day-to-day realities of low-income populations—factors that clearly shape health behaviors and health status. Broad-based policy initiatives designed to reduce social inequalities are likely to contribute to improved health at the individual and community levels (Amick et al., 1995; Anderson and Armstead, 1995; Kaplan, 1995; Minkler, 1989).
The constellation of factors operating at the society level constitutes an extremely complex system with multiple interactions and feedback mechanisms. It is beyond the scope of this report to address the full range of issues that function at this level or their ramifications for the health status of individuals and populations. Therefore, a brief description of several important factors is presented to illustrate the importance of considering them at the society level and of assessing some of their interactions with those that function elsewhere.
Government and Societal Constraints on Health
Many social, economic, political, and cultural factors are associated with health and disease for which changes in individual health behaviors alone are not likely to result in improved health and quality of life. Public health law has been defined as the legal powers and duties of government to assure the conditions for people to be healthy (Gostin, 2000; IOM, 1988). Government uses a number of means to prevent injury and disease and to promote the population’s health. Laws and regulations, like other prevention strategies, can intervene at each level discussed in this chapter in several ways to secure safer behavior among the population (Haddon et al., 1964; IOM, 1999). Finally, public policy interventions undertaken by government are given particular emphasis, but an analogous role can be served by other large components of civil society: employers, unions, health care organizations, citizens’ groups, or public interest foundations. Similarly, the distinctions between levels of government (nation, state, county, etc.) are beyond the scope of this report. For the purposes of discussing behavior and health, government is treated as a single component.
In 1979, the Surgeon General’s report Healthy People (USDHHS, 1979) presented national goals for reducing premature deaths. Soon afterwards, Objectives for the Nation (USDHHS, 1980) provided health objectives for the following 10 years in the United States. These targets proved to be an effective approach to setting priorities and evaluating progress in health promotion and disease prevention. Subsequently, Healthy People
2000 (USDHHS, 1990) and Healthy People 2010 (USDHHS, 2000) cartied on the tradition with updated goals for the coming decade. Health targets have also become part of the strategies for health policy in the United Kingdom, Australia, and the World Health Organization. The advantages and drawbacks to this approach are reviewed by van Herten and Gunner-Schepers (2000). On the positive side, the process of formulating the targets provides insights, reveals gaps, and stimulates debate. By helping to establish realistic goals, it improves resource management and provides benchmarks for progress. The objections to this approach include the concerns that it oversimplifies the health issues and that some objectives that are more difficult to quantify will be ignored. Using health targets incorporates a variety of approaches used at the government-level; national health campaigns and legislation are discussed briefly below.
Health Communication Campaigns
Interventions can be aimed at individual behavior—providing education or incentives for healthier choices. Government health messages can be highly important in advancing the public’s health by informing people about hidden risks and by providing guidance about safer alternatives. The effectiveness of national campaigns is extensively reviewed and analyzed in an IOM report (2001). One example, the National 5-A-Day Campaign, is described here to illustrate the scope of this type of intervention (Stables, 2000; Heimendinger et al., 1996). This campaign was initiated by the National Cancer Institute in partnership with the Produce for Better Health Foundation, to increase the dietary intake of fruits and vegetables to the recommended five servings each day. The intervention has multiple components. Mass media marketing is used to increase public awareness through newsletters, websites, television, publications, special events, and promotional items. Consumers are targeted at time of purchase with brochures, recipes, advertising, coupons, etc. The food industry and retail stores are provided with training and promotional kits, and they agree to display materials and hold special events that advance the message. At the community level, programs are designed to meet the specific needs of the community members. Interventions are aimed at schools, worksites, clinics, religious centers, etc. Activities include such events as garden projects, wellness seminars, booths at state fairs, and local media events. The 5-A-Day Campaign also provides funding for evaluation to assess the impact of the various programs and the effectiveness of the ad-
vertising. Media campaigns regarding the use of tobacco provide an interesting example for both government and the tobacco industry, which are described in Chapter 8.
The government can exercise its legislative powers to deter risk behaviors by imposing civil and criminal penalties (e.g., seatbelt and motorcycle helmet laws). This kind of regulation prescribes specific behavior either for the entire population (e.g., speed limits) or for segments of it (e.g., age-restricted tobacco and alcoholic beverage sales). The government also can create incentives for individual behavior change. For example, it can exercise its taxation authority to discourage unhealthy activities, such as tobacco use or excessive consumption of alcohol, or encourage healthy ones, for example, by providing tax deductions for health care expenditures. The effect of taxation on tobacco use is described in Chapter 8.
The law also can regulate the agents of behavior change, for example by requiring safer product design. Government can regulate unsafe products directly (e.g., passive restraints in cars, trigger locks on handguns, or childproof caps on medicines) or indirectly through the tort system (e.g., tobacco, automobile, or firearms litigation). Government also can help provide the means for safer behavior by removing legal impediments to behavior change (e.g., dismantling drug paraphernalia or needle prescription laws that impede access to sterile injection equipment).
Furthermore, the law can change the informational, physical, social, or economic environment to facilitate safer behavior. Government can demand accurate labeling and instructions (e.g., on foods, pharmaceutical products, nutritional supplements) or restrict commercial advertising of hazardous products and activities (e.g., tobacco, alcoholic beverages, gambling); enact housing and building codes to prevent injury and disease (e.g., sanitation, lead paint); and make environments safer (e.g., guards on upper-level apartment windows, median barriers on highways, regulations for safe disposal of toxic substances).
Addressing Socioeconomic Status and Health
The role of socioeconomic status in health (Chapter 4) is an issue that can only be handled at a societal level. The international scope of
this issue is reflected in the concerns it has raised from the World Health Organization (WHO), the World Bank, and the European Community (Whitehead, 1998; Gwatkin, 2000). Many efforts have been implemented to review the evidence and to search for solutions to the problem (see Gwatkin, 2000). The concern goes beyond providing equitable access to health care to addressing the basic links between social inequality and health.
In 1992, WHO set the following target: “By the year 2000, the differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups” (Dahlgren and Whitehead, 1992). Approaches were aimed at reducing poverty (e.g., compressed income scales or progressive tax systems), decreasing unhealthy living conditions (e.g., urban renewal programs), improving working conditions (e.g., legislation to eliminate physical health hazards at work or organizational reforms for less stressful working arrangements), decreasing unemployment (e.g., creation of new jobs or minimizing the impact through increased public awareness of available assistance), improving lifestyle (e.g., targeting the most disadvantaged groups for smoking or nutrition education or interventions), and providing access to health care (e.g., availability of insurance and culturally appropriate training for health care providers).
More recently, an Independent Inquiry (Acheson et al., 1998) examined the health inequalities in England and put forward several recommendations. Three areas were considered critical: improving the health of families with children, reducing disparity in income while improving the living conditions of the poor, and assessing all relevant public policies for their effect on health inequalities. The report pointed out that many areas not normally associated with health have an impact on the social inequities that influence health; these include poverty, income, tax and benefits, education, employment, housing and environment, transportation, pollution, and nutrition.
Others in the international community have participated in the discussions concerning how to address the problem of health inequities. Gwatkin (2000) suggested directing efforts toward reducing differences between the rich and the poor rather than improving societal averages. Barzach (2000) recommended a focus on prevention and control of certain priority pathologies with the expectation that these efforts would later provide a framework that could be generalized to broader issues. Dahlgren (2000) emphasized progressive financial strategies for health in-
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