The Future of the Public's Health in the 21st Century (2003) / Chapter Skim
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4. The Community
4. The Community
Pages 178-211
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From page 178... ...
William James This chapter is at the heart of the Healthy People 2010 vision reiterated by the committee: "healthy people in healthy communities." Communities are both the physical and cultural settings for and through their residents and community-based organizations participants in action to promote the public's health. They are also points of convergence for the interests of employers, businesses, and academia; the messages of the media; and the services of governmental public health agencies and the health care delivery system.
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From page 179... ...
Other members of the community may come from the private sector, including private schools, colleges, and universities; health care providers and payers; and small and large businesses. A healthy community is a place where people provide leadership in assessing their own resources and needs, where public health and social infrastructure and policies support health, and where essential public health services, including quality health care, are available.
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From page 180... ...
Moreover, the solutions for assuring population health are not owned by governmental public health agencies; they can be found in communities and in community organizations and partnerships (CDC, 1997; WHO, 1998; Bowles, 1999; Mitchell and Shortell, 2000~. Today's health challenges, ranging from jet-setting microbes and soaring obesity rates to emerging environmental risks and bioterrorism, highlight the interconnectedness of people and communities and the need for joint efforts to meet those challenges (McGinnis and Foege, 1993; Ruderman, 2000; Norton et al., 2002~.
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From page 181... ...
For example, a recent study of 10 local health departments from different states found that they were substantially involved with community and youth organizations, schools, and the media in the areas of tobacco use prevention, injury prevention, and physical activity promotion (McHugh et al., 2000~. Many communities, through individuals and organizations, have become partners with health departments in health improvement and have even become leaders in spearheading collaborative efforts (Fawcett et al., 1996; Mitchell and Shortell, 2000; Norton et al., 2002~.
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From page 182... ...
The committee is encouraged to see indications that governmental public health agencies, community health centers, hospitals, and health maintenance organizations recognize that community collaboration is a necessity in health improvement (CDC, 1997; Pronk and O'Connor, 1997; Omenn, 1999~. Some of the major federal and foundation initiatives that require and support the creation of broad-based community coalitions include Healthy Start, a community-based infant mortality reduction program; Turning Point1 and Community Voices,2 1 Turning Point is a grant program of the W
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From page 183... ...
One lesson that has been learned from such experiences, however, is that the community must be engaged before an agenda is set the active participation of community leaders, members, and organizations is needed in the earliest stages of community-based public health action, if it is not already the force that drives such action (The Lewin Group, 2002~. The initial communication and networking necessary to launch a community health improvement project entail frank examination and discussion of motivations, approaches, and goals by all stakeholders.
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From page 184... ...
Research to assess the effectiveness of community collaborations has had somewhat mixed results because of the heterogeneity of communities, the long time lines involved in achieving community health improvement goals, and other complexities inherent in community-driven public health activities (Sharpe et al., 2000; Lasker et al., 2001~. However, a growing base of empirical evidence from programs such as Turning Point and Community Voices provides a good road map for communities and their partners.
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From page 185... ...
At the local level, in particular, health departments can become the facilitators and supporters of strong local public health systems that are informed by community voices, responsive to community needs, and linked to community assets. The committee supports a type of shared governance through which the agenda for population health is truly "owned" by the population it serves (Turning Point Community Health Governance Workgroup, 2001a and b; The Lewin Group, 2002~.
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From page 186... ...
Some of these models include the Planned Approach to Community Health, Mobilizing for Action through Planning and Partnerships, and the Community Health Improvement Process (Kreuter, 1992; IOM, 1997~. The models provide step-by-step guidance for various aspects of the health improvement process, including assessing the health status of the community and the capacity of the local governmental public health agency.
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From page 187... ...
The Health Action initiative in Monroe County, New York, provides a good example of community involvement in assessing, prioritizing, and planning for health improvement (Milbank Memorial Fund, 1998; Health Action, 2001~. Founcleci in 1995, Health Action is a collaborative of health care providers, hospitals and clinics, the local health department, an urban health commission, a university, the chamber of commerce, a large employers' organization, and a professional association.
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From page 188... ...
A community-based approach to health improvement that considers the broad range of social and environmental determinants of health may call for the use of a variety of indicators, including ones that measure characteristics of the community rather than those of individuals (i.e., community-level indicators)
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From page 189... ...
Implementing Targeted Action The second component of community-driven health improvement efforts Is implementing targeted action to address high-priority health issues (Fawcett et al., 2000b)
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From page 190... ...
For instance, the outreach workers of Oakland's Asian Health Services reach Korean groups with information about health care access at church health fairs. Faith-based groups are often community institutions, deeply rooted in neighborhoods, and may play an important role in local public health systems and community-based health improvement initiatives (DHHS, 1999; Lundblad, 1999~.
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From page 191... ...
~ s-u-p-po-rl~ a-n-a~ e-ou-,,,,~,,,-ll-o-n~ sess-~-on-s- a- i~ exam-p-le~ oT~ susla-l-n-ea -- ,~ ~-i sl'-lul'-ona,~-l-zea~ ............................................................................................................................. Communities can also contribute to the process of health improvement through the efforts of individuals who sometimes become part of the public health workforce.
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From page 192... ...
In Orange County, California, Latino Health Access, a community-based organization, receives community input, works collaboratively with the local county health department, and manages paid promotores who provide education and link community members to services and resources, including those provided by the health department (Bracho,2000~. The Asian Health Services and La Clinica de La Raza in Oakland, California, use the services of staff members from several ethnic communities to conduct culturally and linguistically competent health promotion and health care outreach in those communities (see Appendix F)
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From page 193... ...
Informed and mobilized communities can help ensure that government agencies enforce such regulations. The committee found many examples of community-based efforts to modify local conditions as part of a health improvement initiative.
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The Healthy Neighborhoods Project (HNP) in western Contra Costa County, California, brought together community residents, the health department, community organizations, and sometimes other partners from the public, private, and civic sectors (Minkler, 2000~.
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From page 195... ...
At the political level, the commitment of elected officials to communitywide health action can have an enormous influence on broadening the impact of a program and increasing the likelihood of sustainability of programs and outcomes. The American Health Decisions network of state organizations has been pioneering new methods of involving the public in community dialogues about health values and trade-off options.
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From page 196... ...
Achieving Widespread Change in Behavior and Risk Factors Changing individual behavior to avoid health-related risk factors is another stage on the road to health improvement. Behavioral change may sometimes be achieved through interventions, such as health education and counseling, that are aimed directly at individuals, although the evidence base shows that a broad array of interventions go beyond the individual and function at an ecological level (e.g., the neighborhood or the workplace)
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From page 197... ...
They described a vision of improving neighborhoods by adding green spaces to facilitate walking and other activities. In Contra Costa County, California, observation and statistics indicated that African-American women were less likely to receive breast cancer screening for reasons related to the cost of care and a fear of diagnosis, leading to significantly higher rates of mortality from breast cancer in this
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From page 198... ...
This is reflected in the determinants of health discussion in Chapter 2. Efforts to change health behavior and address risk factors cannot reach optimal effectiveness if they depend solely on one-on-one health education or health promotion interventions (Economos et al., 2001~.
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From page 199... ...
has come to be a valued area of public health research, and partnerships among community groups and organizations and public health researchers and practitioners have become more common and fruitful (Israel et al., 1998~. The committee agrees with those who argue that communities and community members must, for both practical and ethical reasons, be partners in health improvement interventions and in the research that guides these interventions (Green and Kreuter, 1991; Kretzmann and McKnight, 1993; Blackwell and Colmenar, 2000; Potvin and Richard, 2001; Norton et al., 2002~.
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From page 200... ...
1 his tension between the nature ot the community and the nature of science may help explain why researching the effectiveness of community coalitions and community intervention has been a complicated endeavor and why investment in community-based research has been limited.
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From page 201... ...
SUSTAINING COMMUNITY ACTION ON HEALTH Assuring the health of communities requires continuous community participation and leadership in the context of a broader partnership with other potential actors in a public health system. Communities can work
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From page 202... ...
The fact that communities may rely on health departments to provide technical assistance underscores the need to enhance the skills and knowledge of the public health workforce (discussed in greater detail in the Chapter 8~. The committee recommends that local governmental public health agencies support community-led efforts to inventory resources, assess needs, formulate collaborative responses, and evaluate outcomes for community health improvement and the elimi
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From page 203... ...
The sustainability of health improvement efforts is reflected in the extent of community change and the degree to which initiatives remain in place after funding ends (Paine-Andrews et al., 2000b)
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From page 204... ...
Such a focus would include realistic time lines, an emphasis on ongoing community engagement and leadership, and a final goal of institutionalizing effective project components in the local community or public health system as appropriate. Given the ever-changing nature of communities, health improvement efforts should be seen as a continuing journey rather than a specific destination.
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From page 205... ...
The National Center for Chronic Disease Prevention and Health Promotion Syndemics Prevention Network. Available online at www.cdc.gov/ syndemics/overview-planeval.htm.
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From page 206... ...
Prepared for California Wellness Foundation's Health Improvement Initiative. Seattle: Group Health Community Foundation.
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American Journal of Community Psychology 29(2)
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1995. 1992-1993 National profile of local health departments.
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1997. Systems approach to population health improvement.
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2000. Community health improvement approaches: accounting for the relative lack of impact.
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From page 211... ...
American Journal of Community Psychology 29(2)
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