EXHIBIT 6.1 Sample survey with data entry codes
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.
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.
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.
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.
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.
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 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 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:
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.
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 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:
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.
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 1.1 Examples 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.
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.
Alma Ata Declaration
Community
Community-based health interventions
Demographic variables
Ecological theory
Levels of prevention
Primary prevention
Secondary prevention
Target community
Tertiary prevention
As discussed in this chapter, communities are not defined solely by geographic boundaries.