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The breadth of studies covered in this review article, combined with the prominence the Journal is giving to the subject in this issue, suggests how far the field has come in its understanding of the links between public health and communities. The authors summarize many of the community-based studies since and draw useful conclusions for strengthening community-based efforts at improving the health of the US population. Moreover, by drawing from the lessons learned from human immunodeficiency virus HIV prevention programs, they provide significant recommendations for improving the potential of community-based strategies.
The term community-based has a wide range of meanings.
In this editorial we focus on 4 categories of community-based projects based on implicit constructions of community employed by investigators: community as setting, community as target, community as agent, and community as resource.
As setting, the community is primarily defined geographically and is the location in which interventions are implemented. Such interventions may be citywide, using mass media or other approaches, or may take place within community institutions, such as neighborhoods, schools, churches, work sites, voluntary agencies, or other organizations.
Various levels of intervention may be employed, including educational or other strategies that involve individuals, families, social networks, organizations, and public policy.
These community-based interventions may also engage community input through advisory committees or community coalitions that assist in tailoring interventions to specific target groups or to adapt programs to community characteristics. As a result, the target of change may be populations, but population change is defined as the aggregate of individual changes.
The term community-based may also have a very different meaning, that of the community serving as the target of change. The community as target refers to the goal of creating healthy community environments through broad systemic changes in public policy and community-wide institutions and services.
What is a Community/ Public Health Nurse?
In this model, health status characteristics of the community are the targets of interventions, and community changes, particularly changes thought to be related to health, are the desired outcomes. Several significant public health initiatives have adopted this model.
For example, community indicators projects use data as a catalytic tool to go beyond using individual behaviors as primary outcomes.
This model is commonly applied in community-based health promotion because of the widely endorsed belief that a high degree of community ownership and participation is essential for sustained success in population-level health outcomes. Whether a categorical health issue is predetermined or whether the community selects, perhaps within certain parameters, its own priorities, these kinds of interventions involve external resources and some degree of actors external to the community that aim to achieve health outcomes by working through a wide array of community institutions and resources.
Although closely linked to the model just described, the emphasis in this model is on respecting and reinforcing the natural adaptive, supportive, and developmental capacities of communities. In the language of Guy Steuart, 8 communities provide resources for meeting our day-to-day needs.
These resources are provided through community institutions including families, informal social networks, neighborhoods, schools, the workplace, businesses, voluntary agencies, and political structures. These naturally occurring units of solution meet the needs of many, if not most, community members without the benefit of direct professional intervention. However, communities are defined as much by whom they exclude as whom they include, and the network of relationships that defines communities may be under stress.
The goal of community-based programs in this model is to carefully work with these naturally occurring units of solution as our units of practice, or where and how we choose to intervene. This necessitates a careful assessment of community structures and processes, in advance, of any intervention. Thus the aim is to strengthen these units of solution to better meet the needs of community members.
This approach may include strengthening community through neighborhood organizations and network linkages, including informal social networks, ties between individuals and the organizations that serve them, and connections among community organizations to strengthen their ability to collaborate.
The model also necessitates addressing issues of common concern for the community, many or most of which are not directly health issues. In other words, this model necessitates starting where people are.
The importance of these models of community-based interventions is that they reflect different conceptions of the nature of community, the role of public health in addressing community problems, and the relevance of different outcomes.
When they are presented as pure types, it is understood that no one model is used exclusively with the practice of community-based health promotion. Although community as setting is obviously limited in its vision, community as agent can be regarded as romanticized, especially in light of the severe structural economic, social, and political deficits plaguing some communities.
The latter 3 models—community as target , community as resource, and community as agent —suggest that appropriate outcomes may not just be changes in individual behaviors but may also include changes in community capacity.
Recent years have seen an explosion in the literature on civic renewal, mediating structures professional organizations, churches, block watch organizations , and social capital starting in the political science field but spilling over into other disciplines and into the popular literature as well.
This suggests a broader context within which community programs take place. It is neither the state nor the market. It is not a collection of individuals pursuing their own interests, but rather collectivities pursuing common interests.
It encompasses both community service, formal and informal, and advocacy, not the least of which includes voting. The morality of a civil society mandates the broadest possible inclusion in the participation and institutions that constitute it. Thus in calling forth the voices of even the weakest among a people, civil society goals are fully compatible with contemporary public health goals of reducing health disparities.
The vitality of civil society provides an essential context for successful community-based health promotion, especially as we come to recognize and increasingly utilize the capacity of communities to mobilize to address community issues. Community capacity may be regarded as a crucial variable mediating between the activities of health promotion interventions and population-level outcomes.
A number of dimensions of community capacity have been identified, among them skills and knowledge, leadership, a sense of efficacy, trusting relationships, and a culture of openness and learning. More profoundly, an appreciation for community capacity shifts the paradigm underlying common intervention strategies to a focus on community building as a pathway to health.
The Origins of Public Health Nursing: The Henry Street Visiting Nurse Service
This may include conscious efforts to develop new and existing leadership, strengthen community organizations, and further community development and interorganizational collaboration. Community capacity represents both a necessary condition, an indispensable resource, and a desired outcome for community interventions.
Based on the work of Urie Bronfenbrenner 15 and other systems models, social ecology 16— 18 places the behavior of individuals within a broad social context, including the developmental history of the individual, psychological characteristics norms, values, attitudes , interpersonal relationships family, social networks , neighborhood, organizations, community, public policy, the physical environment, and culture.
Behavior is viewed not just as the result of knowledge, values, and attitudes of individuals but as the result of a host of social influences, including the people with whom we associate, the organizations to which we belong, and the communities in which we live. Our interventions may include family support as in diet and physical-activity interventions , social network influences used in tobacco, physicalactivity, access-to-health-care, and sexual-activity interventions , neighborhood characteristics as in HIV and violenceprevention programs , organizational policies and practices used in tobacco, physical-activity, and screening programs , community factors observed in physical-activity, diet, access-to-health-services, and violence programs , public policy as in tobacco, alcohol, and access-to-health-care programs , the physical environment used in the prevention-ofunintentional-injuries and environmental-safety programs , and culture observed in some counteradvertising interventions.
Thus we can intervene at multiple levels within the social ecology as a way of addressing behavioral risks. However, social ecology is more than the idea that we can use interventions at multiple levels of the social system. It is also the idea that each level of analysis is part of an embedded system characterized by reciprocal causality.
For example, individuals are affected by the families and informal networks of which they are members, and individual characteristics affect the social networks to which we have access.
Moreover, our social networks are largely developed within the context of organizations and environments that bring us into contact with others. This suggests that ecological interventions may occur at one level and produce change or changes at others.
We need to distinguish clearly between levels of intervention and targets of interventions, 19 whether our focus is on behavioral change, strengthening units of solution, or building the civil society. Models such as social ecology provide us with not only a systems framework for thinking about behavioral change as an outcome of community-based interventions but also a framework for thinking about healthy communities.
Perhaps tobacco use can serve as an example. Since the s, when almost one half of the US adult population smoked, we have cut smoking rates in half. We have seen widespread shifts in perceptions of smokers as masculine Marlboro , sophisticated Winston , and sexy Virginia Slims adults to widespread views of smokers as weak willed and addicted. These changes have occurred despite the deliberate shaping of public opinion by tobacco producers and the marketing of tobacco to vulnerable populations.
The tobacco example suggests that the goal of community-based interventions is not only to change individual perceptions and behaviors but also to embed public health values in our social ecology, including families, social networks, organizations, public policy, and ultimately our culture—how we think about things. Although we lack an effective method for estimating effects, perhaps we should think in terms of community-based interventions as part of the social ecology and in terms of the cumulative effects of multiple community trials rather than the effects of a single project.
Too rarely do community-based interventions actually target organizational, community, environmental, or policy-level changes.
Even for those most interested in individual behavioral change, the targeting of higher ecological levels is essential to create the social context supporting healthy behavior. In recent decades, considerable progress has been made in articulating program or implementation theories, 21, 22 yet there are relatively few advances in developing a theory of community change.
This inadequacy of theory seriously hampers the evaluation of community-based programs, including estimation of the magnitude and timing of outcomes.
Several types of theories are important for thinking about community change. Such theory is invaluable for spelling out the mechanics and activities but provides little understanding of the how and why— the underlying process, dynamics and conditions under which community change takes place.
Moreover, many implementation theories are relatively generic and may not be linked to community dynamics, and although they may use information on context, it is frequently not clear how community context should affect the implementation process. Explaining the how and why of community change is the express purpose of an underlying theory of change.
Logic models are frequently used for this purpose. In addition to more rigorous designs for outcome studies, community change theory would benefit from qualitative research that explores the various factors affecting community change, linkages among the factors, and the conditions under which those linkages occur.
Program assumptions must be made explicit so that data collection and analysis can be undertaken to track performance. We suspect that one would find a limited number of variables being selected for manipulation—most commonly, information—and a general lack of awareness or strategic use of community factors as levers of change.
Shaping Family and Community Health: A Historical Perspective
It would be tempting to conclude from our brief discussion of community change and intervention theories that the problem of strengthening communitybased interventions is largely a technical or theoretical one. These problems do not just result from personal choices; rather, they say something about social structure and who we are as individuals and as a society, and about our place in society. Whether we talk about social class differentials in heart disease morbidity and mortality or access to care, public health is inherently linked to ideas about how the burden of ill health is—and should be—distributed in society.
Public health is more than a body of theory and intervention methods. We cannot separate how we do public health from why we do public health. Whether we talk about changing behavior, changing community structures, or building community capacity, these changes cannot be separated from our ideals about what constitutes a good community or a good society.
National Center for Biotechnology Information , U. Am J Public Health.
History of community health nursing pdf articles
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Requests for reprints should be sent to Kenneth R. Accepted November 22, This article has been cited by other articles in PMC. References 1. Reconsidering community-based health promotion: promise, performance, and potential.