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EDITORIAL |
Kenneth McLeroy, James Burdine, and Ciro Sumaya are with the Texas A&M University System School of Rural Public Health, Bryan. Barbara Norton is a doctoral candidate at the University of Oklahoma School of Public Health, Oklahoma City. Michelle Kegler is with Emory University School of Public Health, Atlanta, Ga.
Correspondence: Requests for reprints should be sent to Kenneth R. McLeroy, PhD, associate dean for academic affairs, School of Rural Public Health, 3000 Briarcrest, Suite 310, Bryan, TX 77802 (e-mail: kmcleroy{at}srph.tamu.edu).
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INTRODUCTION |
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 TOP INTRODUCTION A TYPOLOGY OF COMMUNITY-BASED...CIVIL SOCIETY, COMMUNITY...ECOLOGICAL PERSPECTIVESTHEORIES OF CHANGEReferences |
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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. This typology (many typologies of community approaches have been proposed in the literature, the most frequently used of which is Rothman’s Strategies of Community Intervention2; we chose not to use Rothman’s categories explicitly, although some of his ideas are included in the discussion) is used to illustrate the difficulties in summarizing results across the array of community-based projects (of course we recognize that projects rarely fit our categories neatly and that any one project may have characteristics borrowed from each of the categories). This brief discussion of "types" of projects is followed by a discussion of the importance of community capacity; the use of social ecology as a framework for community interventions; the use of a theory of community change; and the role of public health values.
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A TYPOLOGY OF COMMUNITY-BASED INTERVENTIONS |
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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. 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.3 Indicators can range from the number of days exceeding Environmental Protection Agency standards for air quality to the amount of park and recreation facility space per capita to the proportion of residents living below federal poverty levels.4 Strategies are tied to selected indicators, and success is defined as improvement in the indicators over time.
A third model of "community-based" is community as resource. 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. These programs are aimed at marshaling a community’s internal resources or assets, often across community sectors, to strategically focus their attention on a selected set of priority health-related strategies. 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. Examples of major public health initiatives that have applied this model include "healthy cities" initiatives within several states,5 the National Healthy Start program,6 and the federal Center for Substance Abuse Prevention Community Partnership program.7
Finally, a fourth model of "community-based," and the one least utilized in public health, is community as agent. 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. It also requires an insider’s understanding of the community to identify and work with these naturally occurring units of solution to address community problems. 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.9
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. Moreover, Merzel and D’Afflitti illustrate the difficulties in summarizing across program models with different strategies and expected outcomes. Although many of the earlier projects reviewed by Merzel and D’Afflitti were based on the idea of community as setting, many of the later projects are based on one of the other 3 models. 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.10,11 In fact, it may be argued that contemporary public health has 2 broad goals: strengthening the health of our communities and building community capacity to address health-related issues.
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CIVIL SOCIETY, COMMUNITY CAPACITY, AND COMMUNITY-BASED HEALTH PROMOTION |
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TOPINTRODUCTIONA TYPOLOGY OF COMMUNITY-BASED...CIVIL SOCIETY, COMMUNITY...ECOLOGICAL PERSPECTIVESTHEORIES OF CHANGEReferences |
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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.13 An understanding of the community’s ecology can lead to a better match with community-based health promotion interventions and can provide tools and resources unavailable from outside agents for making gains against complex public health problems like infant mortality, violence, substance abuse, and many others. 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. This may include conscious efforts to develop new and existing leadership, strengthen community organizations, and further community development and interorganizational collaboration.14 These efforts may require ensuring opportunities for community participation, strengthening relationships of trust and reciprocity among community groups and organizations, and facilitating forums for community dialogue. Community capacity represents both a necessary condition, an indispensable resource, and a desired outcome for community interventions.
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ECOLOGICAL PERSPECTIVES |
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TOPINTRODUCTIONA TYPOLOGY OF COMMUNITY-BASED...CIVIL SOCIETY, COMMUNITY...ECOLOGICAL PERSPECTIVESTHEORIES OF CHANGEReferences |
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If individuals’ behaviors are the result of social influences at different levels of analysis, then changing behavior may require using social influences—family, social networks, organizations, public policy—as strategies for change. 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. What would it be like if we were to have the public’s health as one of our core values? Perhaps tobacco use can serve as an example. Since the 1950s, 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.20 These cultural changes in perceptions of smoking have not occurred as the result of any single community-based intervention but are the result of increasing evidence of the harmful effects of tobacco use and the cumulative impact of multiple systemic interventions, including bans on smoking in airplanes and public buildings, rises in the cigarette taxes, antitobacco advertising, and lawsuits against tobacco companies.
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.
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THEORIES OF CHANGE |
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TOPINTRODUCTIONA TYPOLOGY OF COMMUNITY-BASED...CIVIL SOCIETY, COMMUNITY...ECOLOGICAL PERSPECTIVESTHEORIES OF CHANGEReferences |
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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. Implementation theory, for example, identifies the activities—the what and the when—to be undertaken in any change process and their links to expected intermediate- and longer-term outcomes, most often codified in a program’s logic model. Typical implementation theories for community-based programs include a sequenced set of major steps, commonly community diagnosis/assessment, planning, intervention, and evaluation. 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.23 Theories of community change are the least explored and offer the greatest promise for documenting the effectiveness of and improvements in community-based health promotion. To achieve this, we need to make explicit our program assumptions about the causal relationships among an intervention’s activities and the mediating factors that lead to desired outcomes, as well as the effect of potential confounding factors. 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. In fact, building on the excellent review of Merzel and D’Afflitti, one could fruitfully conduct a cross-case analysis of theories of change with a similar inventory of community-based health promotion. 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.
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.24 However, many of the problems around which community-based interventions have been developed—HIV, adolescent pregnancy, diet, tobacco use, other drug use, alcohol consumption, physical activity, access to health services, firearms—have profound personal and cultural meaning. 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.25
Accepted for publication November 22, 2002.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
