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LETTER |
The author is with the Center for Applied Public Health, Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY.
Correspondence: Requests for reprints should be sent to Cheryl Merzel, DrPH, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY 10032 (e-mail: cm449{at}columbia.edu).
I appreciate Kuller’s comments, which give me an opportunity to further elucidate several points that are key to understanding contemporary community-based health promotion. The programs reviewed in our article are based on a model of populationwide primary prevention, implemented through a variety of psychosocial strategies targeting multiple health behaviors and conducted on several levels.1,2 In contrast, the interventions cited by Kuller employed clinical therapies for the purpose of prophylaxis or to treat identified cases. They were not designed to address the goal of population-level behavior change across all levels of risk. Thus, establishing the effectiveness of community-based health promotion programs intended to influence behaviors among an entire population remains a challenge.
Part of this challenge, and the distinction of community-based health promotion, involves the question of the level of impact targeted for intervention. While many particular interventions have worked in specific settings and with small groups of individuals, they have failed to have similar success when implemented on a broader scale.3–5 What we called for in our article were not, as suggested by Kuller, new theories of individual behavioral change but greater attention to understanding the process of community change. This view is based on paradigms of population health that recognize communities as distinct social entities, which are more than the sum of individual characteristics and which interact with individuals who are part of these social units.6 Thus, public health interventions need to focus on upstream influences on health behaviors and health and specifically target communities in addition to individuals.7
This point is nicely illustrated by one of the examples cited by Kuller. While Goldberger’s groundbreaking work on pellagra in the early 1900s was limited to epidemiological analysis and did not involve communitywide intervention (the effect of dietary change was tested among state mental institution inmates), the study’s main conclusion was that the dietary deficiencies that caused pellagra in rural areas of the US South were the result of poverty and the conditions engendered by a single-crop tenant-farming socioeconomic system.8
Finally, I agree that evaluations of these programs should not ignore changes in levels of risk and morbidity. However, as we discussed in our paper, many challenges are involved in establishing the link between community interventions and traditional epidemiological outcomes. As a result, there is growing consensus that attention also needs to be given to intermediate outcomes and important community-level impacts that eventually can lead to improvements in population health.9,10
References
1. Blackburn H. Research and demonstration projects in community cardiovascular disease prevention. J Public Health Policy.1983;4:398–422.[Medline]
2. Shea S, Basch CE. A review of five major community-based cardiovascular disease prevention programs, part I: rationale, design, and theoretical framework. Am J Health Promotion.1990;4:203–213.[Medline]
3. Fisher E. The results of the COMMIT trial [editorial]. Am J Public Health.1995;85:159–160.
4. Luepker RV, Murray DM, Jacobs DR Jr, et al. Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program. Am J Public Health.1994;84:1383–1393.
5. Susser M. The tribulation of trials—intervention in communities [editorial]. Am J Public Health.1995;85:156–158.
6. Schwartz S, Diez-Roux A. Commentary: causes of incidence and causes of cases—a Durkheimian perspective on Rose. Int J Epidemiol.2001;30:435–439.
7. McKinlay JB, Marceau LD. A tale of 3 tails. Am J Public Health.1999;89:295–298.
8. Terris M, ed. Goldberger on Pellagra. Baton Rouge: Louisiana State University Press; 1964.
9. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE. The Community Guide’s model for linking the social environment to health. Am J Prev Med.2003;24(3 suppl):12–20.[ISI][Medline]
10. Steckler A, Allegrante J, Altman D, et al. Health education intervention strategies: recommendations for future research. Health Educ Q.1995;22:307–328.[ISI][Medline]
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