Public health practice in Communities WITH THIRUVENGADAM MUNIRAI CHAPTER OUTLINE a public health agency, such as the commissioner of health THEORIES OF COMMUNITY CHANGE 318 or agency staff. However, the principles of community plan A. Social Cognitive Theory 321 ning and evaluation pertain to B. Community Organization 321 in improving the community(stakeholders, policy cipatory Resea including an employee of a foundation, schoo C. Diffusion of Innovations Theory 322 office, or political party and any interested citizen. Social Marketing in Public Health 322 there are many ideas on how to improve the health of a com- D. Communication Theory 323 munity, many good ideas fail. Reasons include lack of com- Delphi Technique 323 munity or organizational support, lack of coordination, 2. Role of Media Communication 323 turf battles, inefficient and duplicative efforts, and failure E. Environmental Influences on Behavior 323 to use evidence-based interventions. Careful planning before II. STEPS IN DEVELOPING A HEALTH PROMOTION a project begins can make a significant impact on the success PROGRAM 325 of the pre A. Define Strategy and Assemble Team 325 This chapter discusses the steps involved in planning and B. Identify Primary Health Issues 325 evaluating a program, highlighting two special applications PRECEDE/PROCEED Model of community planning:(1) tobacco prevention, as ar 2. Planned Approach to Community Health 326 example of multiple successful community interventions 3. Mobilizing for Action through Planning and Partnerships 32 (Box 26-1), and(2) health disparities, one of the greatest C. Develop Objectives to Measure Progress 3 ublic health problems. a community is only as strong as its Healthy People 2020 327 weakest link. Therefore, public health practitioners shoul D. Select Effective Interventions 328 aim not just to raise health overall, but to raise most the Community Preventive Services 328 health of the vulnerable populations. Box 26-2 lists some 2. Cultural Congruence of Interventions 329 examples how health disparities have been successfully ddressed mplement Innovations 329 Many models and acronyms describe the steps of co munity planning(Box 26-3). They all have their strengths III. FUTURE CHALLENGES 330 and weaknesses. We follow mainly the steps outlined in the A. Integrating CLinical Care and Prevention 330 Centers for Disease Control and Prevention(CDC) model B. Integrating Community-Based Prevention with Other Community Health Assessment and Group Evaluation Community Services 330 (CHANGE). Other models are described in the section that C. E-Health 331 addresses their main emphasis. Any other model of com- IV. SUMMARY 331 munity planning likely works equally well as long as planners REVIEW QUESTIONS, ANSWERS, AND EXPLANATIONS follow the following basic principles Assemble community stakeholders and, in collaboration with them, define the agend nd pri Perform a needs assessment a Design measurable objectives and interventions Chapters 24 and 25 discuss the organization and health of the public health system overall. This chapter discusses the Build evaluation into the entire process theory and practice of improving community health. Theo Table 26-1 provides an overview of the process and pos ries are important because a theory-based program is more ible resources for each step. likely to be effective(see Chapter 15). The technical term for attempts to improve community health is community/ program planning . THEORIES OF COMMUNITY CHANGE Community planning is defined nized proces to design, implement, and evaluate a When behavioral factors are a threat to health, improving based project to address the needs of a health requires behavior change, Unhealthy behaviors(e.g Community planning is often the prov personnel in sedentariness) need to be replaced by healthy ones(e.g 318
CHAPTER 26 Public Health Practice in Communities Box 26-1 Prevention Efforts: Tobacco use(Cigarette Smoking) The decrease in tobacco use has been called one of the 10 great public airlines and buses, and changes to FDA rules for more oversight health achievements in the 20th century. This success illustrates what tobacco production and marketing is required to change community health practices. Several historic 6. States action States used excise tax on tobacco to fund factors came together to enable significant improvements in this smoking control programs, which led to the development important public health problem. and evaluation of community-level approaches to tobacco A. Credible evidence and effective interventions led to medical control 7. New litigation strategies opened up even more monies and created willingness in industry to agree to changes 1. Changes in understanding of the genesis of tobacco addiction eframed the problem as not one of individual control and choice Because of this high level of attention at all levels and significant but of addiction. Evidence for harm to nonsmokers(secondary unding for community prevention programs, multiple tobacco exposure)strengthened the case for regulation interventions to reduce smoking were developed, evaluated, 2. Behavioral and pharmacologic treatments became available, seminated. The U.S. Community Preventive Services recor making it easier to support smokers desiring to quit. combining strategies to B. Trusted experts and grassroots groups provided effective a Reduce exposure to environmental tobacco smoke. a Reduce tobacco use initiation, especially among adolescents, Increase tobacco use cessation 3. The American Cancer Society, American Association, and American Heart Association were each ating against Recommended interventions include tobacco independent from each other. I they formed a Smoking bans and restrictions in public areas, workplaces, and alition on smoking, which was later by the American Medical Association. This broad coalition led legitimacy to the a Increasing the unit price for tobacco produ a Mass media campaigns of extended duration using brief, 4. Grassroots efforts in many communities and from many sources recurring messages to motivate children and adolescents to ang king. Examples include fligh emain tobacco free pendants advocating for their right for a smoke-free workplace Provider reminders to counsel patients about tobaco d the Reader's Digest series educating its readers. The grassroots groups framed their issues as part of the broader Provider education combined with such reminders environmental protection movement and increased consumer a Reducing out-of-pocket expenses for effective cessation health consciousness C. Political will on many levels and available funds led to effective Multicomponent patient telephone support through a state quit 5. On a federal level, Congress passed several laws addressing tobacco labeling, advertising on TV and radio, smoking bans on odified from Institute of Medicine: Ending the tobacco problem: a blueprint for the nation, 2007: Task Force on Community Preventive Services S): Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke, Am/Prev Med 20(2 suppl): 10-15, 2001; and Tobacco. In Zaza S, Briss PA, Harris KW, editors: The guide to community preventive services: what works to promote health? Atlanta,2005,OxfordUniversityPress,http:/www.thecommunityguide.org/tobacco/tobacco.pd Box 26-2 Addressing Health Disparities Health in the U.S. population is characterized by pervasive and per- Empowering communities to a sense of increased ownership sistent health care disparities, sometimes also called health inequities. Despite the deeply rooted and intractable nature of many health care Ity participation parities,many states and communities have successfully imp a Addressing environmental factors such as safe walkabilit mented intervention to reduce them. Characteristics of successful bikeability of environment, and access to high-quality food programs include: n Making health equity a component of all policies, including a Strong data skills with geographic mapping of premature death clusters and other determinants of healtl Interventions against health inequities can be successful even on a a Strong coalitions among agencies, community leaders, and other ery small scale. Examples for such successful interventions include stakeholders librarians who visit schools to give each child a library card; public a Assessment of the community environment as a whole and housing directors who address lead and mold; and safe route to addressing the social determinants at the root of health school initiatives with "human school buses"(group of parents whe equities(e.g,, poverty, low rates for high school graduation take turns in walking children to school) ModifiedfromCentersforDiseaseControlandprEvention:hEalthdisparitiesandinequalitiesreport(chdir),2011.http://www.cdc minorityhealth/chdireport.html#execsummarY.IoMreportsonunequaltreatmentandreducinghealthcaredisparitieshttp://www.iom.edu/ Reports/201 1/State-and-Local-Policy-Initiatives-To-Reduce-Health-Disparities-Workshop-Summary asp
320 SECTION 4 Public Health Box 26-3 Frequently used Acronyms in Program Plannin CBPR Community-Based Participatory Research Community Health Assessment and Group Evaluation Diffusion of effective behavioral Interventions DOI Diffusion of innovations HEDIS Healthcare Effectiv Data and Information Set IOM Institute of Medicine MAP-II Mobilize, Assess, Plan, Implement, Track Mobilizing for Action through Planning and Partnerships NACCHO National Association of County and City Health Officials National Committee for Quality Assurance NPHPSP National Public Health Performance Standards Program PLANEI Plan, Link, Act, Network with Evidence-based Tools PAR CH Planned Approach to Community Health PRECEDE Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation PROCEED Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development RTIP Research Tested Intervention Program RE-AIM Reach, Effcacy, Adoption, Implementation, Maintenance SCT Social Cognitive Theory Specific, Measurable, Attainable, Relevant, and Timely ickness Prevention Achieved through Regional Collaborat lot an acronym, but a program emphasizing verb as a part of speech, meaning an action word Table 26- Overview of Steps for Community Program Design, Implementation, and Evaluation Step/Description Suggested resources 1. Create strategy and elicit COmmunityheAlthAssessmentandGroupEvaluation(change)http://www.cdc.gov/ 2. Identify primary health issues in CountyHealthRankingshttp://www.countyl National Public Health Performance Standar Mobilizing for Action through Planning and 3, Develop measurable process and People2020leadinghealthindicatorshttp://www.healthy gov/2020/default. aspx outcome objectives to assess progress HEDIS(Healthcare Effectiveness Data and Information Set) performance measures 4, Select effective interventions to help ide to Community Preventive Services achieve these objectives Guide to Clinical Preventive services Research-testedInterventionpRogramshttp://rtips.cancergow/rtips/index.do 5. Implement selected interventions. PartnershipforPrevention:http://preventioninfo.org/ CdcyNergYhttp://www.cdc.gov/healthcommunication/cdcynergy/ //rtips cancer. gov/rtip 6. Evaluate selected interventions Framework for program evaluation in public health based on objectives; use this http://www.cdc.gov/mmwr/preview/mmwrhtml/rr481lal.htmCdcyNergy www.re-alm.org Guides/ The-Community CancerControlP.l.A.N.e.t:http://cancercontrolplanet.cancergov/;Communitytoolboxhttp://ctb.ku.edu/en/defaultaspx:Debl:http:// exercise). Individual behavior, however, does not occur in a behavior change( see Chapter 15 for theories of individual vacuum; it is strongly influenced by group norms and behavior change. )A number of theories have been devel environmental cues. Practitioners aiming to change group oped to describe how individual change is brought about norms and environmental cues should be aware of theories through interpersonal interactions and community inter- of community changes. This is because, as with any behavior ventions. These theories can be broadly characterized change, practitioners will have a higher chance of success cognitive-behavioral theories and share the following key if they intervene in accordance with a valid theory of concepts
CHAPTER 26 Public Health Practice in Co a Knowledge is necessary, but is not in itself sufficient increase the problem-solving ability of entire communities produce behavior changes through achieving concrete changes towards social cause. Perceptions, motivations, skills, and social environment The theory includes several key concepts. Empowerment is are key influences on behavior a social action process that improves community's confi dence and life skills beyond the topic addressed. Empower Some well-known theories governing social change are ment is any social process that allows people to gain mastery social cognitive theory, community organization and other over their life and their community. For example, individual participatory approaches, diffusion of innovations, and in a community may feel more empowered as they work ommunication theory, Taken together, these theories can be together to strengthen their cultural identity and their com- ed to influence factors within a social-ecological frame- munity assets. Empowerment builds community capacity work, as follows: Interpersonal: Family, friends, and peers provide role nity to mobilize, identify, and solve social problems. It models, social identity, and support. Organizations: Organizations influence behavior through sen rganizational change, diffusion of innovation, and social many wavs such as through skill-building workshops that marketing strategies allow members of the community to become more effective Community: Social marketing and community organizing leaders n change community norms on behavior Critical consciousness is a mental state by which members Public policy: Public opinion process and policy changes a community recognIze the need for social change and are can change the incentives for certain behaviors and make ready to work to achieve those changes. Critical conscious them easier or more difficult (e ., taxes on high-sugar ness can be built by engaging individuals in dialogues, thei Although behavior can be changed directly through any Social capital refers to social resources such as trust, reci- ments also have a powerful impact on behaviorenviron of these levels, the physical, regulatory, and political procity, and civic engagement that exist as a result of network between community members. Social capital can connect individuals in a fragmented community across social bound A. Social Cognitive Theory aries and power hierarchies and can facilitate community building and organization. Social networking techniques Social cognitive theory(SCT) is one of the most frequently and increasing the social support are vital methods that Ised and robust health behavior theories, It explores the build social capital reciprocal interactions of people and their environments and Media advocacy is an essential component of community the psychosocial determinants of health behavior(see organizing. It aims to change the way community members look at various problems and to motivate community Environment, people, and their behavior constantly influ- members and policy makers to become involved. This occurs ence each other (reciprocal determinism). Behavior is not hrough a reliable, consistent stream of publicity about an mply the result of the environment and the person, just as organizations mission and activities, including articles and the environment is not simply the result of the person and news items about public health issues. Media advocacy relies behavior. According to SCT, three main factors affect the on mass media, which make it expensive. In the 21st centur likelihood that a person will change a health behavior: (1) social media and games can generate extensive publicity with self-efficacy(see Chapter 15),(2) goals, and(3)outcome minimal investment. Table 26-2 summarizes how social expectancies, in which people form new norms or new expec- marketing, public relations, and media advocacy comple- tations from observing others(observatic ment each ot B. Community Organization I. Participatory Research A heterogeneous mix of various theories covers community Immigrants and racial or ethnic minorities often distrust the organization. The social action theory describes how to health care system, making it more difficult for researchers able 26-2 Relationship of Social Marketing, Public Relations, and Media Advocacy Social Marketing Public Relations Media Advocacy Message focus Look at me Enhance image and Change your behavior relationship with public Individuals at risk General public Effect Individuals Social Benefits Motivates individual Develops strategic relationships Community change through policy Generates support for cause ModifiedfromMediaAdvocacytoAdvancePublicHealthPolicyUclaCenterforHealthpOlicyResearch2002.http://www.healthpolicy.uclaedu/healthdata/tw_media2.pdf
SECTION 4 Public Health and health practitioners to identify and address the health concepts. Next, early adopters will try out innovations, fol needs of these communities. For these groups, as well as lowed by members of the early majority and late majority. for building community capacity in general, various par Laggards are the last to accept an innovation. Consequently, ticipatory research methods have been proposed. Parti innovations need to be marketed initially to innovators cipatory efforts combine community capacity-building and early adopters, then need to address each segment in strategies with research to bridge the gap between the sequence. The relevant population segments are generall knowledge produced and its translation into interventions referred to as innovators 2.5% of the overall population) and policies early adopters(13.5%), early majority(34%), late majority Participatory action research(PAR)and communit (34%), and laggards(16%). based participatory research( CBPR)are two participatory The speed of adoption by any group depends on research approaches that have gained increasing popularity ceived characteristics of the innovations themselves. since the late 1980s. Both PAR and CBPR conceptualize advantage, the degree to which an innovation is perceived ommunity members and researchers working together to as being better than the idea it supersedes, is a consequence generate hypotheses, conduct research, take action, and learn of the following ogether. PAR focuses on the researcher's direct action within a participatory community and aims to improve Compatibility, the degree to which an innovation the performance quality of the community or an area of eived to be consistent with the existing values, current concern. In contrast, CBPR strives for an action-oriented processes, past experiences, and needs of potential pproach to research as an equal partnership between tradi tionally trained experts and members of a community. The a Low complexity, the degree to which an innovation is per- ommunity members are partners in the research, not sub ceived as easy to use cts. Both approaches give voice to disadvantaged com a Trialability, the opportunity to experiment with the inno munities and increase their control ar vation on a limited basis community improvement activities. d a Observability, the degree to which the results of an inno- vation are visible to others The guidelines for participatory research in health promotion describe seven stages in participation, from passive or no participation to self-mobilization. For both I. Social Marketing in Public Health goals and methods determined collaboratively, and Social marketing is typically defined as a program-planning findings and knowledge are disseminated to all partners. process that applies commercial marketing concepts and Participatory research is more difficult to execute because techniques to promote behavior change in a target audience. of greater time demands and challenges in complying Social marketing has also been used to analyze the social with external funding requirements. For example, if consequences of commercial marketing policies and activi actions require a negotiated process with the community, ties, such as monitoring the effects of the tobacco and food they may divert from a project plan previously submitted industries'marketing practices. As in commercial market- to a funder ing, social marketing depends on the following: Engaging the community in research efforts is essential in Audience segmentation. Dividing markets into small seg- translating research into practice. However, there are still large gaps in translating conclusions from well-conducted ments based on sociodemographic, cultural, or behav randomized trials into community practice. The Multisite ral characteristics anslational Community Trial is a research tool designed to bridge the gap. This trial type explores what is needed to address specific cognitive and behavioral patterns as well make results from trials workable and effective in real-world individual demographic characteristics. Therefore, tai settings and is particularly suited to practice-based research lored materials are more precise, but also more limited in such as the pre population reach and more expensive. For example, the CDCs VERB campaign(It's what you do")specially pro moted the benefits of daily physical activity to children 9to13 C. Diffusion of Innovations Theory Branding. Public health branding is the application of com To be successful, a community strategy needs to be dissemi mercial branding strategies to promote health behavior nated. Successful dissemination is called diffusion. Diffusion change. For example, a study recruited highly regarded of innovations(DOI) theory is characterized by four ele peers to make condom use"cool"among a group of men ments: innovations, communication channels, social systems t risk for hur (HIV) infec the individuals who adopt the innovation), and diffus ime. The DOI literature is replete with examples of success- Marketing mix. Addressing the four Ps of marketing ful diffusion of health behaviors and programs, including (product, price, place, promotion) and redefining them condom use, smoking cessation, and use of new tests and for social marketing(see next) echnologies by health practitioners. Although DOI theory can be applied to behaviors, it is most closely associated with inclue devices or products benefits that go with it. Price is an exchange of benefits and Groups are segmented by the speed with which they will costs and refers to barriers or costs involved in adopting the adopt innovations. Innovators are eager to embrace new behavior (e. g, money, time, effort), Place (making new
CHAPTER 26 Public Health Practice in Communities 323 behaviors easy to do)is about making the"product"acces- behaviors. Public health managers need to be aware of how sible and convenient, delivering benefits in the right place at messages are produced and how they impact people In par- the right time. Promotion(delivering the message to the ticular, media can play a major role in how a problem is audience) is how the practitioner informs the target market framed. This framing influences how the public understands of the product, as well as its benefits, reasonable cost, and it, how much attention people will pay, and which actions convenience. Social marketing techniques have been used individuals or communities are likely to take. For example, uccessfully in many communities that seemed impervious the Harvard School of Public Health mounted a successful to traditional health promotion messages campaign to persuade television producers to include mes sages about designated drivers with their ads D. Communication Theory Knowledge and behavior change can each precede the other. In dissonance-attribution, behavior change comes mmunication theory describes the use of communication before attitude change and knowledge, whereas in the low ffect change at the community level and in society as well. involvement hierarchy, increased knowledge leads to behav- Communication influences community and societal change or change and finally attitude change. Early studies focused in areas such as building a community agenda of important on opinion or attitude change based on the credibility of the oublic health issues, changing public health policy, allocating information source, fear, organization of arguments, the role esources to make behavior change easier, and legitimizing of group membership in resisting or accepting communica new norms of health behavior tion,and personality differences. Since the 1960s, however, research has emphasized cognitive processing of information I. Delphi Technique leading to persuas ives key concepts and potential change Table 26-3 s The Delphi technique is a method for structuring a group strategies for communication. Table 26-4 outlines theori that it is effectiv a group of individuals, as a whole, to deal with a complex roblem. Furthermore, it is a method for the sy E. Environmental Infuences on Behavior tematic solicitation and collation of judgments on a par ticular health topic through a set of carefully designed Many health promotion campaigns seek to reduce high-risk sequential questionnaires, interspersed with summarized behaviors such as unhealthy eating, alcohol and drug abuse, information and feedback of opinions from earlier and smoking. Such programs should not ignore the material ponses. The Delphi technique is used most frequently to ocial, and psychological conditions in which the targeted integrate the judgments of a group of experts on guidelines behaviors occur. For example, a strong association exists there is insufficient evidence. It can also be among material hardship, low social status, stressful work or decision making in a disparate group such as a community life events, and smoking prevalence. Many strategies that coalition include modifications of the regulatory environment (e. g taxes on tobacco products)and"built"environment(e.g 2. Role of Media Communication impact of an environment that is conducive to exercise or obesity)seem to be at least as effective as those directly aime Media institutions play a crucial role in health behavior at behaviors. The structural as well as the political and socio- change because of their role in disseminating information. economic environment influences how people interact, As agents of socialization, media also have a powerful impact behave, ecover from noxious stimuli. This interaction in legitimizing behavioral norms. Popular and academic per ibed extensively by D. william Haddon for the spectives both hold that media communication plays a pow field of prevention(see Chapter 24). However, Had erful role in promoting, discouraging, or inhibiting healthy of countermeasures to injury is equally able 26-3 Concepts in Communication: Agenda Setting Definition tential Change Strategies Media agenda the media define, select, and emphasize (nghow Institutional factors and processes influenci Understand media professionals' needs and routines for Public agenda The link between issues covered in the media and ships to raise public Policy agend The link between issues covered in the media an the legislative priorities of policy makers licy makers about changes tuucate and tand Factors and process leading to identification of an definitio sue as a"problem"by social institution define an issue for the media and offer solutions. framing lecting and emphasizing certain aspects of a Advocacy groups"package" an important health issue story and excluding others rom Glanz K, Rimer BK, Viswanath K: Health behavior and health education: theory, research, and practice, Bethesda, Md, National Cancer Institute at National Institutes of Health,2008.http://www.cancer.gow/cancertopics/cancerlibrary/theorypdf
324 SECTION 4 Public Health Table 26-4 Overview of Community-Level Theories of Behavior Change The Key Fac Community organization Community-driven approaches to assessing and solving health and social problems Diffusion of innovations How new ideas, products, and practices spread Relative advantage thin a society or from one society to another Communication theory How different types of communication affect Media agenda sett health behavio Public oblem identification and definitio From Glanz K, Rimer BK, Viswanath K: Health behavior and health education: theor, research, and practice, Bethesda, Md, National Cancer Institute at National Institutes of Health2008.https://www.cancer-gow/cancertopics/cancerlibrary/theory.pdf Table 26-5 Application of Haddon Countermeasures to Gun Injury and Cancer Prevention Preventing Injury by Handguns Preventing Cancer Associated with Smoking 1. Prevent the creation of the hazard. Limit the number of handguns lume of tobacco production by changing lowed to be sold or purchased. 3. Prevent the release of the hazard nstall locks on handgun tobacco to certain age groups. 4. Modify the rate of release of the op cigarettes that bu 5. Separate the hazard from Store handguns only at gun clubs Establish shutoff times for vending machines and earlier to be protected by time eather than at closings of convenience stores and groceries. 6. Separate the hazard from th Keep guns in locked containers. Install filters on o be protected by a physical barrier 7. Modify relevant basic qualities of the onalize guns so they can be Reduce the nicotine content of cigarettes. Limit exposure to other potential sy 9, Begin to counter the Provide good access to emergency Set up screening to deter tal carcinogens)among smokers the early stages. pair, and rehabilitate the Provide high-quality trauma ca Provide good-quality health care for cancer patients. object of damage Modified from Runyan CW: Epidemio! Rev 25: 64/64, 2003 pplicable to harmful behaviors such as smoking( programs for poor women, and interventions to change 26-5). Structural interventions for patients with rmful sexual norms infection have been categorized into the following 3. Harm reduction or health-seeking behavior change. These approaches work to make harm reduction tech ologies available to those in need and to change rules, 1. Social change. These approaches focus on factors affe services,and attitudes about these technologies. Examples ing multiple groups(e. g, a region or country as a whole include efforts to provide safe housing for drug users and such as legal reform, stigma reduction, and efforts to cul . 00%condom use"campaigns tivate strong leadership on acquired immunodeficiency yndrome(AIDS) e interaction 2. Change within specific groups. These approaches address behavior and environment (such as those just social structures that create vulnerability among specific allows planners to think through the interaction of people, populations (e.g, men who have sex with men, mine harmful substances, and their environment. It opens up workers, disadvantaged women). Examples include efforts new ways of thinking about prevention in a more compre to organize and mobilize sex workers, microfinance hensive way
CHAPTER 26 Public Health Practice in Communities 325 I. STEPS IN DEVELOPING A HEALTH Are healthier food options in grocery stores available and affordable? Are they of goo PROMOTION PROGRAM low many homes, parks, hospitals, and schools have easy access to tobacco and are exposed to tobacco adver- Community Health Assessment and Group Evaluation. Are there tobacco-free campus policies in hospitals, on CHANGE is a comprehensive data collection tool and college campuses, and in multiunit housing? resource for con munity program planning with the follo ing steps(see Table 26-1) 1. PRECEDE/PROCEED Model 1. Define a strategy and assemble a team. 2. Identify primary health issues The PRECEDE-PROCEED tool, a planning model devel 3. Develop objectives to measure progres oped by Green and Kreuter, provides a comprehensive struc- 4. Select effective interventions ture for(1)assessing health and quality-of-life needs and (2) 5. Implement innovation for designing, implementing, and evaluating health promo- 6. Evaluate tion and other lic health programs to meet those nee Enforcing Some c Program and Enabling Constructs in Educational Diagnosis and Evaluation--outlines a diagnostic planning process to assist resources/programs are described in the development of targeted and focused public health where they have a strong emphasis. programs. The second part, PROCEED, provides an imple- mentation and evaluation program--Policy and Organizational Constructs in Educational VI- A. Define Strategy and Assemble Team PRECEDE. The process starts with desired outcomes and Broad-based participation in the planning process from the works backward to identify a mix of strategies for achieving participants include physicians, nurses, social workers, teach PRECEDE comprises the following five steps ers, emergency medical services(EMS)personnel, health come from churches, businesses, dental clini i educators, parents, and police. However, partners can alse Step I: Social assessment. Determining the quality of life ial problems and needs of a given population. To It is important to stress that building a coalition should come onduct a social assessment, the practitioner may use before gathering any data. There is no reason to gather data ultiple data collection activities(e. g, key informant on problems nobody is willing or able to change. Sustainable interviews, focus groups, participant observation, surveys) oalitions are those that utilize preexisting partnerships, have to understand the community's perceived need access to at least minimal levels of funding, are perceived as Step II: Epidemiologic assessment. Identifying the health well functioning, and plan for sustainability. determinants of these problems and needs. The epide iologic assessment may include secondary data ana- lysis or original data collection to prioritize the communitys health needs and establish program goals B. Identify Primary Health Issues and objectives The second step in program planning is to identify the Step Ill: Behavioral and environmental assessment. Ana primary health issues concerning the community. This yzing the behavioral and environmental determinants of involves a needs assessment(areas for improvement)as well the health problems. This step identifies factors, both asset mapping(identifying the people, institutions, av internal and external to the individual, that affect the able funds, and capacity to solve problems). Tools used in health problem. Reviewing the literature and applying creening and identifying overall problems in the commu theory are two ways to map out these factors nity include the following: Step IV: Educational and ecological assessment. Identifying the factors that predispose to, reinforce, and enable the PRECEDE-PROCEED model behaviors and lifestyles. Practitioners can use individual a Planned Approach to Community Health(patch) interpersonal, or community-level change theories to Mobilizing for Action through Planning and Partnerships classify determinants of behavior into one of these three (MAPP categories and rank their importance. Because each type National Public Health Performance Standards Program of factor requires different intervention strategies, classi NPHPSP) fication helps practitioners consider how to address com- u Data sources(see Chapter 25) Tools within the CHANGE process Step V: Administrative and policy assessment Ascertaining Examples for a needs assessment that emphasizes the which health promotion, health education, and policy environmental factors of diet, exercise, and smoking include related interventions would best be suited to encourage the following questions": PROCEED comprises four additional phases, as follows" Do sidewalks make walking(walkability) and biking(bike ability) easy and safe? Are they connected, continuous, Step VI: Implementation. Carrying out the interventions free from barriers and safe from traffic and crime from step V
SECTION 4 Public Health PRECEDE STEP 5 STEP 4 STEP 2 STEP 1 Educational and and Policy Assessmen Diagnosis Assessment Health Behavior and lifestyle Environment STEP 6 STEP 7 STEP 8 STEP 9 Implementation Outcome Evaluation Evaluation Evaluation PROCEED Figure 26-1 The PRECEDE/PROCEED modeL (Redrawn and modified from Green L, Kreuter M: Health program planning: An educational and ecological approached4,NewYork,2005,Mcgraw-hIll.SlIde8fromhttp://www.lgreen.net/hpp/chapters/chapterolhtm) Step VIl: Process evaluation. Evaluating the process for their health problems and to set measurable health priorities implementing the interventions for health promotion and disease prevention, communities Step VIll: Impact evaluation. Evaluating the impact of the have additional leverage to strengthen their requests for interventions on the factors supporting behavior and on resources. With more data becoming available online(see behavior itself Chapter 25), this step may become less demanding in the Step IX: Outcome evaluation, Determining the ultimate future ffects of the interventions on the health and quality of life of the population 3. Mobilizing for Action through Planning In reality, when implemented in a program, PRECEDE and Partnerships and PRoceed interact as a continuous cycle, since feedback data from the PROCEEd steps indicate how programs m Mobilizing for Action through Planning and Partnerships be modified to more closely reach their goals and targets (MAPP)is a program sponsored by the National Association for County and City Health Officials(NACCHO)in coop 2. Planned Approach to Community Health eration with the Public Health Practice Program Office of he CDC. It is a community-driven strategic planning process The Planned Approach to Community Health(PATCH)was for improving community health. The seven principles of developed by the CDC in the mid-1980s. The primary goal MAPP are as follows: of PATCH was to create a practical mechanism through which effective community health education action could be tar- 1. Systems thinking-to promote an appreciation for the geted to address local-level health priorities. A secondary goal dynamic interrelationship of all components of the local was to offer a practical, skills-based program of technical public health system required to develop a vision of a assistance in which health education leaders in state health healthy community. agencies could work with their local counterparts to establish 2. Dialogue-to ensure respect for diverse voices and per- ffective community health education progran pectives during the collaborative proce interventions included mobilizing the community, collecting 3. Shared vision--to form the foundation for building a and organizing data, choosing health priorities, developing healthy future(visioning a comprehensive intervention plan, and evaluation 4. Data-to inform each step of the process Historically, the most demanding and time-consuming 5. Partnerships and collaboration-to optimize perfor step in patCh has often been the gathering and analysis of mance through shared resources and responsibility local area data to facilitate program planning and evaluation. 6. Strategic thinking-to foster a proactive response to the On average, communities spent about a year collecting and issues and opportunities facing the system nalyzing data. This energy appears to be well spent, however. 7. Celebration of successes-to ensure that contributions With information to document the magnitude and extent of are recognized and to sustain excitement for the process
CHAPTER 26 Public Health Practice in Communities In addition to these seven principles, MAPP also empha- measurable parameters; each objective should be specific identifying community strengths and assessing current relevant, measurable, and associated with a time frame. es of change( Fig. 26-2) Objectives can cover structure, processes, or outcomes(see Chapter 28). When writing objectives, health planners C. Develop Objectives to Measure Progress should follow the acronym SMART: specific, measurable, One of the most important parts in planning change is objectives is the Healthy People database o Tce of SMART to define objectives. Objectives are defined as specific I. Healthy People 2020 During the 1970s, representatives from many public health and scientific organizations began to develop national health promotion and disease prevention objectives. Their efforts national 10-year objectives to improve the health of al Organize E Partnership Americans, The most recent version of these is health for success development People 2020. Although the federal government acted as coor dinator and facilitator of these efforts and supported the Four MAPP assessments goals and objectives outlined, the documents themselves were "not intended as a statement of federal standards or Identify strategic issue requirements. They do represent, however, a national con- trategy of th Formulate goals and strategies tions,and public-spirited citizens. The reports have had a major impact on the way government and other institutions Evaluate in the United States direct their resources in public healt For example, most federal grants require possible grantees to describe how proposals will advance Healthy People 2020 tatus unity health 1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death Partnerships(MAPP).(From National Association of County and City 2. Achieve health equity, eliminate disparities, and improve lealth Offcials, Washington, DC, with Centers for Disease Control and the health of all groups. PreventionAtlanta.http://www.naccho.org/topics/infrastructure/mapp/ 3. Create social and physical environments that promot good health for al Table 26-6 Healthy People 2020: Goals, Foundational Health Measures, and Progress Foundational Health Overarching Goals Measures Categor Measures of progres General health status Healthy life expectancy disability, injury, and Physically, mentally unhealthy days premature death. Self-assessed health status Iternational comparisons(where available) Disparities and inequity imparities/inequity to be assessed b ace/ethnicity health of all groups Socioeconomic status ability status Lesbian, gay, bisexual, and transgender status Social determinants of health determinants can include factors good health for all atural and built environments Promote quality of life, healthy Health-related quality of life ysical, mental, and social health-related quality of life behaviors across all life stages Participation in common activities FromHealthyPeople2020,u.S.DepartmentofHealthandHumanServiceshttp://healthypeoplegow/2020/topicsobjectives2020/pdfs/hp2020_brochure_with-lhi_508.pdf