OBJECTIVES AND PHILOSOPHY

Building on the historical framework from Chapter 1, this chapter extends the concepts of educational, social and environmental interventions. Each type of intervention has been emphasized in a different phase of history. Ecology, one of the five science foundations of community health, is introduced in this chapter, along with the Health Field Concept and its classification of the determinants of health. In addition to the four primary objectives stated at the beginning of Chapter 2, our intent is to help you develop a deeper understanding of the dynamics of communities and populations and to distinguish them from individual patients, clients, students, clinics, worksites, and classrooms as units of analysis and organization.

OVERVIEW

Ecological concepts and components are introduced first. The elements of the Health Field Concept – human biology, environment, behavior, and healthcare organization -- are discussed and then placed in a model of community and population health that shows the dynamics and the relationship to the natural history of health and the social history of health, Figure 2-3. The social history of health is discussed first in terms of community norms, values and organization, then in terms of economic and equity concepts. Community action, innovation and diffusion are described in terms that would distinguish them from individual actions to influence health. 

Quality of Life Rating of US Cities. (AOL, June 15, 1999). A recent study from Penn State University places Portland fourth out of the top five places to live around the country. The main factors in determining the "livability" of a city are: climate, educational opportunities, low crime rate and the arts. The top five places to live are: San Jose, California; San Francisco; Oakland; Portland; Seattle.

Rich Nations to Fight Third World Poverty (Associated Press, May 8, 1996) The more affluent countries of the world have agreed to a 20-year plan to ease suffering and boost living standards in developing countries.

As Nation Tightens Borders, Immigrants Lose Health Benefits (The Nation's Health November 1996) Increased efforts to keep illegal aliens (mostly Mexican) out of the US has limited the social and health services previously afforded to legal and illegal immigrants.

Canada Tops in the World for Quality of Life (Vancouver Sun July 16, 1996) Canada's combined score on this survey just nosed out the US. What factors should be considered in defining quality of life.

  Journal References

Blanks Hindman, E.  (1998).  Community, democracy, and neighborhood news.  JOURNAL OF COMMUNICATION 48(2): 27-39. 
    ABSTRACT: This ethnographic study examines the interplay between communication, democracy, and community at an inner-city neighborhood newspaper, and explores whether this neighborhood newspaper - through its editor and staff - views itself acting as an agent of strong democracy. The study concludes that, through its  focus on neighborhood culture, its acknowledgment of conflict, and its attempts to  provide a forum for the neighborhood's self-definition, the newspaper tries to create and maintain participation in its community.

Catalano, R. A., Lind, S. L., Rosenblatt, A. B., & Attkisson, C. C. (1999). Unemployment and foster home placements: Estimating the net effect of provocation and inhibition. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 851-855.
    The Journal’s Home Page is at: http://www.ajph.org.
    ABSTRACT: Objectives. This study sought, first, to explain and reconcile the provocation and inhibition theories of the effect of rising unemployment on the incidence of antisocial behavior. Second, it tested the hypothesis, implied by the provocation and inhibition theories, that the relationship between unemployment and foster home placements forms an inverted "U." Methods. The hypothesis was tested with data from California for 137 months beginning in February 1984. Results. Findings showed that the hypothesis was supported. Conclusions. Rising joblessness increases the incidence of foster home placements among families that lose jobs or income. Levels of joblessness that threaten workers who remain employed, however, inhibit antisocial behavior and reduce the incidence of foster home placements. This means that accounting for the social costs of unemployment is more complicated than assumed under the provocation theory.

Fullilove, M.T., Green, L., & Fullilove, R.E. III. (1999). Building momentum: An ethnographic study of inner-city redevelopment. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 840-844.
    The Journal’s Home Page is at: http://www.ajph.org.
    ABSTRACT: One factor contributing to the decay of inner-city areas, and to consequent excess mortality, is the massive loss of housing. For complete abstract, go to: http://www.ajpa.org/cgi/content/abstract/89/6/840. 

Geronimus, A. T., & Bound, J.  (1998).  Use of Census-based Aggregate Variables to Proxy for Socioeconomic Group: Evidence from National Samples. AMERICAN JOURNAL OF EPIDEMIOLOGY 148 (5): 475-486.

King, L.A., & Hood, V.L. (1999). Ecosystem health and sustainable communities: North and south. ECOSYSTEM HEALTH 5 (1): 49-57.
    ABSTRACT: It is at the local/community level that the connections among ecosystem health, the health of human communities, and individual livelihoods are most apparent and critical. This paper reports a number of community initiatives aimed at improving or providing alternative livelihoods, while at the same time conserving or restoring the integrity of the ecosystem on which the community depends. Common themes are identified across the case studies, as well the need for indicators and programs that recognize and reinforce the interconnections and guide development programs that integrate community and ecosystem health and sustainability.

Linnan, L. A., Fava, J. L., Thompson, B., Emmons, K., Basen-Engquist, K., Probart, C., Hunt, M. K., Heimendinger, J. (1999). Measuring participatory strategies: Instrument development for worksite populations. HEALTH EDUCATION RESEARCH 14 (3): 371-386.
    ABSTRACT: A participatory strategies approach which involves employees in the planning and delivery of worksite health promotion programs was utilized in the 55 experimental worksites included in the national, NCI-funded Working Well Trial. An initial validity analysis was performed and yielded results which supported some but not all of the hypothesized associations. Implications for further refinement and application of this new instrument in worksite settings are explored.

Berkman, L. and Kawachi, I. (Eds.). Social Epidemiology. New York: Oxford University Press, due Feb. 2000.
    More advanced text on issues and concepts relevant to understanding and altering population health. The table of contents includes:
--A historical framework for social epidemiology (Lisa F. Berkman, Ichiro Kawachi)
--Socioeconomic position (John Lynch and George Kaplan)
--Discrimination and health (Nancy Krieger)
--Income inequality and health (Ichiro Kawachi)
--Working conditions and health (Tores Theorell)
--The impact of job loss and retirement on health (Stanislav V.Kasl and Beth A. Jones)
--Social integration, social networks, social support and health(Lisa F. Berkman and Thomas A. Glass)
--Social cohesion, social capital and health (Ichiro Kawachi and Lisa F. Berkman)
--Depression and medical illness (Robert M. Carney and Kenneth E. Freedland)
--Affective states (Laura Kubzansky and Ichiro Kawachi)
--Health behaviors in social context (Karen M. Emmons)
--Psychosocial intervention (Thomas A. Glass)
--Towards a new social biology (Eric J. Brunner)
--Ecological approaches: rediscovering the role of the physical and social environment (Sally Macintyre and Anne Ellaway)
--Multi-level approaches to understanding social determinants (Michael Marmot)
--Health and social policy (S. Jody Heymann)

Young, T. K. (1998). Population health: concepts and methods. New York: Oxford University Press.
    A foundation book for courses in population health, based in epidemiology, but also draws on relevant social sciences (including sociology, anthropology, and demography). The author has researched and written extensively on the health of indigenous people in North America, especially Canada. Chapters include case studies and exercises under the following headings:
--Measuring health and disease in populations
--Modeling determinants of population health
--Assessing health risks in populations
--Designing population health studies
--Planning population health interventions
--Evaluating health services for populations
--Improving the health of populations

2. Tampering with nature. This boxed issue on page 49 raises one of the thorniest issues facing recent scientific and technological advances as these might affect the environment and health. If possible, you may wish to review recent issues of Science Magazine, a periodical that tends to report on the latest developments and regulations from the National Institutes of Health on genetic research. The successful cloning of animals in 1997 has introduced some serious ethical discussions around the world. Discuss some of the risks and benefits of human cloning.

3. Caveats on coalitions. Consider ways to organize and manage agency partnerships and coalitions to gain advantages they might offer in coordinating programs while avoiding the traps and shortcomings described in the caveats.

4. Diffusion curve. It is important to understand the diffusion curve, because it is has been broadly applied to analyze the spread of all kinds of new innovations from computers to hybrid farm seeds. To see its explanatory ability related to health and disease, graph statistics on the consumption of cigarettes in any country from the beginning of the 20th century to see how well they fit the diffusion curve, figure 2-11, (up to the 1960s when consumption began to decline). Also, estimate where your community falls today on the diffusion curve in its adoption of any positive or negative health practice, such as nutrition.

5. Health promotion vs. health protection vs. health services. In Chapter 1, we defined community health promotion as any combination of educational, social and environmental actions conducive to the health of a population of a geographically defined area. In this chapter, we see that those actions directed exclusively at environmental determinants of health have been referred to in recent national policy as health protection; those directed through health care organization as health services, leaving those directed particularly at behavioral determinants or lifestyle to be called health promotion. In the past, when communicable diseases were rampant, environmental reforms and health services promoted health because they required action to improve the health of the community. Today, most environmental controls are directed at protecting the existing health status of the community, and most health services are designed to restore health or to prevent the progress of specific diseases. Health promotion, then, has come to refer today more specifically to the one remaining front on which further improvements in health can be most fruitful, namely health behavior or lifestyle and discuss social conditions. Discuss these shifts in the definition and use of these terms.