If we want more evidence-based practice, we need more practice-based evidence.*


Chapter 2
Community Ecology, Organization, and Health

Table of Contents

REFERENCES - since publication of 8th edition


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.


Ecological concepts and components are introduced first. The elements of the Health Field Concept Ė 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.

For related news stories, please click here. 


National Health Information Center
P.O. Box 1133, Washington, D.C.
Phone: (800) 336-4797

Government agency that provides free publications and assists in the identification of resources regarding preventive services, nutrition, school health, risk communication, and worksite health promotion.

World Health Organization
Regional Office for Europe
Scherfigsvej 8
DK-2100 Copenhagen
Phone: (45) 39 17 17 17
Fax: (45) 39 17 18 18

e-mail: postmaster@who.dk

This site provides a wide range of policy documents and programs provided by the WHO. For example, the Ottawa Charter (1986) is listed at www.who.dk/policy/ottawa.htm

The WHO Collaborating Centre for Research on
Healthy Cities can be found at:


The Association for the Study and Development of Community
12522 Hialeah Way
Gaithersburg, MD 20878
301.519.0722 (voice)
301.519.0724 (fax)


U.S. Department of Health and Human Services
Phone: (800) 336-4797

An easy to use gateway that brings together consumer health information from many Federal, State, professional and non-profit organizations.

National Rural Health Association

The National Rural Health Association provides resources and support to health care professionals who work in rural areas.  Among the items of interest on its website are a bulletin board for members to exchange ideas, information on advocacy for rural health issues, upcoming rural health meetings, and links to other sites that provide related resources.

Rainwater, L. & Smeeding, T. (1995) No. 127. Doing Poorly: The Real Income of American children in a Comparative perspective. Working Paper 127, Luxembourg Income Study Lee On-line at http://www.lisproject.org/publications/wpapersentire.htm
then http://www.lisproject.org/publications/liswps/127.pdf

Gottschalk, P. & Smeeding, T. (1995) Cross national comparisons of levels and trends in inequality. Working Paper 126. Luxembourg Income Study Lee On-line at http://www.lisproject.org/publications/wpapersentire.htm ; then http://www.lisproject.org/publications/liswps/126.pdf.

Brink, S. & Zeesman, A. (1997). Measuring social well-being: an index of social health for Canada. Report R-97-9E, Applied Research Branch, Human Resources Development Canada. On-line at http://www.hrdc-drhc.gc.ca/sp-ps/arb-dgra/publications/research/abr-97-9e.shtml

Stanford, J. (1999). Economic freedom (for the rest of us). On-line at http://www.policyalternatives.ca /.

Townsend, M. (1998). Health and wealth. Toronto: Lorimer, and available from the Centre for Policy Alternatives http://www.policyalternatives.ca /

University of Toronto Center for Health Promotion, Community Quality of Life Reports: http://www.utoronto.ca/qol

Resources on inequality, poverty and social health available on the Internet. The Brink and Stanford papers, for example document provincial changes in social health in Canada. The Luxembourg papers provide evidence of the differences in poverty and inequality rates between North American and European countries.

Centers for Disease Control and Prevention
1600 Clifton Rd., NE, Atlanta, GA 30333, USA
Phone: (404) 639-3311
netinfo@cdc.gov  http://www.cdc.gov/

The Canadian Institute for Advanced Research
The University of British Columbia
2329 West Mall, Vancouver, BC V6T 1Z4

World Health Organization
Regional Office for Europe
Scherfigsvej 8, DK-2100 Copenhagen
Phone: (45) 39 17 17 17
Fax: (45) 39 17 18 18
postmaster@who.dk http://www.who.dk

U.S. Department of Health and Human Services Phone: (800) 336-4797



  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.

Braden, S., & Mayo, M. (1999). Culture, community development and representation. COMMUNITY DEVELOPMENT JOURNAL 34(3): 191-204, July.

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 Journalís 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 Journalís 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.

Khan, N. A. (1999). Community cooperation in a voluntary environmental project: some lessons from Swansea, Wales. COMMUNITY DEVELOPMENT JOURNAL 34(3): 205-218, July.

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.

McKee, M., Sanderson, C., Chenet, L., Vassin, S., & Shkolnikov, V.  (1998). Seasonal variation in mortality in Moscow.   JOURNAL OF PUBLIC HEALTH MEDICINE 20(3): 268-274.  For the abstract, and other titles/abstracts in this issue, go to:  http://www.oup.co.uk/pubmed/hdb/Volume_20/Issue_03/

Motteux, N., Nel, E., Rowntree, K., & Binns, T. (1999). Exploring community environmental knowledge through participatory methods in the Kat River valley, South Africa. COMMUNITY DEVELOPMENT JOURNAL 34(3): 227-231, July.

Onyx, J., & Dovey, K. (1999). Cohabitation in the time of cholera: praxis in the community sector in the era of corporate capitalism. COMMUNITY DEVELOPMENT JOURNAL 34(3): 179-190, July.

Richard, L., Potvin, L., & Mansi, O. (1998).   The ecological approach in health promotion programmes: The view of health promotion workers in Canada. HEALTH EDUCATION JOURNAL 57 (2): 160.

Savaya, R., Moreno, N., Lipschitz, O., Arset, N. (1999). The application of a model of systematic planned practice to participatory community work. COMMUNITY DEVELOPMENT JOURNAL 34(3): 240-251, July.

Schuftan, C. (1999). Sustainable development beyond ethical pronouncements: the role of civil society and networking. COMMUNITY DEVELOPMENT JOURNAL 34(3): 232-239, July.

Szwarcwald, C. L., Bastos, F.I., Viacava, F., & de Andrade, C. L. T. (1999). Income inequality and homicide rates in Rio de Janeiro, Brazil. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 845-850.
    The Journalís Home Page is at:
    ABSTRACT: Objectives. This study determined the effect of income inequality on homicide rates in the state of Rio de Janeiro, Brazil. The findings suggest that social policies specifically aimed at low-income urban youth, particularly programs to reduce the harmful effects of relative deprivation, may have an important impact on the homicide rate.


Books and Reviews

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


1. Health without organization. The first boxed issue asks you to draw on the sense of history from the previous chapter to imagine what survival was like before there were organizations, and to consider how human organization has altered the natural history of health. Consider the question asked in that boxed issue. Use Figure 2-2 to explore your answer
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.

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