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This research paper considers theories and methods underlying successful community-based health interventions, emphasizing four exemplars. Three exemplars relied heavily on modern means of mass communication and social marketing, relatively low-cost approaches with the potential to reach and change lifestyle behaviors of entire populations, in contrast to traditional individual or group counseling. One exemplar, studying alcohol involved trauma, used community organizing for adherence to existing laws, rather than public education for behavior change. The paper also describes barriers to change and lessons learned for future extensions of such endeavors.
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By deﬁnition a community-based program is organized locally, achieving its goals through the community’s institutions and communication networks. A community here is deﬁned as a residential area with legally deﬁned geographic boundaries, where a governmental system regulates certain local aspects of schools, businesses, transportation, policing, and recreational activities. A community is ordinarily last in a nation’s regulatory chain, where education must ultimately occur, although for rural areas the county becomes the governing agent for education.
The relevance and intellectual context of community-based health education are addressed through these questions. (a) What is the rationale for community-wide interventions rather than in more limited locales, such as clinics, hospitals, work sites, or schools? (b) What theories, methods, and resources underlie success? (c) How does a community become committed to a novel health education campaign? (d) How can barriers to success be overcome in such interventions? (e) What roles do community activism, laws, and regulations play? (f) What is the future of community-based health education?
Health education in schools, work sites, and clinics have a long history of individual success, but synergistic interactive eﬀects can occur when they are imbedded in a total community campaign that adds inherently cost-eﬀective mass media and environmental change (Schooler et al. 1997). Lifestyle changes, so powerfully inﬂuenced by custom and by the media in developed countries, cannot be countered eﬀectively through simple means. Community-wide approaches ﬁt the public health model because the traditional medical model can neither prevent most chronic disease nor reach the entire population in need. The community provides inﬂuence through locally produced electronic and print mass media and through work sites, schools, medical and hospital settings, and social gatherings of many sorts. It oﬀers opportunities for health-promoting regulations, such as providing opportunities for physical activity for all, school ﬁtness classes, healthful school lunches, alcohol sales limits, and preventing tobacco product marketing to children.
Studies at the Stanford Center for Research in Disease Prevention (SCRDP) have shown that only multiple inﬂuences produce meaningful changes in the dietary, exercise, or tobacco-use behavior of adults, adolescents, and children. For adolescents, always resistant to health behavior change, the following inﬂuenced success: parent and teacher roles; school environments; amount and quality of school-based education on tobacco, ﬁtness, and nutrition; peer inﬂuence; and amount and quality of community-wide health education. (Also, certain personal characteristics were inﬂuential, for example, self-eﬃcacy toward one’s behavior-change abilities; Fortmann et al. 1995.)
2. Theoretical Formulations
Community-based health education carried out by SCRDP and by some analogous projects have been guided by three major theoretical and management models (Flora et al. 1989).
(a) The community organization framework provides methods of identifying the health problem (and resources needed or available), mobilizing the community’s opinion leaders and organizations, gaining populace support, forming coalitions, launching and maintaining education programs, achieving regulatory changes, and empowering communities to reach and maintain their goals.
(b) Social marketing provides methods of designing and sequencing messages for population subgroups based on their health needs, cultural attributes, social networks, media habits, and readiness for change.
(c) The mass communication–behavior change model describes theories underlying educational content, such as social cognitive theory (Bandura 1986) and methods of reaching and inﬂuencing the total population in multiple ways.
3. Intervention Principles, Methods, And Resources Needed For Success
Both relevant organizations and political and opinion leaders must be recruited into a coalition that sanctions any novel health education project. This coalition must identify the health problem (needs assessment), provide a resource inventory, obtain populace support, and plan the intervention.
Interventions must go beyond attempting to change knowledge, the usual goal of an educational system, by providing training in behavior-change skills. They must also go well beyond the individual, enlisting multiple community organizations in campaigns for change and seeking changes in the social environment and in regulations that promote access to the facilities and resources needed for healthful practices. Multiple communication channels (i.e., both mediated and faceto-face) are needed to reach diﬀerent audiences, recognizing their preferences, stage of knowledge, and readiness for change.
A comprehensive intervention should involve schools, work sites, churches, and facilities for sport, recreation, and health. These organizations and others can serve as education conduits, with the community’s electronic and print mass media organizations assisting in message design and delivery. The Internet provides a new channel, whose community education role is as yet poorly deﬁned. Interactive computer learning, now becoming common in classrooms, can be designed for large groups—an emerging variant of mass media.
Comprehensiveness requires variety. For example, in tobacco control components of Stanford’s CVD campaigns, local medical clinics, dental oﬃces, pharmacies, and libraries distributed a low-cost skills training Quit Kit; a local smoking cessation class, was shown on television; many newspaper articles and columns appeared; a local business supported costs of a smoking cessation contest; and all newspapers and electronic media ‘cross-advertised’ activities designed for mass audiences.
Success requires an appropriate mix and sequence of programs delivered through varied channels. This integration, with goals set in advance and goal changes based on early results, is analogous to a commercial marketing campaign, hence the term ‘social marketing.’
3.5 Message Design And Audience Segmentation
Social marketing requires message tailoring to ﬁt each subgroup’s needs and preferences, taking into consideration cultural diﬀerences, learning styles, and preferred learning sites. A message sequence should increase awareness, then, increase knowledge, and last, increase motivation and provide training in the skills needed for adoption and maintenance of a new behavior (Bandura 1986). Electronic media can carry out the ﬁrst two parts of this sequence and stimulate use of the more information-dense print media of newspapers and booklets, which are inherently more eﬀective in skills training than are electronic media (Flora et al. 1997).
Messages must be clear, focused, and salient. Salience requires broad reaching media, arousing interest and awareness—topics must break through passive indiﬀerence engendered by the information overload of many societies and become ‘on the public agenda.’ Given the large advertising budgets of today’s mass media, health agencies’ messages must be of suﬃcient production quality to compete for the public’s attention.
3.6 The Message Must Be Eﬀective
Behavioral research conﬁrms the rather self-evident rule that ‘learning by doing’ is more eﬀective than ‘learning from observing’ (modeling a behavior), and both are more eﬀective than an ‘information-only’ approach that changes knowledge alone. These principles are contained in Bandura’s social cognitive theory, which posits that guided practice in a new behavior can lead to increased self-eﬃcacy and to greater behavior change (Bandura 1986). Thus, ‘knowledge-only’ campaigns have been found less eﬀective than those that apply Bandura’s recommendations.
3.7 Intervention Dose
The dose needed depends on many factors: lesser amounts are needed in smaller communities, at earlier stages in a country’s adoption of a ‘health innovation,’ and when the advocated behavior change is reasonably simple (such as mammography and hypertension screening and immunization campaigns). Clearly, more complex changes are needed in individuals and in society’s norms to alter eating or exercise patterns or to control tobacco use. Complexity in respect to nutrition arises from many sources, including longstanding cultural beliefs and practices; entrenched methods in agriculture, food production, and retailing; advertising of ‘unhealthful’ foods; and the advent of widespread fast-food chains that are dominated by commercial interests unresponsive to local demands and needs.
Few projects have measured intervention dose. One excellent method records the total number and duration of messages distributed over a deﬁned time period, albeit with a defect due to lack of message quality measures (Farquhar et al. 1990). However, even this rough method, were it widely adopted, would be of great value to public health practitioners.
3.8 Role Of Activism And Advocacy
Successful community-based health education requires eﬀective leaders, community activists with the courage and charisma to advocate health innovations. Waves of advocacy ﬁltering down from international, national, state, or provincial sources can wash up on the shore of an inert community to provide a local activist leader with the popular support to ‘ﬁght city hall’ or other entrenched bureaucrats who defend the status quo. Tobacco control in Australia and the US provide examples. National and state advocacy groups with access to mass media created a strong mass movement for change, allowing advocates to enlist popular support for local tobacco control measures. In both California and Australia’s State of Victoria this popular support led to statewide increases in tobacco taxes, with some retained for education against tobacco, a measure that had been resisted by state legislators who had long been inﬂuenced by tobacco lobbyists—an example of community activism ﬁltering up the chain to a higher political level (Catalonia Declaration 1996).
3.9 Role Of Policy, Laws, And Regulations (PLR)
Local actions can aﬀect alcohol and tobacco sales and create environments that improve nutrition and enhance physical activity. However, national, state, or provincial actions can magnify local PLR and education eﬀorts on topics such as tobacco taxation, automobile seat-belt laws, food and drug safety, school nutrition, school physical activity policies, and (in the United States) laws on ﬁrearms. As described in Section 4.8, widespread popular attitude changes in numerous communities can also aﬀect the political process at the state or federal level.
4. History Of Comprehensive Community Health Education
The history since the 1970s is restricted largely to 13 formal research projects designed to aﬀect CVD risk factors. They involved entire populations of at least one education community, compared with at least one control community. Three of the four exemplars to follow are drawn from these 13 projects. Dissemination into practical applications of community organizing and mass communication technologies, derived in part from these research projects, occurred throughout many parts of the world.
4.1 The First Two Exemplars: The First Decade
The ﬁrst and second exemplars, Stanford Three community Study (TCS), in three small agricultural marketing towns in California (total population 45,000), and the North Karelia Study (NKS), in two adjoining predominately rural Finnish counties (North Karelia population about 180,000), each began in 1972. TCS, the ﬁrst Stanford project, was carried out from 1972–75 in both English and Spanish, comparing eﬀects of mass media alone in one community and mass media plus 10-session risk reduction classes for high-risk adults in a second, with a third as a control (Schooler et al. 1997). Groups exposed to varied education amounts showed a dose-response change in smoking, blood pressure, and blood cholesterol, with a proportionately larger eﬀect in the Spanish-speaking residents than in the Anglo majority. (This minority population outcome required a compensating increase in intervention resources.) A composite CVD risk reduction of about 23 percent and 30 percent occurred in the mass media—only and mass media—plus classroom conditions, respectively. Thus, a relatively modest amount of mass media (about 30 television and radio ‘spots,’ weekly newspaper columns on heart health, and four separate mass mailings of booklets) was suﬃcient to change the population’s body weight, cholesterol and blood pressure levels, and smoking prevalence. The education followed Bandura’s principles but adapted to the mass media (as was also the case with exemplars two and three).
NKS, evaluated two, matched, rural Finnish counties that contained many villages with farming and lumbering as the main occupations. North Karelia (about 180,000 population) received an education campaign that began in1972, continuing to the present. After 5 years, CVD risk factor changes comparable to the TCS occurred, and signiﬁcant net reductions in CVD events occurred (Schooler et al. 1997). This study was marked by extensive community organizing, resulting in strong partnerships with residents and their organizations. The NKS inﬂuence on its country’s policies was unparalleled among the CVD projects, providing its most important lesson—that a well-executed project led by respected scientists can move an entire country. As examples, Finland’s food and agricultural industries made large changes: Fertilizers were supplemented with selenium (a substance low in Finland’s soil that is needed for health), milk pricing was changed (based on protein instead of fat content), programs were created to replace dairy farms with berry farms, a new canola industry replaced jobs lost in dairying, and increased production of low-fat foods occurred (Catalonia Declaration 1996).
In 1972 population-wide nutrition change and smoking cessation interventions were an innovation internationally, which may partly explain the success of these two pioneering programs (TCS and NK).
4.2 Early International Diﬀusion, 1977–1983
Studies patterned after the TCS done in Italy, Australia, Switzerland, and South Africa all had signiﬁcant risk factor changes, adding evidence for the eﬀectiveness of the TCS model (Farquhar et al. 1991).
4.3 The Second And Third Decades: Projects Begun In The 1980s And 1990s
The third exemplar is the Stanford Five-city Project (FCP) (USA). Its intervention phase from 1980 to 1986 extended TCS methods to larger populations (total population of about 360,000) with multifactor CVD prevention directed at two northern California cities. There were three control cities (Farquhar et al. 1990). It diﬀered from TCS in greater use of community organizing and in greater collaboration with the communities’ health, media, and education organizations in planning and implementing pro- grams. It was similar in generous use of mass media, both print and electronic (63 percent television and 36 percent print). It was unique in measuring total dose of education (about 5 hours year and about 100 episodes of exposure year to all forms of media and classroom education).
FCP’s initial year of television messages (deﬁned as ‘high reach/low involvement’) stimulated the public’s use of print media, which supplied more eﬀective skills training than television (Flora et al. 1997). Results were comparable with the TCS (about a 15 percent fall in composite risk of CVD), with a major impact on blood pressure (Farquhar et al. 1990). Health bureaucracies, usually timid, should gain courage from the FCP’s ‘David and Goliath’ demonstration that only 3 hours year of high-quality television health education can counteract the public’s exposure to about 100 hours year of television advertising devoted to unhealthy nutrition. Although all preceding CVD studies showed eﬀects in small towns and/or rural districts, FCP showed beneﬁt in cities (with populations as high as 100,000). Also, these eﬀects occurred despite the advent (at least in the state of California) in the 1980s of dual working families and increasing public use of fast food, factors that made achieving nutrition- behavior change more diﬃcult.
FCP’s modest resources and greater eﬀects, as compared with some comparable projects, support the beneﬁts of the skills training aspects of Bandura’s social cognitive theory. Perhaps the most practical lesson to policymakers is that adult residents saved 30 times more money from their decreased cigarette purchases ($120 adult year) than the cost of the campaign ($4 adult year)—savings retained by the community. Lastly, the communities adopted FCP’s technologies, later applying them to seat-belt promotion and violence and adolescent pregnancy prevention.
Other successful CVD projects, both large and small, occurred in these decades in the US, Sweden, Denmark, Canada, the Czech Republic, and China. Also, World Health Organization-sponsored projects began in about 23 other countries (Schooler et al. 1997). In all instances, they borrowed heavily from the experiences of the three exemplars and in many instances received training from either the Stanford or the North Karelia groups.
4.4 Community Projects In Other Health Topics
Interventions on alcohol, mammography, tobacco control, motor vehicle injuries, and HIV AIDS are prominent examples of other community-based projects, but with fewer well-controlled studies than in CVD. One of these, Preventing Alcohol Trauma (PAT), is the fourth exemplar. This 5-year study of three US communities showed a 10 percent decrease in alcohol-related traﬃc injuries and a 50 percent decrease in adolescent alcohol use (Holder et al. 1997). Coalition building and organizational behavior change among the police, alcohol sales outlets, and alcohol servers were the main interventions. The public responded to a fear, instilled through publicity, of the penalties of greater enforcement of existing laws on underage alcohol purchases or drinking and driving. Therefore, in contrast to the three CVD exemplars, PAT showed that major public education is not needed for large public behavior changes. PAT estimated a cost saving of $2.88 for every dollar invested, a number close to that found in many worksite health promotion studies. PAT found their communities had the required infrastructure for the campaigns, requiring only training provided by one indigenous community coordinator, a part-time clerk, an imaginative plan, and the will to proceed.
TCS, the ﬁrst, and PAT, the fourth exemplar, are opposites: TCS had a maximum of mass-media education and a minimum of organizing, whereas PAT had the opposite. Thus, either model works, but to change complex behaviors, one needs sophisticated behavior-change methods, such as those adapted from Bandura. If fear of arrest for breaking existing laws on alcohol use suﬃces to change personal drinking-and-driving habits, then the education process is simpler.
5. Lessons Lead To A ‘Master Plan’
A ﬁve-step approach emerges from these studies.
(a) Deﬁne the problem. Does the community need a health education campaign? A decision can be made from national or local survey data.
(b) Organize the community, creating a campaign that includes education, continued organizing, training of community organizations, empowerment of the public and the community’s organizations, and future maintenance of programs developed during an initial phase of about 2 years.
(c) Implement an intervention, delivering 3–5 hours of education exposure year for 2 years, using initially about 50 percent television to arouse interest, followed by about 25 percent from more speciﬁc print media (emphasizing newspapers, if available) and 25 percent from community events and programs (such as health fairs, contests, and classes).
(d) Institutionalize programs. The community becomes a demonstration project, with its ‘empowered’ organizations functioning as health promotion resource centers for a wider region.
(e) Use the new community resources and its residents’ potential power to advocate for local, regional, and national governmental regulations and laws that will increase local intervention eﬀects and extend them beyond the community.
Any individual or organization that wishes to engage in community-based health education should gain courage from the words of Margaret Mead, as quoted in the closing passage of the Catalonia Declaration (1996, p. 75), ‘Never doubt the capacity of a few dedicated individuals to change the world, in fact, it is the only way it ever has.’
6. Barriers And Challenges
A healthy city has been deﬁned by the absence of crime, crowding, and poverty and by the presence of educated residents and enlightened (and trained) organizations. Together these lead to a community empowered to solve its social problems (i.e., to increase its social capital) (Travers 1997).
Considering barriers, MacIntyre (2000) found Glasgow’s environmental factors to be major barriers to healthful exercise behavior. Certain macroeconomic factors inherent in globalization, such as capital ﬂight and increased wealth and income gaps, have been described as barriers to planned change (Bezruchka 2000, Cahill 1983). All such barriers threaten community stability, inhibiting greatly the success of health promotion attempts. However, wise compensatory resource allocation can overcome many barriers, as was shown in the Hispanic minority of the TCS. Therefore, the challenge for the future is: Responsibility for success in community-based health interventions lies with the interventionist, not with the community’s residents!
Three decades of the ‘total community’ health education approach strongly support the feasibility, at relatively low cost, of achieving transfer of public education technologies to a community’s infrastructure (public health, media, schools, etc.), resulting in signiﬁcant changes in health habits of populations. Although most studies derive from small communities, recent successes in Tianjin (China), a city of 400,000 (two exemplars examined populations of 100,000), suggest that the model also works in large populations (Schooler et al. 1997). Organizing and educating communities requires advocacy, activism, coalition building, and leadership; success is enhanced by regulatory change. Theory matters: when the population gains self-eﬃcacy through education, the result—community eﬃcacy—enhances capacity to change institutional policy and practice, thus maintaining community change.
Science cannot serve society if its evidence for educational beneﬁt is ignored. This is not a new concept. As written over 2,000 years ago, ‘If a virtuous and learned scholar aims to inﬂuence the people as a whole, one must ﬁrst educate the people’ (Legge 1983).
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