4
The Community

The community stagnates without the impulse of the individual. The impulse dies away without the sympathy of the community.

William James

This chapter is at the heart of the Healthy People 2010 vision reiterated by the committee: “healthy people in healthy communities.” Communities are both the physical and cultural settings for and—through their residents and community-based organizations—participants in action to promote the public’s health. They are also points of convergence for the interests of employers, businesses, and academia; the messages of the media; and the services of governmental public health agencies and the health care delivery system.

This chapter examines the multiple dimensions of community and its critical importance to an effective public health system. This critical role has been a fundamental concept in the international literature on population health for many years. The Health For All initiative, begun by the World Health Organization in the 1970s, called for a strong primary care system to include basic health services, clean water and air, basic sanitation, adequate nutrition, and full engagement with the community served. In the United States, the sophistication of the health care delivery system and the emphasis on individual health have led to the focus of policy and resources on the high-technology and research ends of the health care delivery spectrum and an underestimation or overlooking of the role of the community in achieving health gains. This is changing.

DEFINING THE COMMUNITY

A community can be described as a group of people who share some or all of the following: geographic boundaries; a sense of membership; culture



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The Future of the Public’s Health in the 21st Century 4 The Community The community stagnates without the impulse of the individual. The impulse dies away without the sympathy of the community. William James This chapter is at the heart of the Healthy People 2010 vision reiterated by the committee: “healthy people in healthy communities.” Communities are both the physical and cultural settings for and—through their residents and community-based organizations—participants in action to promote the public’s health. They are also points of convergence for the interests of employers, businesses, and academia; the messages of the media; and the services of governmental public health agencies and the health care delivery system. This chapter examines the multiple dimensions of community and its critical importance to an effective public health system. This critical role has been a fundamental concept in the international literature on population health for many years. The Health For All initiative, begun by the World Health Organization in the 1970s, called for a strong primary care system to include basic health services, clean water and air, basic sanitation, adequate nutrition, and full engagement with the community served. In the United States, the sophistication of the health care delivery system and the emphasis on individual health have led to the focus of policy and resources on the high-technology and research ends of the health care delivery spectrum and an underestimation or overlooking of the role of the community in achieving health gains. This is changing. DEFINING THE COMMUNITY A community can be described as a group of people who share some or all of the following: geographic boundaries; a sense of membership; culture

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The Future of the Public’s Health in the 21st Century and language; common norms, interests, or values; and common health risks or conditions (IOM, 1995; Jewkes and Murcott, 1996; Ruderman, 2000; Ricketts, 2001). Members of communities typically experience the shared reality of living or working in the same location or environment and so are in a position to influence and be influenced by the social, economic, and physical risk factors in that environment (Roussos and Fawcett, 2000; Kreuter et al., 2001). Although acknowledging the increasing influence of “communities of interaction” such as online groups, this chapter focuses mainly on activities based in geographic communities—neighborhoods, cities, counties, and in a few cases, states—that are critical to creating the conditions for a community to be as healthy as it can be. Communities consist of individuals and families, as well as the various organizations and associations that make up a community’s “civil society”: nonprofit, nongovernmental, voluntary, or social entities, including ethnic and cultural groups; advocacy organizations; and the faith community (Salamon et al., 1999; Himmelman et al., 2001). Organizations exist between the level of the individual and that of the community or society. The United States has both a history of individualism and, as de Tocqueville observed in 1831, a rich civic tradition of individuals associating or organizing to accomplish common goals. The public sector at the community level encompasses local government officials and agencies traditionally seen as having health-related responsibilities, as well as many others that have important but sometimes less obvious roles in health but whose policies and objectives may have potential health consequences. The latter may include city councils, public schools, colleges and universities, police and fire departments, zoning boards, housing authorities, parks and recreation agencies, and agricultural development and cooperative extension services. Other members of the community may come from the private sector, including private schools, colleges, and universities; health care providers and payers; and small and large businesses. A healthy community is a place where people provide leadership in assessing their own resources and needs, where public health and social infrastructure and policies support health, and where essential public health services, including quality health care, are available. In a healthy community, communication and collaboration among various sectors of the community and the contributions of ethnically, socially, and economically diverse community members are valued. In addition, the broad array of determinants of health is considered and addressed, and individuals make informed, positive choices in the context of health-protective and supportive environments, policies, and systems (Goodman et al., 1996; CDC, 1997; Norris and Pittman, 2000). Health is a “fundamental resource to the individual, the community and to society” (Kickbusch, 1989:13). When people are healthy, they are

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The Future of the Public’s Health in the 21st Century better able to work, learn, build a good life, and contribute to society. However, as noted in Chapter 2, the health of neither individuals nor populations occurs in a vacuum. Instead, it is shaped by a wide range of factors, such as income and education, social connectedness, employment, and access to quality health care. Inadequate and dangerous physical environments in homes, schools, neighborhoods, and workplaces and risk factors such as air and water pollution, unsafe food, social isolation, high rates of unemployment, violence, and crime constitute some of the problems experienced by communities. It may seem that these types of problems can be distanced from the concerns of the general population, as if these circumstances affect only certain groups (e.g., those with high blood pressure, smokers, or people who live in specific neighborhoods). In reality, the effects of health risks touch us all in many ways, and actions to address health at the population level benefit everyone in society (Rose, 1992). Moreover, the solutions for assuring population health are not owned by governmental public health agencies; they can be found in communities and in community organizations and partnerships (CDC, 1997; WHO, 1998; Bowles, 1999; Mitchell and Shortell, 2000). Today’s health challenges, ranging from jet-setting microbes and soaring obesity rates to emerging environmental risks and bioterrorism, highlight the interconnectedness of people and communities and the need for joint efforts to meet those challenges (McGinnis and Foege, 1993; Ruderman, 2000; Norton et al., 2002). The linkages among people and communities and people are clearly evident in the processes set into motion by globalization. A local community in many areas of the United States may be a microcosm of the world community, with a complex mix of beliefs, traditions, and languages. Given the rich fabric of most American communities, it has become impossible to consider threats to health someone else’s problem. Disease and disability do not differentiate between cultures and ethnic backgrounds—microbes and environmental toxins move easily among and across nations and regions, and no person or community is completely safe unless all are safe. COMMUNITY-BASED COLLABORATION Growing Commitment to Collaboration Although this report defines public health as “what we as a society do collectively to assure the conditions in which people can be healthy” (IOM, 1988:1), in practice, the community’s role in health programs has sometimes been that of passive recipient, beneficiary, or research subject, with active work in public health carried out by experts (e.g., governmental public health agencies) using approaches that are frequently unsuccessful in responding to the complex issues and needs of the community (Schwab and

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The Future of the Public’s Health in the 21st Century Syme, 1997). A great deal has changed since the Committee for the Future of Public Health observed that health departments and public health professionals worked largely in isolation, with little in the way of “constituency building, citizen participation, or continuing (as opposed to crisis-driven) communications with elected officials or with the community at large” (IOM, 1988:5). Today, dialogue and collaboration between local health departments and the communities they serve have become more common in practice and more critical in concept. For example, a recent study of 10 local health departments from different states found that they were substantially involved with community and youth organizations, schools, and the media in the areas of tobacco use prevention, injury prevention, and physical activity promotion (McHugh et al., 2000). Many communities, through individuals and organizations, have become partners with health departments in health improvement and have even become leaders in spearheading collaborative efforts (Fawcett et al., 1996; Mitchell and Shortell, 2000; Norton et al., 2002). The present committee found during its site visit to the Caring Community Network of the Twin Rivers, a Turning Point site in New Hampshire (see Appendix F), an example of an innovative way to create a local public health system that works effectively despite a limited governmental public health infrastructure. This community, a spread-out cluster of 12 towns, has no health department. Instead, each town has a more or less volunteer health officer, who in some cases is not a health professional. The work of assuring the public’s health is carried out through the collaborative efforts of committed individuals and groups, including the local public health officials, health care and mental health services providers, social service and community development organizations, educators, and the chamber of commerce (CCNTR, 2001). In authentic community-based partnerships, the participation and contributions of various stakeholders are likely to produce benefits in the form of increased effectiveness and productivity by reducing duplication of effort and avoiding the imposition of solutions that are not congruent with the local culture and needs. Community partnerships are also likely to have the benefits of empowering the participants, strengthening social engagement, establishing trust, and ensuring accountability (Israel et al., 1998; Mitchell and Shortell, 2000; Robinson and Elliott, 2000; Steele, 2000; Butterfoss et al., 2001; Chaskin et al., 2001; Lasker et al., 2001; Williams and Yanoshik, 2001; Wolff, 2001a, 2001b). A variety of vehicles can be used for community collaborations, including coalitions, partnerships, community advisory boards, consumers’ rights and advocacy groups, and nonprofit organizations. These groupings can bring together participants from many sectors of a community, including businesses, ethnic groups, faith-based organizations, and various public agencies. The Kansas LEAN (Leadership to Encourage Activity and Nutri-

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The Future of the Public’s Health in the 21st Century tion) Coalition is an example of a statewide coalition that began at the local level in 1990. By 1997, it had expanded to include 60 organizations and 100 individuals. The coalition brought together governmental agencies such as the state and local public health departments and state and local extension offices, nonprofit community and professional organizations, and businesses such as supermarkets to prevent chronic disease through dietary change and exercise (Johnston et al., 1996). Some opportunities for collaboration have less obvious but important health effects, as in the case of community redevelopment efforts. The economic condition of a community has clear implications for health. Higher employment levels, for example, tend to improve not only personal income and access to health insurance but also a community’s tax revenues and, thus, its ability to address health threats and to provide opportunities for health improvement. In some communities, local health departments have become partners in efforts to revitalize neighborhoods through the remediation of areas with industrial waste and environmental contamination (NACCHO, 2000a). Empowerment zones and enterprise communities are examples of public–private partnerships with significant government resources requiring collaboration at the local level to improve health in communities. A recent study found that 119 of the 144 national empowerment zones and enterprise communities initiatives had an interest in health issues (PHF, 2000). Some collaborations come into existence through the independent initiative of communities or community groups, whereas others are created in response to an outside stimulus, such as when government agencies or foundations require the formation of broad partnerships as part of grant processes (Mitchell and Shortell, 2000). The committee is encouraged to see indications that governmental public health agencies, community health centers, hospitals, and health maintenance organizations recognize that community collaboration is a necessity in health improvement (CDC, 1997; Pronk and O’Connor, 1997; Omenn, 1999). Some of the major federal and foundation initiatives that require and support the creation of broad-based community coalitions include Healthy Start, a community-based infant mortality reduction program; Turning Point1 and Community Voices,2 1   Turning Point is a grant program of the W. K. Kellogg and Robert Wood Johnson Foundations that began in 1996 and ended in 2002. The goal of Turning Point has been to “transform and strengthen the public health infrastructure in the United States” by supporting states and local communities to “improve the performance of their public health functions through strategic development and implementation processes” (www.wkkf.org). 2   Community Voices is a 5-year initiative launched by the W. K. Kellogg Foundation in 1998 in 13 U.S. communities. The goal of Community Voices is to improve health care for the uninsured and underinsured by strengthening and securing the safety net and community support services.

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The Future of the Public’s Health in the 21st Century privately funded community public health improvement grant programs; and Center for Substance Abuse Prevention programs, which support community-based substance abuse prevention “systems” that involve community coalitions and intersectoral collaboration (Lasker et al., 2001). Ingredients for Successful Collaboration Although collaborations to improve community health have become increasingly common, the committee recognizes that bringing together diverse agendas, institutional cultures and jargon, personalities, and expectations can be complicated, frustrating, and sometimes disappointing. One lesson that has been learned from such experiences, however, is that the community must be engaged before an agenda is set—the active participation of community leaders, members, and organizations is needed in the earliest stages of community-based public health action, if it is not already the force that drives such action (The Lewin Group, 2002). The initial communication and networking necessary to launch a community health improvement project entail frank examination and discussion of motivations, approaches, and goals by all stakeholders. At times, agencies and organizations may seek to implement their own unilateral agendas in communities, driven by scientific, political, economic, or professional interests, with token community involvement and often negative outcomes (Schwab and Syme, 1997; Fawcett, 1999; Norton et al., 2002). Many communities have been “coalitioned to death” without reaping any significant benefits (Himmelman et al., 2001). Such problems illustrate the need for thoughtful, broadly inclusive, well-planned, and realistic community health improvement approaches. Clearly, community health initiatives involve complex social and relational dynamics, as well as efforts to produce change that require significant investments of time and resources (Wickizer et al., 1998; Kreuter et al., 2000; Sharpe et al., 2000; Shortell, 2000; Rhein et al., 2001). The importance of allotting adequate time to the process of collaborative planning was well illustrated during the committee’s site visit to Healthy New Orleans, a Turning Point project in Louisiana (see Appendix F). Healthy New Orleans worked over a period of 2 years to build a partnership of diverse stakeholders. After establishing and clarifying roles and relationships, the partnership was able to develop a plan for community health improvement that was truly a product of community knowledge and effort (Healthy New Orleans, 2001). The HIV/AIDS movement provides another example of successful collaboration for community action (Stewart and Weinstein, 1997). AIDS volunteerism has uniquely demonstrated the effectiveness of turning people affected by AIDS into experts who both (1) mobilized community building

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The Future of the Public’s Health in the 21st Century and (2) transformed community attitudes and norms to achieve behavioral change. Communities working on a range of health issues may have much to learn from the example set by the gay and lesbian communities’ collaborative action. Yet, although the HIV/AIDS movement has succeeded in mobilizing public opinion and action, more research is needed to show what has worked best in mobilizing action and changing community norms and thus warrants replication (Kegeles and Hart, 1998; Reger et al., 2000). Research to assess the effectiveness of community collaborations has had somewhat mixed results because of the heterogeneity of communities, the long time lines involved in achieving community health improvement goals, and other complexities inherent in community-driven public health activities (Sharpe et al., 2000; Lasker et al., 2001). However, a growing base of empirical evidence from programs such as Turning Point and Community Voices provides a good road map for communities and their partners. Health improvement and other positive outcomes typically result from collaborations that are sustained over the long term, that institutionalize effective programs and processes, and that mobilize and utilize all available resources to deal with evolving challenges and population health issues (Fawcett et al., 2000b, 2000c). Success is also more likely with strong community engagement, an awareness of the community’s social dynamics, and leadership that reflects the racial and ethnic diversity of the community (CDC, 1997). Other important ingredients include having a clear vision and goals to guide action planning; allotting adequate time and financial, technical, and other supportive resources to collaborations and their health improvement efforts; and recognizing the importance of data collection and dissemination (CDC, 1997; W. K. Kellogg Foundation, 1997; Fawcett et al., 2000c; Roussos and Fawcett, 2000). Success in specific health improvement activities can depend on the use of varied strategies and on their intensity, duration, and penetration into the community (Fawcett et al., 2000b; Wilcox and Knapp, 2000; Lasker et al., 2001; Paine-Andrews, 2002). Problems arise around leadership, governance, and other management issues, such as planning and evaluation. Inadequate resources of various sorts— insufficient or inadequate funding or data, short time lines, or a lack of technical support—also contribute to problems, as does a lack of broad and authentic community engagement, which may be reflected in narrowly formed partnerships that do not include all the sectors of the community needed for efficient and effective action (Himmelman et al., 2001; Lasker et al., 2001). Sharing Public Health Governance Ultimate legal responsibility for safeguarding and promoting the health of the population rests with governmental public health agencies at the federal, state, and local levels (see Chapter 3), but those agencies cannot be

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The Future of the Public’s Health in the 21st Century effective acting alone. They must be partners in a broader network of individuals and organizations with the potential to act within a public health system. At the local level, in particular, health departments can become the facilitators and supporters of strong local public health systems that are informed by community voices, responsive to community needs, and linked to community assets. The committee supports a type of shared governance through which the agenda for population health is truly “owned” by the population it serves (Turning Point Community Health Governance Workgroup, 2001a and b; The Lewin Group, 2002). This entails providing opportunities for community input and leadership in planning and in funding decisions. It also requires educating the public about the concepts of public health, including the core functions and essential services (see Chapter 1), to help ensure that public health agencies are accountable to those they serve (Becnel, 2001). An approach used in some communities is governance of the health department by a local board of health, whose members come from various sectors of the community (see Chapter 3). The committee also encourages community involvement in the governance of other health-related activities. For example, a majority of the members of oversight boards for community health centers that receive federal funding (under Section 330 of the Public Health Law) must be community users of those facilities’ services. The Turning Point initiative—which involves 41 communities across 14 states—exemplifies shared governance. The most successful of the Turning Point sites mobilized the community from the earliest stages of assessing needs and setting an agenda for public health system change. These partnerships made community engagement a permanent and ongoing element. In fact, the community’s role became institutionalized in the local public health system through formal policies, investments, and programs (The Lewin Group, 2002). This national experiment in transforming local governmental public health agencies (Turning Point Community Health Governance Workgroup, 2001b) suggests that making shared governance a reality requires tools that formalize the governance structure so that it can achieve legitimacy. Also necessary are optimal communication between the community and the governing group and systematic, efficient and flexible management of operations (Turning Point Community Health Governance Workgroup, 2001b). The National Public Health Performance Standards Program3 includes an evolving set of model standards for the role of a 3   The National Public Health Performance Standards Program is a collaborative effort by the Centers for Disease Control and Prevention, Association of State and Territorial Health Officials, National Association of County and City Health Officials, National Association of Local Boards of Health, American Public Health Association, and Public Health Foundation to develop measurable performance standards to help ensure that state and local public health systems are able to and do deliver the 10 essential public health services (CDC, 2001).

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The Future of the Public’s Health in the 21st Century governing body in a local public health system and an instrument for assessing the performance of that governing body (National Association of Local Boards of Health, 2002). FRAMEWORK FOR COLLABORATIVE COMMUNITY ACTION ON HEALTH Once the collaboration has been created, several frameworks are available for use by communities, health departments, and their partners. Some of these models include the Planned Approach to Community Health, Mobilizing for Action through Planning and Partnerships, and the Community Health Improvement Process (Kreuter, 1992; IOM, 1997). The models provide step-by-step guidance for various aspects of the health improvement process, including assessing the health status of the community and the capacity of the local governmental public health agency. This chapter uses a simple framework provided by Fawcett and colleagues (2000b) to help describe the activities and processes involved in community action on health (CDC, 2002). This framework illustrates five key components of the activities and processes needed in community health action (Figure 4–1). Figure 4–1 illustrates a process that is often cyclical rather than linear, with work on one health improvement initiative leading to subsequent reassessments of a community’s health needs and priorities. FIGURE 4–1 A framework for collaborative public health action by communities. SOURCES: Fawcett et al. (2000b); CDC (2002).

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The Future of the Public’s Health in the 21st Century Although the five components of this particular framework do not necessarily take place in the sequential fashion shown, the diagram reflects the progression of events that has been documented in successful community-based public health initiatives (Fawcett et al., 2000b; Foster-Fishman et al., 2001). Each step of the framework for collaborative action will be discussed and illustrated with examples from the experience of community health improvement programs and initiatives. Assessing, Prioritizing, and Planning The processes of assessing, prioritizing, and planning will help community partnerships formulate a clear statement of goals to guide their work. These collaborative tasks are the first components of community action for health, but they also must be ongoing activities throughout a community’s health improvement efforts (IOM, 1996b, 1997; GHCF, 2001). By engaging in these activities, communities come to understand the context, causes, and solutions for various health problems. They include taking inventory of community assets and resources, identifying priorities for community action, and planning the actions to be taken. Community organizing and coalition building are necessary if these activities are to be collaborative. The Health Action initiative in Monroe County, New York, provides a good example of community involvement in assessing, prioritizing, and planning for health improvement (Milbank Memorial Fund, 1998; Health Action, 2001). Founded in 1995, Health Action is a collaborative of health care providers, hospitals and clinics, the local health department, an urban health commission, a university, the chamber of commerce, a large employers’ organization, and a professional association. Between 1998 and 2001, report cards were developed and released for five areas: (1) the health of mothers and children, (2) the health of adolescents, (3) the health of adults, (4) the health of older adults, and (5) environmental health. Focused goals and action plans were developed for each area. For adults and older adults, Health Action selected two goals: to promote healthy behaviors that prevent or delay chronic disease and to promote the use of preventive health services. Health promotion objectives included increasing physical activity and providing nutrition education and weight management, with the aim of decreasing the chronic disease risks posed by overweight and obesity. In 2001, Health Action’s Adult/Older Adult coalition began work on a communications campaign supported by program activities (such as workplace fitness) to make Monroe County a more physically active community. Certain types of quantitative data, such as rates of disease, injury, and death, have usually been available to communities. Other data have become more readily available as more states and local communities, usually with the leadership or support of governmental public health agencies, have begun to

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The Future of the Public’s Health in the 21st Century conduct systematic assessments of health status and the determinants of health. The availability of data for small areas (at the subcounty level) has been an issue in general for community health programs, and it highlights the need for high-quality, comprehensive assessments of community health to guide action. In 2000, the Health Resources and Services Administration’s Community Health Status Indicators (CHSI) Project produced a set of health assessment documents for each of the 3,082 counties in the United States and made them available online (www.communityhealth.hrsa.gov/). The CHSI documents, which used a set of indicators for which comparable data were available for nearly all counties, can serve as a useful starting point for selecting indicators of particular interest to a given community, for making comparisons with other communities throughout the country, or for planning an update of a community’s indicators. A community-based approach to health improvement that considers the broad range of social and environmental determinants of health may call for the use of a variety of indicators, including ones that measure characteristics of the community rather than those of individuals (i.e., community-level indicators). Community report cards and other types of regular assessments should include not only measures directly related to health, such as infant mortality rates and the incidence of infectious diseases, but also measures related to various health determinants (IOM, 1997). Indicators could include local employment rates, housing stocks, and levels of income and education, along with less conventional indicators such as the density of liquor stores; the quality of air and water; the availability of parks and green spaces, housing, and public transportation; and other measures of livability. In addition, qualitative or anecdotal data (e.g., residents’ satisfaction with the community, feelings of community cohesion, or informal measures of social capital) may also be an important part of the assessment process. The interest in community-level indicators is reflected in the work of a panel organized by the Centers for Disease Control and Prevention, which developed indicators for cardiovascular health in three risk areas: diet, physical inactivity, and tobacco use (Cheadle et al., 2000). The community-level indicators for physical inactivity, for example, included “miles of walking trails per capita” and “presence of local policy to include physical education in public K–12 curriculum” (Cheadle et al., 2000:112). Cross-cutting indicators included the number of media reports that dealt with smoking, nutrition, and physical activity and the number of assessments or screenings within the community for all cardiovascular risk factors. An added benefit of community-level indicators is the fact that they are sometimes easier and less expensive to measure than indicators based on the behaviors or characteristics of individuals, which may require costly household surveys.

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The Future of the Public’s Health in the 21st Century ing discussion of how to ensure that such research is conducted with the highest regard for those who participate. The committee believes that discussion and debate about the ethics of community-based research are necessary and that creating a forum for such dialogue is important. Because the community is a complex and dynamic subject, the committee agrees with those who assert that entirely new paradigms of research and analysis must be developed, along with a “postmodern epidemiology” or a “participatory eco-epidemiology” that does not sacrifice rigor but that shares power and involves all local perspectives and opinions (Schwab and Syme, 1997). Collaborative public health research that engages the community at every possible level may mean that research will be applicable and useful to them (Israel et al., 1998; Sullivan et al., 2001). Furthermore, the expertise of local community members and groups would constitute a valuable addition to a research project’s assets (Omenn, 1999; Schwab and Syme, 1997). A social marketing project to improve the health of agricultural workers in Florida provides an example of a fruitful partnership in community-based research (Flocks et al., 2001). Florida nursery and fernery workers, who are primarily Hispanic and Haitian, are exposed through their work to a large volume of pesticides known to be harmful to humans. In 1997, health researchers from the University of Florida entered into a partnership with a union, the Farmworker Association of Florida, and a social marketing firm for a project to help expand existing educational efforts and focus them into an effective, wide-scale intervention. Fernery employees participated at all stages of the research, contributing valuable cultural and occupational insights and information. The process has been lengthy and challenging because of the varied interests of the parties involved (workers, unions, health care providers, industry, academia, government agencies), but the initial work has begun to pay off. More funding has been secured, additional research has been launched, and work has begun on social marketing interventions to change employer practices and worker behaviors and on efforts to address barriers to adequate health care for this vulnerable population of workers exposed to environmental hazards (Flocks et al., 2001; L. Clarke, personal communication, April 9, 2002). Additional discussion of issues in community-based research and the benefits of academic collaboration with communities appears in Chapter 8, which focuses on the role of academia in the public health system. SUSTAINING COMMUNITY ACTION ON HEALTH Assuring the health of communities requires continuous community participation and leadership in the context of a broader partnership with other potential actors in a public health system. Communities can work

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The Future of the Public’s Health in the 21st Century with health departments, hospitals and other health care providers, and the corporate sector and employers. Communities can also develop the expertise and linkages needed to attract media attention to their efforts and messages. Although specific programs may end once concrete objectives are achieved, communities and their populations are continually changing, as are their health status and the factors influencing their health. The cross-linkages that are created within communities from the pursuit of one health goal should be sustained and expanded or modified to respond to other persistent or emerging needs. Under what circumstances are health improvement efforts most likely to continue? Institutional and community memories are replete with examples of community initiatives that came and left without much effect, projects that accomplished little, and great collective disappointments about squandered promises and resources (Mitchell and Shortell, 2000; Lasker et al., 2001). It is important to recognize that opposition and conflict are definite possibilities and to appreciate that small wins along the way in terms of program goals can be important in sustaining interest and commitment (Fawcett, 1999). Success appears to be the result of a synergistic blending of community capacity with the capacity of governmental public health agencies and other partners (NACCHO, 2000a; Becnel, 2001; Lasker et al., 2001; McHugh et al., 2001). Capacity describes the mix of conditions (e.g., shared values, quality of programs and strategies, program congruence with community needs, and political support) and resources (e.g., knowledge, skills, money, time, and technical assistance) necessary for communities and community coalitions to accomplish and sustain change (Blackwell and Colmenar, 2000; Chaskin et al., 2001; Foster-Fishman et al., 2001; Norton et al., 2002). For example, a community can develop capacity by expanding its knowledge about best practices for organizing coalitions, planning programs, or conducting advocacy. Additionally, governmental public health agencies are increasingly aware of the need to build their own capacity by enhancing their ability to provide technical assistance, training, and support to build capable communities (Howat et al., 2001; Norton et al., 2002). Local health department staff generally possess the knowledge and resources needed in the community’s efforts to assess local health status, assets, and needs and to evaluate the outcomes of health initiatives. The fact that communities may rely on health departments to provide technical assistance underscores the need to enhance the skills and knowledge of the public health workforce (discussed in greater detail in the Chapter 8). The committee recommends that local governmental public health agencies support community-led efforts to inventory resources, assess needs, formulate collaborative responses, and evaluate outcomes for community health improvement and the elimi-

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The Future of the Public’s Health in the 21st Century nation of health disparities. Governmental public health agencies should provide community organizations and coalitions with technical assistance and support in identifying and securing resources as needed and at all phases of the process. The sustainability of health improvement efforts is reflected in the extent of community change and the degree to which initiatives remain in place after funding ends (Paine-Andrews et al., 2000b). A study of six community initiatives, three for teen pregnancy and three for substance abuse prevention, found that after the end of a 5-year grant period, at least a quarter of the activities initiated in each of the six projects were continuing. These activities included mentoring programs and an annual youth job fair, as well as alternative activities (Paine-Andrews et al., 2000b). Among the strategies for sustainability of initiatives identified by the study were grant writing, making a business plan, and integrating programs or individual program components into the regularly budgeted activities of a partner agency (Paine-Andrews et al., 2000b). Governmental and private-sector funders can play an essential role in supporting the sustainability of changes in a community’s conditions for health. Funders can encourage communities to develop clear goals and to follow practices proven to be effective (W. K. Kellogg Foundation, 1997; Wickizer et al., 1998) (see Box 4–7). For example, funders can require or support the adoption of specific program elements, such as the development of a business plan, and they can BOX 4–7 Lessons from Turning Point A review of the Turning Point initiative identified five key lessons for public health policy: Recognize the need for direct and explicit support for partnerships; Move beyond hierarchical top–down approaches to allow direct investments in communities and responses to community priorities; Integrate community-based partnerships into program and funding strategies; Broaden the education of the public health workforce to include communication and facilitation skills in nongovernmental and even nonhealth issues; and Model interagency and public–private integration at the federal and state levels. SOURCE: Baxter (2001).

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The Future of the Public’s Health in the 21st Century encourage linkages with key local partners, including health departments (Fawcett et al., 2000c; NACCHO, 2000a; Paine-Andrews et al., 2000b; Brunner, 2001). Communicating or even partnering with local health departments may help prevent duplication of effort and may help coordinate activities with multiple participants. In addition, funders must realize that significant community change projects require long-term support and, often, active assistance in identifying continuing sources of financing when the initial grants expire. Because of the time lag between initiation of a community-level intervention and measurable health results, short-term “demonstration project” models are rarely effective and may increase community cynicism about outside partners. The committee recommends that governmental and private-sector funders of community health initiatives plan their investments with a focus on long-lasting change. Such a focus would include realistic time lines, an emphasis on ongoing community engagement and leadership, and a final goal of institutionalizing effective project components in the local community or public health system as appropriate. Given the ever-changing nature of communities, health improvement efforts should be seen as a continuing journey rather than a specific destination. CONCLUDING OBSERVATIONS Communities and community organizations can be vital contributors to the resources and capacity of a public health system. A community’s right to self-determination, its knowledge of local needs and circumstances, and its human, social, and cultural assets, including the linkages among individuals, businesses, congregations, civic groups, schools, and innumerable others, are all important motivations for community health action. In cases in which community health promotion and protection activities are initiated by a health department or an organization, engaging the community is a primary responsibility. Realizing the vision of healthy people in healthy communities is possible only if the community, in its full cultural, social, and economic diversity, is an authentic partner in changing the conditions for health. REFERENCES ACS (American Cancer Society). 2002. American communities can change lifestyle habits to prevent cancer. Available online at http://www.cancer.org/docroot/nws/content/nws_1_1x_american_communities_can_change_lifestyle_habits_to_prevent_cancer.asp. Accessed March 6, 2003. ATSDR (Agency for Toxic Substances and Disease Registry). 2000. Geographic information systems in public health: proceedings of the third national conference. Available online at www.atsdr.cdc.gov/gis/conference98/index.html. Accessed October 30, 2002.

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