Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Sunday, December 9, 2007

Public Policy and Environmental Change: Where Did the "Public" Go? – Jaime Hoebeke

Despite recommendations from the esteemed Institute of Medicine, larger philanthropies, such as the Robert Wood Johnson Foundation, and public health experts, such as the Centers for Disease Control and Prevention, continue to support a top-down approach to public health practice at the local level.

Consequently, this approach eliminates a critical partner in the community change process – the community. In order to implement sustainable, community-wide change that results in the reduction of chronic diseases, public health officials must be willing to shed their “Ivory Tower Ideals” and engage the community as an empowered partner.

More specifically, there have been two recent grant funding opportunities to address risk factors of chronic disease that were released by the Robert Wood Johnson Foundation, Childhood Obesity Leadership Academy, and by the Centers for Disease Control and Prevention, Action Communities for Health, Innovation and Environmental Change Initiative. Both of these opportunities promote a top-down approach by advocating for the establishment of a steering committee solely comprised of organizational leaders. As a Senior Public Health Specialist employed by a local health department in New England, I find this approach to be counterproductive when enacting true public health change at the local level. Local public health officials are well aware of the impacts of social factors on the health of populations. We must be able to actively engage community residents in health improvement efforts to address root causes of disease that lead to significant, population-based risk reductions.

Changing community conditions and systems through public policy involves changing aspects of the physical, social, organizational, and even political environments to eliminate or reduce factors that contribute to health problems or to introduce new elements that promote better health (1). Success appears to be the result of a synergistic blending of community capacity with the capacity of governmental public health agencies and other partners (2). By advocating a “highest levels of leadership” approach, grant funders are neglecting to realize the importance of community representation in the development and implementation of public policy and environmental change aimed at decreasing the prevalence of chronic diseases.

Local Resident Participation will Increase Social Capital and Collective Efficacy

By including local residents in the development of responses to community needs, it will bolster community cohesion and empower local residents to take a leadership role. According to the foundation of Social Capital Theory, local residents will serve as community catalysts to support the adoption of public policy-based initiatives and environmental change at the neighborhood-level. Additionally, participation in the design and implementation of community solutions will not only inspire change in the local leaders, but their leadership will also influence their social networks.

The core meaning of social capital is tied to the broader concept of social cohesion, which refers to the absence of social conflict with the presence of strong social bonds and mutual trust (3). In a study examining the correlation between social cohesion and mortality rates, lower levels of trust were associated with higher rates of most major causes of death, including coronary heart disease, unintentional injury, and cerebrovascular disease (3). Involving local leaders in the health improvement process will increase community trust and bolster organizational accountability to the public’s health that will strengthen relationships between leadership and its constituents.

Collective efficacy, in positive terms, refers to shared expectations and resident engagement through social networks at the neighborhood level. Unfortunately, social networks can restrict local ties and support to geographically defined areas; thus, prohibiting the broader reach and potential of social networking. “It appears that what many impoverished and dangerous neighborhoods have in common is a relatively high degree of social integration (high levels of local neighboring while being relatively isolated from contacts in broader mainstream society) and low levels of informal social control (feelings that they have little control over their immediate environment, including the environment’s negative influences on their children)” (4). Resident participation in a broader community process will expand local ties to include members outside of their geographic sphere of influence. Subsequently, these new linkages will strengthen the community’s ability to respond to local health concerns.

The Assessment Process is Most Effective with Local Resident Input

As a core function of public health practice, assessment is a critical component to the effective design of a community intervention. Local resident participation in the development of public policy-based strategies will enhance the assessment process by enabling individuals from the highest levels of leadership to more clearly understand social/neighborhood-level indicators.

The Advertising industry has long realized the potential of formative research in effectively marketing products to the general population. These elements of Marketing Theory can and should be applied when designing public health campaigns and interventions targeted at behavior change. Formative research, in the form of local resident input, will assist the public health experts to delve beyond the risk factors for disease and focus their efforts on the fundamental causes of disease, which are social in context. This interaction will contribute invaluable qualitative information highlighting social and cultural influences on health behavior at the neighborhood level. A notable success in the utilization of formative research in public health is the State of Florida’s Truth Campaign, an anti-tobacco campaign that led to significant reductions in youth tobacco initiation (5).

Local Resident Participation from Inception to Evaluation will Create the Community Leaders Necessary to Initiate Behavior Change in the Target Population

According to the Diffusion of Innovations Theory, behavior has a characteristic pattern of adoption overtime that is sparked by early adopters. Involving community leaders in the formulation of public policies aimed at behavior modification and risk factor reduction will naturally provide the early adopters necessary for behavior change in the target population. Furthermore, since the community leaders were involved in the development of the initiative from inception to evaluation, this strategy will also increase long-term sustainability of public health efforts and build the capacity necessary to address other public health concerns.

The Diffusion of Innovations Theory emphasizes that the creation of innovators and early adopters within a community can help to facilitate population change. This theory has been traditionally utilized and best understood in its applications within the marketing of material items to a specific target audience. For example, athletic shoe companies often contract with high profile celebrities (innovators/early adopters) to promote the release of a new product line in their advertising campaigns. These campaigns have proven to be very effective in their ability to increase sales and create population trends.

Since the Diffusion of Innovations Theory fundamentally involves population change, its application can be expanded to include a role within health behavior change. In fact, Everett Rogers' definition of the theory contains two key elements to support this notion (6). First, the theory is based on communication channels or the means by which messages get from one individual to another. Community leaders serving as early adopters can inform their social networks about public health messages and local resources. This can also be portrayed in the form of modeling, which is related to concepts of social learning theory. Second, social system development, or a set of interrelated units that are engaged in joint problem solving, is essential to accomplish a common goal. It is this element of the theory that builds long-term sustainability and community-wide reach of public health efforts by strengthening collaboration.


In summary, engaging the community as an empowered partner in the development of public policy is essential to keep pace with the changing face of epidemiology and its utility at the local level, and the increasing promotion of community-based participatory research as the new frontier in public health practice. To truly achieve this ideal, public health officials must be willing to broaden their traditional focus and update their toolbox for addressing issues to include theories and principles from other professional fields, such as sociology, communications, and social policy. Since the community is a complex and dynamic subject, an entirely new paradigm 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 (1).

Public health officials must also be comfortable in working with the community as an equal partner in the process by acknowledging that the public’s health is a shared responsibility among community members, political leaders, social service organizations, health care entities, and public health agencies. Philanthropies and national leaders in public health have the power to make this ideal a reality by encouraging collaborations that include a blending of local community residents with individuals from the “highest levels of leadership.” For this will dramatically increase and improve our successes, build the capacity to address neighborhood-level concerns, and positively change the approach of public health practice at the local level.


1. Institute of Medicine of the National Academies. The Community (pp. 178-211). In: Institute of Medicine of the National Academies, ed. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press, 2003.
2. Becnel B. Community-based public health lessons on power, policy and grassroots leadership. Oakland, CA: Community-Based Public Health Policy & Practice, 2001.
3. Sampson R. Neighborhood-Level Context and Health: Lessons from Sociology (pp. 132-146). In: Kawachi I, Berkman L, ed. Neighborhoods and Health. New York, NY: Oxford University Press, 2003.
4. Wilson WJ. The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy. Chicago, IL: University of Chicago Press, 1987.
5. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
6. Appalachian State University. Theories Used in IS Research. Boone, NC: Appalachian State University.

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