This glossary collects the key concepts, people, and ideas you will meet in this lesson. Use it as a reference while you work through the material, or as a review before assessments. Type in the search box to filter entries.

Choosing the scale of a program

Individuals are embedded in communities, cultures, and societies, so interventions commonly happen in communities, the mixing pot where multiple factors interact. Most are geographic places, but online groups, which we can call virtual communities, count too. Your assessment (the PRECEDE-PROCEED work from Lesson 6) tells you which issues, factors, and people to target. One of the first decisions it forces is a decision about scale.

Universal, selected, indicated

Should you target the community in general with a broad-based or multilevel program, or reach a smaller setting and a specific population group? We call the first a community intervention and the second an intervention in a community, and both can be related to the way the Institute of Medicine classifies prevention, a scheme that began with Robert Gordon's 1987 operational classification.

A third possibility does not target individuals at all: you might work on systems or policies. Laws on smoking in indoor spaces are the standard example, and every Canadian province now has one. Where a community has no system for prevention, building one is the intervention.

Small change for many, or big change for few

Community interventions tend to produce smaller changes over a larger number of people. Suppose a mass media campaign produces a 3% decrease in smoking. Over a whole community, that might mean hundreds or thousands of people actually quit. An intervention in a community works the other way. An HIV program might focus on people who inject drugs because sharing equipment carries high risk and because the group can act as a multiplier or bridge for transmission to others. Working with a few social groups, the share who stop sharing might be 32%, a big change, but over a small subset, so smaller in absolute numbers.

Community, systems, and REACH

The Centers for Disease Control and Prevention is well known for building a community focus into prevention. A good example is REACH (Racial and Ethnic Approaches to Community Health), which funds community coalitions and other capacity building and developed one of the few evaluation protocols aimed at nonmedical factors in minority health disparities. Its framework assumes five stages that build on one another.

Interactive: which kind of program is it?

Decide whether each program is a universal community intervention or an intervention in a community, selected or indicated.

Four worked examples

Four cases show the distinction in practice.

Two cases to decide

Both cases point to the next section. COMMIT varied more by community than by pair, and Long Beach rewrote its materials on the street. The community itself, with its politics, structures, and expertise, is always part of the picture.

The intervention is only part of the picture

One truism for community interventions, large or targeted, is that the intervention itself is almost always just part of the picture. Because a community is involved, its interests, needs, politics, resources, and social structures will inevitably play a role; COMMIT varied more by community than by pair for exactly this reason. This section works through those factors, widens the lens to populations, and closes with two obligations: tailoring a program to the people it serves, and making sure it survives its funding.

The politics of choosing an issue and a population

In any community, several health issues matter at once. Imagine a rural mining community in West Virginia, call it Minerville, with low incomes and poor access to care, and five candidate issues: mine safety, lack of health insurance, cardiovascular health, youth drinking and driving, and tobacco-related cancer. How do you choose? Each issue has a political dimension, with advocates pushing attention and resources toward it. And the issue may be dictated by the source of funds: American maternal and child health money funds that mission, and substance abuse prevention money funds that one. Canadian planners face the same pattern through Health Canada's Substance Use and Addictions Program, Public Health Agency of Canada streams, provincial ministries, and foundations, each with a mandate that may clash with community wishes. Decide what you would do in each scenario before opening the guidance.

Coalitions and structures of power

When you implement a project you typically do so through, or in collaboration with, community structures. Any of them may have motives tied to community politics, to preserving or enhancing their position, or to controlling an issue in order to set the agenda, and any may carry internal conflicts from rivalries or different goals.

You may have but one issue in mind. Carrying it out in a community means recognizing the social and political forces that intersect with it; Lesson 5's community organization and organizational change theories are the tools.

Communities as experts

Despite all this, there is no better expertise on the community than expertise from the community itself and the diverse groups in it: the people who know its habits, customs, values, attitudes, social groups, and where things happen. Suppose you were disseminating obesity prevention messages. How would you know the contributing factors here, which themes to emphasize, the best places to deliver messages, or how to get key members to reinforce them? Community participation would be necessary.

The model here is the community health outreach worker. In HIV programs with people who inject drugs, one of the best strategies has been to employ members of the population to connect peers to the project, distribute information, and advise on reaching the group. They know local drug use patterns, how to talk about HIV, and the customs that relate to risk. Even more important, because they are closely connected to the population, they are perceived as knowing how it is, and they bring legitimacy.

From communities to populations

Working with communities is one subset of the larger topic of working with populations. Communities have a geographic component, a place with its own blend of people, resources, climate, economy, and social structure, although virtual communities without boundaries have become important too. Health problems exist in aggregates of people at every level, and those aggregates may share a place or already form a social group: socioeconomic, ethnic, gender or age, virtual, or occupational. Public health is by nature the business of population aggregates.

Four examples show how different the shared factor can be: a genetic predisposition, such as sickle-cell anemia among African Americans or Tay-Sachs disease among Ashkenazi Jewish immigrants; living where prevention services are limited and tobacco barely regulated; adolescents, whose beliefs about invulnerability raise the risk of alcohol-related crashes; and intense Internet gamers whose energy drink use and inactivity put them at risk. Then a caution that matters in Canada: overemphasizing a group's shared characteristics stigmatizes and stereotypes. Still, to work with a population at risk because of factors common to the group, you have to gain familiarity with it and work with its environment, dynamics, social structures, and behaviour, as with a community.

Tailoring

A key to health promotion in communities and populations is tailoring, which in a sense is what this whole course has been discussing. Click each card for one of its five requirements.

Tailoring does not mean starting from scratch. If every program had to be unique, enormous energy would go into design each time. There are usually commonalities across situations, and programs developed before that you can draw from, so tailoring becomes a process of adapting an existing program as much as developing a new one. The catch is that you want to adapt a program that is effective, which is why so much weight now rests on best practice or evidence-based programs. American sources include federal clearinghouses, nonprofit associations, model program databases such as the CDC's Community Guide and the SAMHSA National Registry of Evidence-based Programs and Practices, and professional associations. Canadian planners can add McMaster University's Health Evidence database of rated systematic reviews, and for many years used the Public Health Agency of Canada's Canadian Best Practices Portal.

Developing or adapting a program usually involves three steps: assessment of the problem, as in PRECEDE-PROCEED; formative research with members of the population, through interviews and focus groups, to learn what adaptations are needed and which components, messages, and materials fit; and ongoing evaluation during implementation so changes can be made. Long Beach's revisions were the third step in action.

Sustainability

Most funding for community programs lasts three or four years, and it may take a year or more before a program is even established. So what happens when the funding dries up? It is very awkward to up and leave a community just when a needed program gets going, and it does not help relations. The answer is to plan from the start: add steps along the way that build community capacity to run the program and link with other funding. Five steps do that work: train and hire community members to operate the program, bring in stakeholders with a stake in keeping it going, search for other sources of funds, write applications and train community members to write them, and link the program to others like it. Test a plan against them.

Whatever steps you take, the idea is to connect the program with the community and build its capacity to carry on. The next two sections apply that principle to schools and worksites.

Settings, channels, and the classroom

Whatever your intervention, it will be delivered somewhere: in specific places, which we call settings (schools, hospitals, worksites, mobile units), or through channels (print media, community groups, the Internet, social media). Settings and channels have characteristics of their own and draw on theoretical approaches that make sense for the setting and its population. A school-based intervention is likely to be a curriculum in a classroom, so community mobilization is probably not the approach you would reach for. This lesson pairs schools and worksites because they share a few characteristics.

Why schools, and why they are hard

Schools are the classic setting for health education, for four reasons. Health and education are intertwined: students cannot learn, and sometimes cannot attend, if they are not healthy. Students spend much of the day at school, a captive audience. Families interact with schools, so schools are a channel for reaching them too. And school health promotion dates from early in the 20th century, so infrastructure such as school nurses and health classes already exists. Because school activities are classroom based, school health programs have typically been curricula, educational or skill-building in nature.

Comprehensive and coordinated school health

Comprehensive school health education, in the American usage, is classroom instruction that addresses the physical, mental, emotional, and social dimensions of health, develops health knowledge, attitudes, and skills, and is tailored to each age level. Broader still is the Coordinated School Health Program supported by the CDC and the American School Health Association. Click each component.

If you consider the ecological model, these approaches make a lot of sense, though they require resources. Greenberg and colleagues at the Collaborative for Academic, Social, and Emotional Learning likewise advocate school health within a coordinated effort to develop students academically, socially, and in healthy behaviour and work habits. Canada organizes the same territory under a different name: the Pan-Canadian Joint Consortium for School Health, a partnership of federal, provincial, and territorial health and education ministries formed in 2005, promotes comprehensive school health as a whole-school framework with four interrelated components drawn from the World Health Organization's health promoting schools approach.

The fit is close: the CDC's curricula sit in teaching and learning, its services and family involvement in partnerships and services, its environment and staff health in the social and physical environment, while healthy school policy names the administrative level the CDC model leaves implicit. The Canadian framework puts policy on the diagram.

Assessing the school setting

To decide which theory applies, run a brief PRECEDE-PROCEED style assessment.

Which theory fits?

What can a classroom address? Knowledge of consequences, personalizing risk, skills to counter risk, knowing where to go for support, confidence building and role-playing, supportive networks, and the school's physical environment. But interventions may not focus on classrooms at all. If the assessment finds crumbling facilities, the fix is funding, a political issue for the board or legislature. If the key is reaching families, other theories apply. The candidates fall into four families.

Three theory-based school programs

Three programs each give a different answer to the matcher.

Two Canadian policies to decide

Schools have a captive audience, a purpose that favours education, and a political environment that must be assessed and sometimes changed. Next, the worksite, where the audience is adult and the purpose is productivity.

The worksite as a setting

There are a lot of good reasons to conduct health promotion in the workplace. More people are in workplaces than in most other accessible institutions, and they are there for most of their waking day; in the United States, many get their health benefits through work. Workplaces and schools share access to a population and a synergy between health objectives and organizational goals. This section works through the worksite as a setting and ends with Canada's national standard for psychological health and safety.

Why the workplace

Health, work performance, safety, and productivity are intertwined. Unhealthy workers miss time and have more accidents, and many studies find workplace health promotion cost-effective. The best-known figures are American: Procter and Gamble found its program cut health care costs by 29%, Johnson and Johnson estimated savings of almost two million dollars, and reviews found that programs using tailored communications and individualized counselling for high-risk employees returned roughly $1.40 to $4.70 per dollar over three years. Employees, like students, are a captive audience; workplaces have built-in communication and social support; and there is a long record of success. The CDC's Community Guide task force concluded that, in population health terms, workplace programs provided substantial benefits in health, awareness, and linkages to services.

How workplace health grew and changed

The workplace has gained currency as a site for health promotion since the mid-1900s.

Assessing the worksite

Run the PRECEDE-PROCEED assessment again, and notice that the phases read differently at work. The social assessment is unlike a community's: workplaces can span several communities or be global and have their own culture and norms; Émile Durkheim, in The Division of Labor in Society, remarked on the differences between workplaces and communities. The workplace cares about productivity, hazards, and employee continuity more than general well-being, but external factors matter: a single employer in a down economy leaves workers under pressure to keep quiet about unsafe conditions. The epidemiological assessment concerns work-related conditions; the leading occupational illnesses and injuries include hearing loss, lung disease, cancer and lead poisoning, carbon monoxide poisoning, dermatitis, fertility and pregnancy abnormalities, infectious diseases, back and upper-extremity disorders, traumatic injuries, and adverse mental health outcomes. The behavioural and environmental assessment covers a truck driver or pilot who drinks before work, protective gear worn or not, long hours without breaks, unsafe chemicals and equipment, and environmental contributors to obesity: if the only food is a vending machine of chips and donuts and a burger place down the road, with no time or place to walk, the environment will produce diet-related problems and eventually type 2 diabetes. The educational and ecological assessment treats the workplace as a small, contained social setting where people spend a lot of time together, so networks, support, and norms are the key issues, along with organizational culture, rewards, and whether employees know a hazard exists, perceive it as a threat, and intend to act. The administrative assessment maps policies, structures, and resources: a wellness committee, benefits, an assistance program, gym discounts, screenings, unions, community organizations that offer workplace activities, and the regulations that govern the worksite.

Interactive: reading a worksite

Cedar Ridge Forest Products runs a sawmill with about 240 unionized employees in a small town in the British Columbia Interior and has invited a public health unit to help. Sort each site-visit observation into the phase it informs.

Which theories fit the workplace?

Think first about the context for education. When would a workplace offer a program? At lunch, when employees want to eat, or after work, when they want to go home? Health fairs have worked in many situations. And employees are adults who attend by choice, so the approach should be engaging and hands-on, or should sell the benefits of the behaviour. The natural candidates are social marketing, the Health Belief Model, and diffusion of innovations. Workplaces are also organizations with cultures of their own. Click each characteristic.

To affect the culture itself, or build support for an intervention or policy, it may be necessary to engage in organizational change and bring influence from the surrounding community. The table gathers the matches.

Two theory-based workplace programs

Both examples come from the SAMHSA evidence-based program registry.

Two Canadian cases to decide

Schools and worksites both offer a present population, an organization whose goals overlap with health, and structures that must be assessed and sometimes changed. In both, the method is the one the first two sections used for communities: assess, choose the theory the setting calls for, tailor, and build capacity. The final review pulls those threads together.

Bringing It All Together

This lesson moved the course from theory to the places where theory is used. The first section opened with a decision about scale: a community intervention targets a community in general and buys a small percentage change over a large number of people, while an intervention in a community targets a specific group or setting and buys a large change within a small subset. The Institute of Medicine's universal, selected, and indicated categories describe the same choice, and a third path works on systems and policies rather than individuals. The Minnesota Heart Health Program and COMMIT showed what community-wide programs can and cannot do; COMMIT moved light and moderate smokers but not its primary target, heavy smokers, and its effects varied more by community than by matched pair. The Long Beach AIDS Community Demonstration Project showed an intervention in a community built on a composite theory, peer volunteers, role model stories, and materials rewritten repeatedly on audience reaction, and the Dr. Meg trial showed that a virtual community can be a setting too.

The second section explained why the program is never the whole picture. The choice of health issue and target population is political and often funder-driven, the community structures a program works through carry motives and rivalries of their own, and the best expertise on a community comes from the community itself, as community health outreach workers show. Working with communities is one subset of working with populations, aggregates defined by place or by a shared characteristic, with the caution that overemphasizing shared characteristics stigmatizes. Two obligations follow: tailoring, usually by adapting an effective existing program on the basis of assessment, formative research, and ongoing evaluation, and sustainability, planned from day one because funding ends in three or four years.

The last two sections applied the method to two settings. Schools offer a captive audience, a channel to families, and a century of infrastructure, and are complicated by developmental stage, politics, expanded demands, and scarce resources; comprehensive and coordinated school health, eight components in the CDC model and four in Canada's, is the ecological model applied to a school, and a PRECEDE-PROCEED assessment tells you which of four theory families a problem belongs to, as Life Skills Training, South Windsor, and Not On Tobacco illustrate. Worksites offer a similar audience, adult and voluntary, with a business case, an evolving history, and barriers of culture, time, and management-union relations; their assessment centres on networks, norms, organizational culture, and rewards, the theories that fit follow from that, and the Healthy Workplace Program, Coping with Work and Family Stress, and Canada's National Standard for Psychological Health and Safety in the Workplace show three ways of acting on it.

Final Knowledge Assessment

This assessment covers all material from this lesson. You must score 100% to complete the lesson. Review the feedback for any incorrect answers and try again.