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Design of a health-promoting neighborhood intervention.

Design and implementation of health-promoting community interventions can advance public health and community well-being; however, realization of such programs is often challenging. Even more challenging is the implementation of ecologic interventions to revitalize built urban environments. A structured intervention entitled ;Intersection Repair; was devised in Portland, Oregon, by a non-profit organization, to implement urban gathering places in the public right of way; specific steps included situation analysis, community outreach, asset mapping, design workshops, construction permitting, building workshops, and process evaluation. The community created human-scale urban landscapes with interactive art installations to encourage social interactions. Such aesthetic improvements, which included painted street murals, information kiosks, hanging gardens, water fountains, benches, and so on, were intended to strengthen social networks and social capital by providing places for residents to engage in conversation. Community engagement in neighborhood design benefits the public at multiple levels, by promoting a healthier lifestyle, over and above urban landscape improvements.

Adolescent↗

[Smoking-free workplaces in the municipality of Nordkamp. A project within the Health and Unequality program in Finnmark].

The local health service has introduced a proposal to act against smoking habits among the employed in the municipality of Nordkapp. The health politicians have accepted the plan. The local council has given its approval. The article presents the plan and discusses the strategy of this process of preventive medicine. It stresses the importance of choosing the right pedagogic principles and how to put the plan into action. The article also shows an example of how a relatively conflicting political decision can be based successfully on convincing and sober argument by the health authorities. It is important that the health service still consciously follows up the matter.

Community Health Planning↗

Can deinstitutionalised care be provided for those at risk of violent offending?

OBJECTIVE: The aim of this article is to explain the current status of deinstitutionalisation and of community care development in the UK. DESIGN: Literature review of articles and reports on deinstitutionalisation. SETTING: Articles included in the review related either to the whole of the UK, to England and Wales, or to a specific area such as London. MAIN OUTCOME MEASURES: The review was carried out pertaining to the question of the extent to which community care can or should take over the functions of the asylum, with particular reference to those at risk of behaving violently. These functions include those that are manifest, or explicit, and those that are latent, or unintended but implicit (Bachrach, 1976). RESULTS: The example of patients at risk of violent behaviour is-one that highlights the continuing relevance of both these sets of functions, which are argued to be exerting a powerful influence on the processes of asylum closure and community care development. This influence is seen in delayed asylum closure, transinstitutionalisation (the shift of some patients from asylums to other institutions), and the institutionalisation of aspects of community care. CONCLUSIONS: Both the manifest and the latent functions of asylums must be acknowledged by those involved in planning community care; where it is felt desirable that community care does not take over certain functions, the consequences of this must be anticipated so that they can be prevented or dealt with in other ways.

Community Health Planning↗

The process and impact of implementing injury prevention projects in smaller communities in New Zealand.

It has been argued that developing community projects is an effective means by which to reduce injury. Two pilot community injury prevention projects (CIPPs) were established in small communities in New Zealand based on the World Health Organization (WHO) Safe Community model. The process and impact of the implementation of these CIPPs was monitored over 3 years. The setting was two small New Zealand communities with populations of <10 000. An external process and impact evaluation was conducted, with data gathered from written documentation, informant interviews and observation. The WHO Safe Community criteria formed the basis of the evaluation framework used. Other essential factors included were identified through the literature and the projects themselves. Findings from each CIPP were considered independently, followed by an examination of the differences observed. The findings from the evaluation of the implementation of these CIPPs are reported in relation to the themes identified in the evaluation framework, namely: community context, ownership and participation, focus and planning, data collection, leadership, management, sustainability and external links. Despite the different contexts, a common conclusion was that if the CIPPs' success was dependent on achieving a meaningful reduction of injury, they were unlikely to succeed. There were, however, a number of strategies and outputs for achieving change that could contribute to increasing safety for the population of interest. These were closely linked to community development strategies and needed greater acknowledgement in the evolution of the CIPPs. Critical to the development of the CIPPs were community capacity and the context in which the projects were operating. These conclusions are likely to apply to other projects in such settings, irrespective of the health outcomes sought.

Accident Prevention↗

A sustainable approach to planning housing and social care: if not now, when?

The publication of Supporting People (Department of Social Security 1998) has given urgency to discussions around needs analysis, planning, user voice and the development of 'normal' housing for people with support needs. This paper explores a project, which aimed to design a collaborative model for identifying supported housing needs. We provide an overview of the research background, local imperatives and findings, and point to the probability of increasing conflict between the policy of developing 'sustainable communities' and the development of housing for people with support needs.

City Planning↗

[Choice of nutritional interventions in Congo: an approach for primary health care centres and for the community].

This research is aimed at testing and adapting a comprehensive and participatory approach to identification, selection and evaluation of nutritional interventions in Congo. The mains tools utilized here are a causal model, a ranking table and a HIPPOPOC table. The causal model was built by a multi-sectional team of 35 persons and used to conceptualize the nutrition of young children in Congo, to identify vulnerable determinants and relevant interventions. Three main determinants were identified: i) Food consumption of the child; ii) Health status of the child and iii) Caring practices of children and mothers. Each determinant was developed into a sub-model. For each sub-model, the team identified vulnerable factors and relevant interventions. The identification of six interventions was based on experience, scientific knowledge and on-going interventions of the members of the group during participatory discussions. As resources were limited, it was not possible to implement all of the six interventions; thus a selection of the most appropriate interventions was made using a ranking table. Before building the ranking table, a choice of the most appropriate criteria was made by the group: technical feasibility, acceptability by the population, acceptability by health workers, financial feasibility, short-term impact, potential of participation and sustainability. The ranking table for intervention selection allows a critical discussion on each intervention and leads to prioritization. Once the table was completed, the three most appropriate interventions were selected: communication for behavior change, improvement of quality of care, and promotion of improved complementary foodstuff production. Two of the interventions (psychosocial stimulation and community-based) identified needed more research for implementation. In order to determine clear objectives for intervention and to set up a monitoring and evaluation system, a practical tool was used: the HIPPOPOC table. This table represents a simplified view of the intervention in which project inputs (resources), processes (activities), outputs (immediate results), outcomes (short- or mid-term effects) and impacts (long-term effects) are clearly defined. The approach used here is based firstly on completeness as a way of guaranteeing the success of the design, implementation and evaluation of an intervention. Completeness means that all factors that may affect actions and their impact are taken into account. Secondly, participation is a key element of the process. All actors playing an active role in the decision-making process are present during the planning and evaluation process. This approach is meant to empower individuals and the community as a whole and develop within the community an awareness and a competence for problem solving. It involves multiple stakeholders (target groups, supervisors, sponsors, central as well as peripheral workers, experts, etc.) in design, implementation, needs assessment, monitoring and evaluation.

Child↗

The effectiveness of human impact assessment in the Finnish Healthy Cities Network.

OBJECTIVES: To develop a framework for analysing the effectiveness of prospective assessment and to apply the framework to human impact assessments (HuIA) carried out in the Finnish Healthy Cities Network. METHODS: The framework was formed by synthesizing and developing the themes that emerged from the published literature on effectiveness. The research material consists of interviews with people who participated in the assessment process in the municipalities (19 interviews). The research material also included assessment documents, proceedings of working meetings, municipal policy documents, background material and project reports produced in the municipalities studied. The research datasets were examined by content analysis. RESULTS: HuIA increased the decision-makers' awareness of effects and functioned as a tool for empowerment. The latter was apparent, for instance, in the social welfare and healthcare sector, finding a role for itself in decisively co-ordinating interdisciplinary work and actively seeking to alleviate identified negative effects. The assessment process also opened up the planning process, committed various actors to the decision, helped select the right alternative and promoted social learning. CONCLUSIONS: From the viewpoint of preparation and decision-making, the effectiveness of a HuIA increases when assessment becomes a recurring process and an integral part of an organization's activities. Integration of an assessment into permanent structures or activities, such as drawing up programmes or preparing strategies, helps the results of the assessment to be seen more clearly. From the viewpoint of decision-making, it is also important to strengthen the decision-makers' expertise in prospective assessment. When the effectiveness of HuIA is looked at in a new way (i.e. from the viewpoint of goal achievement, decision-making or learning), a more comprehensive interpretation can be given.

City Planning↗

[Analysis of factors that influence the desire to use public health nursing visit and visiting nursing agencies' service].

PURPOSE: The purpose of this study was to forecast the demand for public health nursing visit and visiting nursing agencies' service, and to obtain basic information on public policy after the Long-term Care Insurance Project Plan starts. METHOD: 8,940 randomly sampled subjects aged 65 and over, and 7,984 aged 64 and below, were selected for the surveys and mailed the questionnaire. A total of 5,775 aged 65 and over and 4,774 aged 64 and below responded to the questionnaire. RESULTS: 2,474 (42.8%) aged 65 and over and 1,643 (34.4%) aged 64 and below knew the name 'public health nursing visit', and the service provided, 1,635 (28.3%) aged 65 and over and 1,073 (22.5%) aged 64 and below, were aware of the visiting nursing agencies' service. The percentage of those who desired to use the service was significantly higher among the respondent aged 65 and over than among those aged 64 and below. It was also significantly higher among those who had already experienced the service previously. CONCLUSION: Awareness of the service and the number of those who use the visit will increase, as those aged 64 and below become more the elderly. We therefore can expect that service demand will increase in the future.

Aged↗

A method to guide community planning and evaluation efforts in tobacco control using data on smoking during pregnancy.

BACKGROUND: Effective community based tobacco control programmes are critical for state and nationwide impact. However, there is little discussion in the literature of methods for setting local objectives which use locally collected data and account for historical variation in progress. OBJECTIVES: To develop and illustrate a method that uses locally available birth certificate data to model trends in tobacco use during pregnancy among women giving birth, predict future prevalence, and use predictions to set community specific tobacco control objectives. DATA SOURCE: Vital statistics. Wisconsin standard birth certificates, 1990-2000, which record the smoking status of the mother during pregnancy. DATA ANALYSIS: Trends in the prevalence of smoking during pregnancy in Wisconsin statewide and in all counties (n = 72) were modelled using linear regression of log prevalence on year. Model fit was assessed using R(2). Regression slopes, indicating estimated relative annual percentage change in prevalence, were used to predict prevalence in 2005, and objectives were calculated as a 20% reduction from the predicted prevalence in 2005. CONCLUSIONS: Modelling trends in the prevalence of smoking using locally collected data enables communities to set reasonable future tobacco control objectives that account for historical trends in progress.

Community Health Planning↗

Forging local level partnerships to make health programs possible.

The quintessential difference between most successful rural health programs and unsuccessful ones is local leadership. The ways in which a community invites, values, develops, nurtures, and supports the involvement of diverse stakeholder groups form an important part of the base for local rural health program success. Successful programs are initiated by local stakeholder groups who are committed to collaboration, have a working governance structure, a good understanding of their health and healthcare challenges, and a plan for sustainability. A key first step for rural community health planning is to contact one's local state Office of Rural Health. Most ORHs will provide information, guidance, and technical assistance. There are many challenges in rural health, but there are also great successes. North Carolina communities fare better than many because the North Carolina Office of Rural Health has demonstrated how effective state and local leadership work together to directly benefit rural communities and rural people.

Community Health Planning↗

The provision of services for alcohol problems: a community perspective for understanding access.

Alcohol use is related to numerous health and social problems. The article describes the prevalence of alcohol problems and dependence across a county and its institutions. While high rates of problem drinking were found across health, mental health, criminal justice, welfare, drug, and alcohol programs, the proportion was highest for primary health clinics, the criminal justice system, and welfare agencies. This also was the case when the county's most serious alcohol problem cases--individuals who were alcohol dependent--were examined. Thus it may be useful to develop screening procedures, mainstream treatment interventions in non-alcohol specialty agencies, and include non-specialty agencies in services research on access.

Alcoholism↗

Cost-effectiveness of a community-level HIV risk reduction intervention for women living in low-income housing developments.

We conducted a cost-effectiveness analysis of a multi-site community-level HIV prevention trial that enrolled women living in 18 low-income housing developments in 5 U.S. cities. A mathematical model of HIV transmission was used to estimate the number of HIV infections averted and quality-adjusted life years (QALYs) saved by the community-level intervention, based on data obtained from community-wide sexual behavior surveys at baseline and 12-month follow-up. Results indicated that the intervention prevented approximately 1 infection per 3500 women reached by the intervention, at a total cost of 174,845 dollars. The cost per QALY saved by the intervention was 37,433 dollars and the cost per HIV infection averted was 732,072 dollars. The community-level intervention was moderately cost-effective in comparison with other HIV prevention programs for at-risk women. Synergistic approaches to HIV prevention that combine community-level sexual norm change interventions with more intensive risk reduction programs for high-risk women are needed. EDITORS' STRATEGIC IMPLICATIONS: The authors present a promising and efficient community-level HIV prevention approach, with effects beyond the limited scope of individual or small group interventions. This paper represents an example of how an analysis of cost-effectiveness can provide policymakers with information needed for difficult decisions about prevention resource allocations.

Adult↗

Ethnographically informed community evaluation: a framework and approach for evaluating community-based initiatives.

OBJECTIVES: This paper describes ethnographically informed community evaluation (EICE), a framework for evaluating complex community-based interventions, and illustrates its use in the evaluation of Baltimore City Healthy Start, a federally funded infant mortality prevention project. EICE, which is influenced by cultural anthropology and assets-based community assessment, supports continuous program improvement, resident involvement, and measurement of community-level change. This approach takes into account both individual and contextual levels of analysis. METHODS: The evaluation coupled a participatory approach with qualitative and survey research methods to study community context and how it might contribute to infant mortality and influence program implementation, and to assess community change resulting from the program. Data collection included focus groups, key informant interviews, surveys, neighborhood mapping, journaling, and a study of community problem-solving. RESULTS: The evaluation provided program-related feedback to staff, contributed to a collective understanding of the local context, validated and augmented outcome findings, and imparted skills and a sense of empowerment to the neighborhood. Results reveal a community burdened by crime and social problems, yet showing great diversity in physical and social conditions when examined at the census block group level. Nevertheless, these social and physical hazards in the community are more salient than any specific health issue such as infant mortality. CONCLUSIONS: EICE is a powerful evaluation approach able to respond to the complexities of community-based maternal and child health initiatives designed to institute changes across multiple domains. EICE may be used, in whole or in part, as a supplement to traditional designs.

Anthropology, Cultural↗

Health education to promote community involvement in the control of tropical diseases.

Health Education is any combination of learning activities that promote voluntary adaptations in health-related behaviour. In pursuing this definition, health workers generally work in two main directions, a community development approach and a behavioristic, communications approach. While Health Education in tropical, developing countries often takes the developmental approach with full community involvement, including the setting of programme priorities, Health Education for disease control has more often been characterized as the behavioristic mode utilizing simplistic, professionally determined messages and short-term campaigns to attempt to influence health behaviours related to disease transmission. Efforts in Idere, Nigeria, have tried to merge the two approaches building on community concern about one endemic tropical disease, Guinea worm. From this base, volunteer village health worker (VHW) training was developed. VHWs, once trained, developed their own association, which served as an organizational base for further health development programming, directed by the VHWs themselves.

Community Health Planning↗

Paradigms lost: toward a new understanding of community participation in health programmes.

Community participation has been a critical part of health programmes, particularly since the acceptance of primary health care as the health policy of the member states of the World Health Organisation. However, it has rarely met the expectations of health planners/professionals. This paper argues that the reason for this failure is that community participation has been conceived in a paradigm which views community participation as a magic bullet to solve problems rooted both in health and political power. For this reason, it is necessary to use a different paradigm which views community participation as an iterative learning process allowing for a more eclectic approach to be taken. Viewing community participation in this way will enable more realistic expectations to be made. Community participation in disease control programmes focusing on community health workers is used as an example to show the limitations of the old paradigm. Participatory rapid appraisal is used to illustrate the new.

Community Health Planning↗

Integrated local health systems in Central America.

This paper describes a few Central American experiences related to the development of integrated, participatory health care systems. Theory and analytic method center on the tensions inherent in the dichotomies of professional/popular, center/periphery and biomedical/traditional. Using a framework rooted in the World Health Organization's 1978 call for 'health for all' based on community-oriented primary care, this paper concludes that the underlying conditions necessary for truly integrated local health systems have not yet developed. Except for the cases of Costa Rica during 1978-1982 and Nicaragua during 1979-1990, the political will to create and support such systems has not existed. Perhaps more importantly, the cultural milieu in which Central Americans interact with their society fosters an individualistic, commercial, and paternalistic citizen/society relationship rather than the cooperative, community-oriented and democratic spirit needed for successful development of integrated local health systems. Nevertheless, there are a number of positive examples from which we can learn, and a growing tradition of citizen participation which may lead toward appropriate, sustainable, and truly integrated local health systems.

Central America↗

The reach of a computer-tailored nutrition education program in the Dutch heart health community intervention "Hartslag Limburg".

OBJECTIVE: To study the reach of an efficacious, computer-tailored nutrition education tool in a field setting. DESIGN: Data from self-administered questionnaires were used. SETTING: The computer-tailored nutrition education tool (CTT) was adopted by a regional public health service organization and implemented in a regional heart-health community project. PARTICIPANTS: The 1293 inhabitants of the region that requested the computer nutrition education tool during a 25-month implementation period. MAIN OUTCOME MEASURES: Demographic characteristics; intake of fat, fruit, and vegetables; and psychosocial behavioral determinants. ANALYSIS: Descriptive statistics. RESULTS: The CTT reached almost 1% of the targeted population. Most participants were female (82%), and almost half were low educated. Many participants had diets higher in fat and lower in fruits and vegetables than recommended, were unaware of their unfavorable diets, and had low self-efficacy and intentions towards change. CONCLUSIONS AND IMPLICATIONS: Only a small, but possibly important, part of the target population was reached. Additional ways to reach more people should be explored.

Adolescent↗