During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health promotion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.

An Ecological Perspective on Health Promotion Programs

Lincoln, Yvonna, and Egon Guba, "Postpositivism and the Naturalist Paradigm," pp. 14-46 in Yvonna Lincoln and Egon Guba, Naturalistic Inquiry . Beverly Hills, CA: Sage, 1985.*

Community-based research in public health focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and to integrate the knowledge gained with action to benefit the community involved. This review provides a synthesis of key principles of community-based research, examines its place within the context of different scientific paradigms, discusses rationales for its use, and explores major challenges and facilitating factors and their implications for conducting effective community-based research aimed at improving the public’s health.

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Review of community-based research: assessing partnership approaches to improve public health.

Progress in public health and community-based interventions has been hampered by the lack of a comprehensive evaluation framework appropriate to such programs. Multilevel interventions that incorporate policy, environmental, and individual components should be evaluated with measurements suited to their settings, goals, and purpose. In this commentary, the authors propose a model (termed the RE-AIM model) for evaluating public health interventions that assesses 5 dimensions: reach, efficacy, adoption, implementation, and maintenance. These dimensions occur at multiple levels (e.g., individual, clinic or organization, community) and interact to determine the public health or population-based impact of a program or policy. The authors discuss issues in evaluating each of these dimensions and combining them to determine overall public health impact. Failure to adequately evaluate programs on all 5 dimensions can lead to a waste of resources, discontinuities between stages of research, and failure to improve ...

Evaluating the public health impact of health promotion interventions: the RE-AIM framework.

The Social Psychology of Organizations.

Although community capacity is a central concern of community development experts, the concept requires clarification. Because of the potential importance of community capacity to health promotion, the Division of Chronic Disease Control and Community Intervention, Centers for Disease Control and Prevention (CDC), convened a symposium in December 1995 with the hope that a consensus might emerge regarding the dimensions that are integral to community capacity. This article describes the dimensions that the symposium participants suggested as central to the construct, including participation and leadership, skills, resources, social and interorganizational networks, sense of community, understanding of community history, community power, community values, and critical reflection. The dimensions are not exhaustive but may serve as a point of departure to extend and refine the construct and to operationalize ways to assess capacity in communities.

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Identifying and Defining the Dimensions of Community Capacity to Provide a Basis for Measurement

Both the qualitative and quantitative paradigms have weaknesses which, to a certain extent, are compensated for by the strengths of the other. As indicated in this article, the strengths of quantitative methods are that they produce factual, reliable outcome data that are usually generalizable to some larger population. The strengths of qualitative methods are that they generate rich, detailed, valid process data that usually leave the study participants' perspectives in tact. This article discusses how qualitative and quantitative methods can be combined and it introduces the articles included in this issue.

Toward Integrating Qualitative and Quantitative Methods: An Introduction:

In the last several years, health promotion specialists have stressed the importance of multiple interventions aimed both at individuals who are at health risk, and at risk-producing environments and policies (Milio, 1980; McLeroy et al., 1988; Pentz et al., 1989; Winett et al., 1989). The current emphasis on multiple interventions at multiple levels of the 'social ecology' is a response to the severity and complexity of chronic health conditions that are rooted in a larger social, cultural, political and economic fabric. The current wisdom in health promotion holds that targeting the behavior of individuals, without also intervening at these other social levels that shape behavior, will not have as great an impact on health status (McLeroy et al., 1988; Minkler, 1989; Hawkins and Catalano, 1992; Stokols, 1992). The development of coalitions of community agencies, institutions and concerned citizens to combat chronic health conditions is gaining popularity as an intervention aimed at strengthening the social fabric. Currently, hundreds of millions of dollars are being invested in coalition development as a health promotion intervention. For instance, both the COMMIT and ASSIST community tobacco control programs, funded by the National Institutes for Health, require coalitions of citizens in order to develop local strategies to decrease tobacco use (National Cancer Institute, 1988; Shopland, 1989).

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Community coalitions for prevention and health promotion

Coalitions currently are a popular tool for promoting community-based solutions to health problems, such as alcohol, tobacco, and other drug (ATOD) abuse. Private foundations, granting agencies, and other public health organizations assume that participation of community members in health promotion coalitions will increase the likelihood of program success. This article examines whether key characteristics of coalitions are related to effectiveness as measured by member satisfaction, commitment to the coalition, and the quality of planning efforts. Member survey data from the first year evaluation of an ATOD coalition were analyzed using factor analysis, chi-square, and multiple regression techniques at both the individual and group levels. The results suggest that community leadership, shared decision making, linkages with other organizations, and a positive organizational climate were key determinants of member satisfaction and participation. These same factors were not related to the quality of coalition plans. However, the significance of coalitions for community empowerment and health promotion is discussed.

Robert M. Goodman

Papers

Identifying and Defining the Dimensions of Community Capacity to Provide a Basis for Measurement

Toward Integrating Qualitative and Quantitative Methods: An Introduction:

Community coalitions for prevention and health promotion

Community Coalitions for Prevention and Health Promotion: Factors Predicting Satisfaction, Participation, and Planning

A model for the institutionalization of health promotion programs