There is a long history of community intervention in the field of public health. Mitler’s review of contemporary approaches to community health promotion traces them to the late 1800s. The goals of community interventions are diverse, ranging from decreasing morbidity or mortality, to increasing the practice of a healthy behavior or healthy organizational practices, to securing passage of public health policy. Policies can be oriented to active prevention (i.e., policies that require individuals to take action in order to be protected) or passive prevention (i.e., policies that protect individuals without the individual engaging in a health-protective behavior).
Community interventions typically employ an array of programmatic approaches including those that focus on changing individual behavior and those that target contextual influences that facilitate or impede individual behavior. Thus, a predominant theme in community intervention is the need for comprehensive intervention at multiple levels including individual, organizational, and community levels.
Characteristics of Successful Community Health Interventions
Several characteristics of intervention strategies have been found to be successful. Interventions that utilize data-based planning and feedback systems (epidemiologic, public opinion, strategic) are effective in the development and refinement of interventions. Successful interventions also involve the target population in some aspects of the effort. Success is also related to developing clearly articulated, highly focused, agreed-upon goals and objectives, maintaining flexibility at the tactical (programmatic) level, and emphasizing passive prevention approaches whenever possible so that people are protected automatically rather than having to engage in an active behavior. Furthermore, effective interventions often change the social norms around which individual behavior occurs and target the root causes of problems, especially those in the sociocultural environment. Finally, community intervention strategies that take into account the resources available (i.e., ends being adjusted to the means) and consider the timing and location of intervention in design and implementation are typically more successful.
Although in practice, health promotion is implemented through multiple levels (from the individual through policy), the community level is key to building a comprehensive strategy to promote health and prevent disease among the population at large. The importance of community intervention is often based on the assumption that greater improvement in health can be obtained by small changes in the behaviors (or environments) of large numbers of people than by large changes among a small number of people at high risk. That is, the goal of many community interventions is to affect small shifts in the distribution of risk and protective factors.
Theory of Community Health Interventions
Ecological Perspective
From an ecological perspective, the potential to change individual risk behavior is best considered within the social and cultural context in which behavior occurs. Interventions that are informed by a social-ecological perspective attend to extraindividual level factors such as community norms and the structure of community services including their comprehensiveness, coordination, and linkages, in addition to individual motivations and attitudes. Thus, individual change is understood within the social and cultural context in which it is to occur.
Social Cognitive Theory
Social cognitive theory has been a key theory guiding the development of community health promotion interventions. Bandura noted that self-efficacy, outcome expectancies, and perceived incentive value are key aspects of social cognitive theory. Self-efficacy refers to a person’s belief about how capable he or she is to perform a specific behavior and relates to a person’s willingness to participate in community change. Outcome expectancy refers to a person’s belief that a behavior will result in a specific outcome. A person will be more willing to spend time and effort to bring about a change to the extent he or she perceives the change will have the intended effect. Perceived incentive value refers to the relative importance one places on a possible outcome. In general, a person is more likely to engage in a behavior if he or she considers the behavior to be important (i.e., valuable).
Social Marketing Approach
Social marketing has also influenced the design of community interventions. Social marketing is the extension of marketing principles to social and health issues, and focuses on the marketing context structure, made up of product, price, promotion, position, and place. The social marketing approach emphasizes the context (marketplace) and the needs of the target population (consumer) so that tailored interventions are designed and delivered. Social marketing is based on two general assumptions: (1) programs/messages should be designed on the basis of the perceived needs and expectation of consumers and (2) successful programs are those that achieve a successful exchange between message sender and receiver.
Community Development Approach
Community development (or community organization) is the study of or intervention around the natural organization of persons and institutions in community systems. A key to this approach involves comprehensive planning and community diagnosis/analysis. There are three critical dimensions at the core of successful community development: (1) multisectoral inclusion, (2) organizational linkages, and (3) enabling and support. Multisectoral inclusion refers to the involvement and subsequent active participation of diverse community members and organizational constituencies in planning, implementing, and evaluating community health programs. Organizational linkages can be described as the communication, coordination, and collaboration among multiple community sectors toward joint goals and objectives. Enabling and support refers to a community’s ability to determine its own “health.” An enabling approach will change the typical hierarchical relationship between researchers (giving direction) and community groups (taking direction).
Mass Media Approach
The mass media are often used in community interventions. Mass media can influence awareness, interest (or motivation), trial attempts (or experimentation), and adoption of behavior. The media are important in setting the public agenda about health issues (i.e., what people think about and how issues are framed). Thus, the media can create and reinforce public awareness about an issue, contribute to its salience, serve as a cue to action, and reinforce action is that taken.
Empowerment
Empowerment, defined as efforts at individual, organizational, and community levels of analysis to exert control and gain mastery over salient issues, has also influenced community intervention. Wallerstein (1992) and Zimmerman (1990) defined empowerment by the absence or low levels of normlessness, powerlessness, social isolation, and helplessness. Critical components of empowerment include participation, control, and critical awareness. Community coalition and other strategic alliances such as networks, consortia, leadership councils, and citizen panels exemplify the “empowering” process. Members pool their individual resources to develop a critical mass in leveraging community change. Important benefits result from participating if the group climate is supportive of members, the group is highly committed to the work, and the group has a strong identification with its community.
Evaluation of Community Health Interventions
Evaluation of the success of community interventions has resulted in mixed findings. Multiple factors may account for the inconsistency in success of community interventions, including methodological or implementation concerns and measurement issues. Difficulties in detecting outcomes often stem from issues such as random assignment, appropriate control sites, and measuring intermediate and long-term outcomes. Difficulties in producing effective outcomes may also result from a lack of use of “best practices” and difficulty implementing intervention strategies.
Conclusions
Community interventions are popular because they have the potential to improve health above and beyond what can be achieved by individual approaches alone. Indeed, part of the rationale underlying the efficacy of community intervention is the belief that changing the community at large is a more cost-effective means of achieving societal health goals then reaching individuals one person at a time. Also, community interventions have the potential advantage of delivering beneficial programs both to those who explicitly desire assistance as well as those who could benefit from intervention but who do not know they could benefit or who do not have access through more traditional service delivery mechanisms.
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