In bringing about behavior change in public health, we often focus on the individual mother, student, or farmer. We should not forget the community structure and norms constrain for encouraging individual health behaviors. This course examines the community context of the changes needed to promote the public’s health. We begin by examining the various definitions of ‘community’ and the processes by which we ‘diagnose’ or seek to understand the structure and characteristics of different types of communities. An appreciation of community similarities and differences is necessary lest we fall into the trap of designing one-size-fits-all interventions. We need to recognize that no matter that outsiders may view a community as poor or neglected, we can find strengths and capacities for improvement in each community. Identifying community capacities and resources is the first step in facilitating community change. Different practical and philosophical approaches to change and therefore, examined. Specific to the change process is our recognition of the need for communities to participate in the design, implementation and evaluation of any intervention. We examine the concept of participation in an effort to see how different levels of involvement may affect sustainability of community change efforts. Finally a case study of a community participatory approach to onchocerciasis control in Africa is presented. Community Directed Intervention has subsequently been successfully applied to providing other essential primary health care services by and in the community, such as insecticide treated bednets, malaria treatment, vitamin A distribution, deworming medicines, and pneumonia and diarrhea case management.
Lecture 4A: Community Change Models
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來自 Johns Hopkins University 的課程
Community Change in Public Health
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Module 2
Welcome to Week 2 of Community Change in Public Health. This week's lectures will focus on Community Efficacy and Community Change Models. Learning these concepts will help you gain a deeper understanding of the forces at work within communities and how they can be harnessed to affect positive change.
與講師見面
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
[MUSIC]
In the last lecture, we talked about developing community competence, and
this implies the need for community or
social change to help a community build its competence.
There are different views and different models about how communities change.
One view is to see social change as a gradual or
adaptive process oriented toward system reform.
In a way, this would be sort of a natural social change in the community.
There are different systems that we've talked about, different institutions,
different sources of leadership.
And this functional, or systems approach, looks at change in terms of cooperation
and consensus, interaction that builds social norms and values.
Consider social goals, norms in this sense.
As we've talked about before in terms of the interpersonal or
social network system are those links that help hold a social system together.
The norms are expected behaviors.
Social change occurs when parts of that system break down or
are no longer able to contribute to the maintenance of that system, or
when the external environment changes and overwhelms the system.
In this case, social norms change,
providing new rules of conduct to help reform and maintain the system.
Such changes have been witnessed in a number of African countries.
Due to economic hardships,
health departments are no longer able to provide quality care.
Staff may be underpaid and seek part time work outside.
Medicines are no longer available, cannot be purchased by the system.
And when the system, that component of the broader community system breaks down,
people search out other systems, other sources of care.
The private sector may become more prominent.
Self-care through the use of medicine shops may increase.
So when these changes occur, people, the community members adjust, adapt.
Other systems may come to the forefront to take over and fill the gaps.
Change occurs when different interest groups gain ascendancy.
Very obvious example of this is political parties.
Recently, in some states in Nigeria, political parties that favored
free health care were voted into power in those states.
And thus before when there was emphasis on revolving drugs cost recovery,
now people can get their drugs free.
This has been tried before during the 1980s and it was found ultimately
that the government could not continue to purchase and
provide enough medicines for everyone.
And so there would be lean periods, the supply of drugs would reach a dispensary
or a clinic and within a month would be finished.
The community members would adjust to this system.
They would come and give a variety of complaints so
that they could get medicines and store them at home.
But what would happen, of course, is, like we said, toward the end of the quarter,
no drugs would be available for others that were in need.
So, people will continue to evaluate these changes in policy changes and
availability of resources, and adapt.
Social norms can provide a basis for consensus,
agreement upon acceptable behaviors, both at the individual and group level,
but also norms can be used for coercion, laws can be passed that may or
may not be popular, and this embodies the conflict view.
In the conflict view, those who control parts of the community social system,
especially the economic and political systems, are seen as the ones who
establish and enforce the norms, and attempts to change the norms are resisted.
Examples of this have been seen in countries such as South Africa
where a white minority controlled power, controlled access to jobs,
controlled access to education.
Social change ultimately resulted in a democratically elected government.
And in similarity to the power coercive approach to planned change,
can see that the conflict point of view looks at changes in social norms,
power relations, distribution of resources
from the perspective of opposing interest groups in which ones are able to
exert more influence over the system to control more power within the system.
So again, in summary, there are views of the community that has a natural
system of different institutions and groups that evolve norms over time,
or the conflict view that sees groups with different levels of power coercing,
opposing, or struggling with each other to gain ascendancy.
A very useful model for community change, or models, has been proposed by Rothman.
And these parallel in large part, Benne and Chin's theories of planned change.
Rothman looks at community change from the social policy planning model.
As a situation where experts, whether they're people trained in public health,
trained in city and regional planning, trained in engineering,
trained in education, but experts designing programs for
communities assessing available data and information.
Identifying appropriate strategies and interventions, and providing leadership.
In large part, this represents in health things like our immunization programs,
our antenatal programs, environmental health control.
A second model for community change is community action.
And this resembles the conflict view that we've just discussed and
the power coercive approach to planned change in the context of community action.
Community members recognize that there's an imbalance of power.
They don't have access to good jobs.
They don't have proper sanitation in their area.
Their children do not have good educational opportunities and
they organize themselves to redress this through the political system,
through protests, through lobbying, and this is community action.
A third model is community development.
This is embodied in the concept of self-help.
It's also known as community organization.
People mobilize their own local or internal resources, and
this is very much a normative, re-educative approach to change.
A fourth model, which was not proposed by Rothman, but
follows suit from these, is community mobilization.
It has in common with social policy that programs
are externally designed by experts, but whereas social policy may use tax,
public, or other moneys to provide services, community mobilization
requires that a large part of the expenses for
health services, for community programs are donated or come from the community.
What we could say is that social policy planning has ideas generated from
outside the community by experts and brings in for a large part the resources,
whether it's staff, whether it's equipment, whether it's funds,
into the community to deliver that program or solve that problem.
In community action, the idea for
change comes from community members themselves, they perceive the discrepancy,
they perceive discrimination, they perceive lack of resources.
And they organize and demand that these resources that are outside the community
be brought in, that they have their fair share of these resources.
In community development, the idea and the resources for
change come from within the community.
And with community mobilization the ideas come from outside, but
the agency staff try to get the community to buy into and
contribute much of the resources needed to solve the particular problem.
In social policy planning, we have the typical agency-centered, or
expert-centered, approach, so we said it's empirical-rational in philosophy.
Prime example is city and regional planning.
New communities, such as Columbia in Maryland, between Baltimore and
Washington are examples where land use, educational
institutions, shopping and industry, the whole design of the community,
how neighborhoods are structured, warehouses are built are designed by
experts through their social epidemiological environmental research.
In health, we observe rates, outbreaks, trends, and
plan programs to address those.
We set up surveillance system to look for
acute flaccid paralysis, an indicator of Polio.
In a community in where we discover there is a trend of increasing
paralysis then we organize our resources to go to those areas.
In social policy planning the planning focuses around a problem, not so
much about people.
This appeals to the ready responders.
If you think about our adoption of innovation curve, the people who have
the knowledge are aware of scientific explanations and
these days when services are made available through social policy planning,
promotion of those services relies heavily on social marketing.
In particular we will look at the difference between social marketing and
advocacy in our final chapter and you may look ahead to see those distinctions.
Community action as we said is related to the conflict perspective on change,
redresses imbalances of power,
imbalances in resource allocation within the community.
It concerns empowerment.
It acknowledges that empowerment is something that people do for themselves.
One cannot reach into a community and empower people.
People have to realize their needs and take actions for
themselves in order to become empowered through their own initiatives.
This is a power-coercive approach to change in the sense that power is used.
Power can be used in a positive way.
One of the most famous examples of this approach was the community organization
done by Saul Alinsky and company in Chicago where poor people
who do not have services engaged in a variety of disruptive activities,
concerning garbage collection, various kinds of protests, etc until
the power elite were made aware of them and their needs, and changes occurred.
In this case the change agent acts as an organizer to help community members
identify the pressure points, where they could lobby, where are their connections.
Media advocacy plays an important role in getting the attention of decision makers.
In the next slide we see a youth group from a church in a small community in
Honduras.
Working together in many communities groups like this form an important
part of the broader social system of the community.
They not only are concerned about their own immediate social needs
that want to make a contribution into the community.
In this case, the youth are taking part in community environmental cleanup exercises.
These are things in terms of locality development or community development
model where people organize, recognize a problem and organize to help themselves.
Again, as we were talking about community diagnosis, it's important for
us to identify such social groups in the community and the role they play
in keeping the community strong socially, and keeping it healthy.
For example, we've mentioned in communities in the eastern part of
Nigeria, there are formalized age grades within the community.
People born within a three year period are automatically joined together in an age
grade, and as these groups mature, they have different responsibilities for
the welfare, the security of the community.
In locality development, we see embody,
the normative re-educative approach to change.
This model builds on existing community capacity.
The goal is problem solving, and sustaining this, because the community
is involved in seeking its own solutions to its own problems.
Emphasis is on community control.
In locality, development,
or community development, the change agent is a facilitator.
The change agent does not have an agenda other than to enable the community
to identify its own problems, seek its own strategies and solutions.
The primary expertise of a facilitator is in the process of change.
In contrast, the primary expertise of the change agent in a social
policy approach is that of technical competence in a particular area,
health, engineering, education, a content emphasis.
Locality development builds on indigenous knowledge.
How people themselves have solved problems.
How people themselves have organized and gotten things done over the years.
Through these indigenous organizations people can organize themselves for
change and
they can identify the local technologies that will allow change to occur.
Finally, community mobilization, as we said,
is the fourth approach, although not originally proposed by Rockman.
If one looks at a matrix, as we said of the source of the idea internal or
external to the community, and the source of the resources to solve the problem,
primarily internal or external to the community,
the community mobilization box in that matrix becomes apparent.
In this sense we have agency oriented priority setting, and
effort is made to bring people together for action.
It's usually specific program or goal oriented.
And a good example is in the area of immunization coverage.
Now, the agency will provide the vaccines, but in terms of getting mothers and
fathers to bring their children, this role falls primarily on the community.
Effort is made to reach community leaders and
have them identify resources to bring people in.
Town criers go from door to door, people in the association of taxi or
lorry drivers will go out and bring mothers in, social groups such as boy and
girl scouts will go house to house, tracing children who have defaulted.
Community members will be encouraged to provide food and lunch for
mobile teams of immunize immunization staff.
And so the community is encouraged to make a contribution
to a program that the agencies have brought in.
Social marketing is a major strategy for
creating demand interest in the specific service itself
as well is in mobilizing different social groups and agencies in the community.
So far we've looked at the functionalist versus the conflict
view of community change.
We've also looked at four different approaches or
models of change according to Rothman.
Finally, another perspective contrasts the process approach to change verses
the content approach to community change In the process approach, the community
itself is actually part of the change process, it's part of what changes.
New structures, new norms, new relationships, a new leadership,
new problem solving capacity, new local organizations evolve,
as the community improves it's problem solving capacity.
In the process approach, there's a focus on sustainability.
This approach looks at community change
as building on the strengths of indigenous community-based organizations.
Recognizing that these organizations have already been engaged in
community development.
This is quite common in many of the Nigerian communities where I've worked.
There are community development associations,
town improvement societies, or town improvement unions.
And these groups meet, at least, on an annual basis.
They identify needs, they raise funds, supervise projects,
collaborate with the traditional leadership of chiefs and
kings in the community, and work together to meet their own needs.
There are cooperative societies.
There are rotating credit groups.
Different kind of groups exist in the community and
their strengths can be built upon for community change.
The various kinds of strategies that are used in the process
approach include community organization and advocacy, and
these are based on social learning and community capacity theories.
In other words, seeing the community as a dynamic environment where people and
organizations are learning new behaviors, new ways of solving problems.
The content approach sees the community as simply the place, or the location,
or the context, wherein individual change occurs.
Existing organizations and social networks are recognized, but
they're used primarily as communication channels to get the word out to people
about the specific changes that may be needed.
Changes in home management of certain diseases, like malaria.
Changes in sexual behavior.
Changes in waste disposal, to clean up the community.
The content approach is very similar to social policy planning,
empirical rational, where specific behaviour changes are targeted and
the community is encouraged to adopt those changes.
The strategies, again, rely on mobilization, social marketing, where
socially desirable goods are promoted, and particularly is based on diffusion theory.
The chart compares the process aspects and
the content aspects with Rothman's model.
As can be seen, sometimes social planning, which often deals with specific content,
health, environmental, educational issues, can have process implications.
For example, planners may design appropriate schools and
curricula for primary students.
Provide teachers, provide books, in other words,
set up a system based on the need for education.
In the process, as more female students enroll, over time
these female students develop a greater sense of their roles in the community,
their ability to affect change, the potential contributions they could make.
They become more assertive, more questioning, more willing to access and
use new information.
And later, as they grow up, they become more effective mothers,
their children have less diarrheal diseases and other problems.
So roles, and functions, and relationships within the community can change.
Locality development focuses primarily on process,
how the community solves the problems it wishes to tackle, its own priority needs.
And through the process of problem solving, develops new approaches,
new relationships.
In community action, very much, focus is on
the process of gaining influence, power, resources.
A particular content issue may stimulate, such as the lack of electricity
in an area, the lack of sanitation in a community, in a neighborhood, but
the focus is very much on the process of how power differences can be redressed.
In summary, look at Rothman again, noting that in terms of what is happening
in the community, what the implications are for sustainability, social policy
planning is based on external decisions using external resources.
Programs come in to a community, people accept them, but
they may not continue them, the just would simply utilize them.
Although, they may be long-term changes,
as we gave with the example of female education.
Locality development, in contrast,
is internal decisions using internal resources, self-help projects.
In reality, communities may not have all the resources they need.
And so community action may be needed where internal decisions, improving roads,
improving schools, improving health, improving water supplies, may be made.
But then, community members realize that they don't have access to the resources,
that there are political or
powerful groups that are controlling those resources.
Simple case where a local government commissioner
focuses location of wells in villages where he has relatives.
People recognize that these wells are a valuable resource and organized
to pressure, to put political pressure on them to distribute those more equitably.
And in this case of mobilization, agencies make their plans and
then seek help from the community in carrying them out,
using local resources to mobilize people.
In conclusion, it's important to look at these political economy
issues in the context of many of the health programs that we promote.
Many programs assume or take on an empirical rational or
social policy approach, where they assume that people,
if provided with information and services, will be rational to use them, when,
in fact, laws, prejudices, power differences,
may create a situation where people cannot change their individual behavior.
A situation where women, young girls, become pregnant and
cannot further their education because of ethnic policies.
Where young people are encouraged to drink alcohol and not
be able to take up responsible positions, and take advantage of opportunities.
Where the broader political system, the powers that be that control the economy,
that decide the context of the economy,
make these decisions, set the rules, individuals, and social groups,
families in the communities may not be free to choose to behave in a healthy way.
