Health education, public policy and disease prevention: a case history of the New York City Coalition to End Lead Poisoning

Environmental Health Promotion Interventions: Considerations for Preparation and Practice

Interventions to address current, future, and potential public health dilemmas, such as air pollution, urban sprawl, brown field reclamation, and threats of intentional toxic exposures would benefit from a synergy between the disciplines of environmental health and health education. A comparison between the Protocol for Assessing Community Excellence in Environmental Health and the PRECEDE-PROCEED model used in health education illustrates some similarities and differences in terminology, assessment procedures, intervention design, and types of evidence used by the two disciplines. Promising intervention strategies draw on the expertise of both fields and include social action, policy and media advocacy, coalition building, organizational change, lay health advisers, risk communication, and tailored educational messages. Appropriate targets of change can range from the equitable distribution of resources to individual behavior change. Significant interdisciplinary evaluation research is necessary to accelerate the identification of successful models for reducing the burden of environmental health problems in communities.

Advocacy 101: Getting Started in Health Education Advocacy

Advocacy for the public’s health and for the profession are widely recognized as responsibilities of health educators. Increasing emphasis on advocacy by professional organizations has peaked the interest of health educators, yet knowing where to begin as an advocate is, to many, a mystifying process. This article provides basic advocacy terminology, dispels concerns about participating in advocacy activities, and provides a practical and stepped approach to becoming an effective advocate. A tiered approach is used in relation to the advocacy strategies of voting behavior, electioneering, direct lobbying, grassroots lobbying, Internet use, and media advocacy to help individuals in their quest to begin or enhance their engagement in advocacy. A compendium of highly accessible resources is also provided. Finally, this article provides motivation for the beginning advocate.

Modeling the sustainability of community health networks: novel approaches for analyzing collaborative organization partnerships across time

Sustainability is important if community health organizations are to be effective in collaborating to achieve long term health goals. We present a multi-method set of longitudinal analyses examining structural markers applied to a group of organizations brought together to reduce cancer disparities among older African American adults. At the overall network level, sustainability was seen in the growth of outgoing connections and multiplexity. Results of hierarchical clustering analyses identified distinct patterns of collaborative activation over time at the relationship level. Growth modeling indicated the effects of continuing network membership and participation in collaborative events on several structural markers of sustainability. Results of these analyses provide longitudinal indicators for how collaborations among partner organizations impacted their likelihood of continuing in the community network program. The strategy presented here introduces novel methods to assist with planning and evaluation of future community based public health endeavors.

Are local laws the key to ending childhood lead poisoning?

Although lead paint was banned by federal law in 1978, it continues to poison children living in homes built before that time. The lifelong effects of childhood exposure to even small amounts of lead are well established by medical research. Federal and state laws have reduced rates of lead poisoning significantly in the past three decades. However, pockets of high rates of lead poisoning remain, primarily in low-income urban neighborhoods with older housing stock. Recently, several municipalities have passed local lead laws to reduce lead hazards in high-risk areas. There has been no systematic attempt to compare the design and effectiveness of these local policies. To address this gap, we conducted comparative case studies of eight innovative lead laws promulgated since 2000. The laws used a wide variety of legal structures and tools, although certain elements were common. The impact of the policies was intertwined with local housing, economic, and legal environments. While data do not yet exist to systematically evaluate the impact of these laws on lead poisoning rates, our analysis suggests that local laws hold great promise for reducing lead hazards in children's homes.

Rochester's lead law: evaluation of a local environmental health policy innovation

BACKGROUND

Significant progress has been made in reducing the incidence of childhood lead poisoning in the United States in the past three decades. However, the prevalence of elevated blood lead in children (≥ 10 μg/dL) remains high in some communities, particularly those with high proportions of pre-1978 housing in poor condition. Increasingly, municipalities are using local policy tools to reduce lead poisoning in high-risk areas, but little is known about the effectiveness of such policies.

OBJECTIVES

In this article, we evaluated the effectiveness of a comprehensive rental housing-based lead law adopted in Rochester, New York, in 2005.

METHODS

This policy evaluation integrates analyses of city inspections data, a survey of landlords, landlord focus groups, and health department data on children's blood lead levels from the first 4 years of implementation of the 2005 law.

RESULTS

Implementation has proceeded consistent with projected numbers of inspections with nearly all target units inspected in the first 4 years. Higher than expected inspection passage rates suggest that landlords have reduced lead hazards in rental housing affected by the law. Implementation of the lead law does not appear to have had a significant impact on the housing market.

CONCLUSIONS

Although many uncertainties remain, our analysis suggests that the lead law has had a positive impact on children's health. Strong enforcement, support for community-based lead programs, and ongoing intergovernmental coordination will be necessary to maintain lead-safe housing in Rochester. Lessons learned from the Rochester experience may inform future local lead poisoning prevention policies in other communities.

Boundary networks and Rochester's "smart" lead law: the use of multidisciplinary information in a collaborative policy process

The Rochester, New York, Coalition to Prevent Lead Poisoning formed in 2001 with the goal of eliminating childhood lead poisoning by 2010. The Coalition recruited diverse community stakeholders into a collaborative process committed to using the best available science. The Coalition successfully infused the debate about a new lead poisoning law with local data, national analyses, and the latest medical research. We argue that this was facilitated by a boundary network of individuals who provided technical input throughout the process. As a result of the Coalition's advocacy, in 2005 the Rochester City Council unanimously passed an ordinance that has been hailed as one of the nation's "smartest" lead laws. Many communities are looking to Rochester's new lead ordinance as a model. Both the process and outcome of this case provide valuable lessons for collaborative efforts to promote scientifically sound local environmental health policy.

Public health educators' participation in teams: implications for preparation and practice

Collaboration among public health organizations is essential to ensuring the health of the public. Much of the day-to-day work of public health educators is done in groups or teams or in consultation with others. This study examined the extent of health educators' work in teams as a proxy for collaboration. Health educators participated in an average of four teams per individual; three of these were interorganizational teams. Moreover, 40% of the respondents participated in five or more teams. Health educators supervised by other health educators were more likely to work in interorganizational teams than were those supervised by other professionals. Certified Health Education Specialists were more likely to participate in intraorganizational teams. Curricula in academic programs should reflect the extensive teamwork in which health educators are involved. Employers need to provide health educators with grounding in organizational priorities and support to carry out their collaborative work.

Promotion of Service Integration Among Home Visiting Programs and Community Coalitions Working With Low-Income, Pregnant, and Parenting Women

This study assessed service integration promoted by home visitors and community coalitions in Baltimore's Comprehensive Family Support Strategy. The study first assessed home visitors' coordination of services for their clients. Two yearly home visitors surveys (n = 32) assessed changes in their perceptions of 11 community resources' availability, service quality, and referrals made to those resources. There were statistically significant increases in the percentage of home visitors who (a) reported availability of seven resources, (b) gave high service quality ratings for six resources, and (c) referred clients to all 11 resources. The study also assessed six community coalitions' actions to promote service integration during 1 year through observation of coalition meetings. Coalitions discussing more service integration exhibited greater increases in home visitors' perceptions of high service quality and referrals. Home visiting practitioners should consider including coalitions as part of their program models in order to better link clients to appropriate community resources.

Community coalitions to control chronic disease: Allies against asthma as a model and case study

There is a rich and extensive literature regarding coalitions as vehicles for amassing resources, influence, and energy in pursuit of a health goal. Despite insufficient empirical data regarding outcome, a number of observers have posited the aspects of coalition processes thought to lead to goal attainment. The supplement, which this article is part of, is devoted to an examination of how these elements fitted together (or did not) in the seven areas across the United States where Allies coalitions devoted themselves to achieving asthma control. The aim of this article is to present the theoretical bases for the work of the coalitions. It illustrates and emphasizes how the community context influenced coalition development, how membership was involved in and assessed coalition processes and structures, and the community-wide actions that were instituted and the capacities they were trying to strengthen.

Community capacity for environmental health promotion: determinants and implications for practice

The human response to an environmental hazard can either reduce or exacerbate its impact on health. This article reviews determinants of community-level responses to environmental health hazards. The aim is to identify factors that can enhance a community's capacity to protect itself and to suggest public health strategies that can increase such capacity. Four case histories of community environmental health action are presented to test a theoretical model for understanding the determinants of community capacity to promote environmental health. Specific actions public health professionals can take to strengthen community capacity include increasing access to accurate science, building strong relationships between communities and local health departments, and supporting political reforms that level the playing field for communities that seek to challenge corporate or government practices.

Building collaborative capacity in community coalitions: a review and integrative framework

This article presents the results of a qualitative analysis of 80 articles, chapters, and practitoners' guides focused on collaboration and coalition functioning. The purpose of this review was to develop an integrative framework that captures the core competencies and processes needed within collaborative bodies to facilitate their success. The resulting framework for building collaborative capacity is presented. Four critical levels of collaborative capacity--member capacity, relational capacity, organizational capacity, and programmatic capacity--are described and strategies for building each type are provided. The implications of this model for practitioners and scholars are discussed.

A review of collaborative partnerships as a strategy for improving community health

Collaborative partnerships (people and organizations from multiple sectors working together in common purpose) are a prominent strategy for community health improvement. This review examines evidence about the effects of collaborative partnerships on (a) community and systems change (environmental changes), (b) community-wide behavior change, and (c) more distant population-level health outcomes. We also consider the conditions and factors that may determine whether collaborative partnerships are effective. The review concludes with specific recommendations designed to enhance research and practice and to set conditions for promoting community health.

A community-initiated study of blood lead levels of Nicaraguan children living near a battery factory

OBJECTIVES

In response to requests by parents in Managua, Nicaragua, whose neighborhood borders a battery factory, 97 children were tested for blood lead, as were 30 children in a neighborhood without an obvious source of environmental lead.

METHODS

Venous blood was examined by atomic absorption spectrophotometry. Educational workshops were conducted.

RESULTS

Mean blood lead levels were 17.21 +/- 9.92 micrograms/dL in the index children and 7.40 +/- 5.37 micrograms/dL in the controls (P < .001).

CONCLUSIONS

Children living near the battery factory are at increased risk of lead poisoning. The parents were able to petition the government to control the factory emissions and to improve appropriate health services. The factory is now closed.

Creating tobacco control policy at the local level: implementation of a direct action organizing approach

This article describes the community activation and policy change process in seven Minnesota communities involved in the Tobacco Policy Options for Prevention (TPOP) study. The study's intervention employed a direct action organizing model, which relies on mobilizing large numbers of people to alter decision making and leverage the power of elites. As part of the organizing process, TPOP organizers and teams made 1,319 personal contacts with community members, generated 309 media stories, and initiated 445 public events related to tobacco use. These actions resulted in the establishment of comprehensive tobacco ordinances in all seven communities. The authors discuss the goals, training, activities and political factors relevant to four phases of the TPOP intervention: information gathering and team recruitment, community awareness building and ordinance development, preparing for city council, and ordinance establishment and enforcement. Included are suggestions for practitioners interested in using policy change and community-based advocacy to resolve public health problems.

An HIV/AIDS prevention project for Mexican homosexual men: an empowerment approach

In this intervention, participants design and implement an HIV/AIDS prevention project for Mexican homosexual men. The intervention is consistent with, and contributes to, empowerment theory because it enhances collective action, provides opportunities to develop knowledge and skills, creates needed resources, and includes shared control with professional and among participants. The intervention described provides an illustration of an empowering process and distinguishes itself from empowerment outcomes. An evaluation of the project is also described, but the outcomes were HIV/AIDS-related behaviors rather than psychological empowerment of the participants. The results suggest that the participants' HIV/AIDS knowledge and preventive behavior improved when compared to individuals who did not participate in the intervention. In addition, the intervention generated community change initiated by participants. Implications for designing interventions using an empowerment approach are discussed.

Alcohol advertising and violence against women: a media advocacy case study

This article describes one effort to help prevent violence against women by addressing some of the larger societal factors involved. The Dangerous Promises campaign is based on the premise that sexist advertising images contribute to an environment conducive to violence against women. The goal of the campaign is to convince alcohol companies to eliminate sexist alcohol advertising and promotions. Using the tools of community organizing and media advocacy, the campaign pressures the alcohol industry to change the ways in which they portray women in much of their advertising. Media advocacy has been instrumental in the successes of the campaign. This article examines the strategies and outcomes of the Dangerous Promises efforts to date and makes a case for application of media advocacy as a tool for increasing community voice in policy-making processes.

Strengthening individual and community capacity to prevent disease and promote health: in search of relevant theories and principles

The dominant theoretical models used in health education today are based in social psychology. While these theories have increasingly acknowledged the role of larger social and cultural influences in health behavior, they have many limitations. Theories seek to explain the causes of health problems, whereas principles of practice, which are derived from practical experience, assist intervenors to achieve their objectives. By elucidating the relationships between theory and practice principles, it may be possible to develop more coherent and effective interventions. The key research agenda for health education is to link theories at different levels of analysis and to create theory-driven models that can be used to plan more effective interventions in the complex environments in which health educators work.

A conceptual model for community interagency collaboration

Although interagency community collaboration has been suggested to increase programming and decrease costs, theoretical understanding for this in nursing is limited. A conceptual framework for community interagency collaboration is described that depicts collaboration as a function of environmental conditions, organizational situations, and task characteristics. Transactional patterns including intensity, formalization, interrelational patterns, and structured relationships are discussed as are outcomes pertaining to organizations, interorganizational relations, clients, and communities.

Increased lead absorption caused by working next to a lead recycling factory

The objective of this study was to determine whether workers at a factory in Taiwan, adjacent to lead recycling plant, were affected by lead contamination. Workers at the lead recycling plant itself were found to suffer from lead poisoning; air and soil outside the plant were heavily contaminated by lead. Forty-one of the 45 workers in a forging factory next to the lead recycling plant were enrolled as the exposed group. A comparison group of 51 workers were selected from another forging factory about 20 km away. Each subject was interviewed about his lifestyle, work history, and residence, and blood was drawn for lead measurement by graphite furnace atomic absorption spectrometry. The results showed that two groups were compatible in age, sex, and smoking patterns. Blood lead of the exposed group was significantly higher than that of the comparison group (mean +/- SD: 20.4 +/- 9.4 micrograms/dl vs. 5.9 +/- 2.9 micrograms/dl). The difference was independent of sex and working zones. Blood lead levels were lower among exposed workers who had been employed less than 2 months compared with those employed longer. There was no difference among exposed workers in different outdoor working zones. Five months after improvement of pollution control and decrease in the production volume of the lead factory, 30 exposed workers were retested for blood lead. The blood lead of outdoor workers had an average decrease of 4.2 micrograms/dl while that of indoor workers showed no significant difference.(ABSTRACT TRUNCATED AT 250 WORDS)

Health education and community empowerment: conceptualizing and measuring perceptions of individual, organizational, and community control

The prevailing emphasis in health education is on understanding and changing life-style choices and individual health behaviors related to health status. Although such approaches are appropriate for some health problems, they often ignore the association between increased morbidity and mortality and social, structural, and physical factors in the environment, such as inadequate housing, poor sanitation, unemployment, exposure to toxic chemicals, occupational stress, minority status, powerlessness or alienation, and the lack of supportive interpersonal relationships. A conceptual model of the stress process incorporates the relationships among these environmental factors, powerlessness (or conversely empowerment), social support, and health status. The concept of empowerment has been examined in diverse academic disciplines and professional fields. However, there is still a lack of clarity on the conceptualization of empowerment at different levels of practice, including its measurement, relationship to health, and application to health education. The purpose of this article is to address these issues as they relate to the concept of community empowerment. It provides a definition of community empowerment that includes individual, organizational, and community levels of analysis; describes how empowerment fits within a broader conceptual model of stress and its relationship to health status; and examines a series of scales that measure perceptions of individual, organizational, community, and multiple levels of control. The article concludes with broad guidelines for and barriers to a community empowerment approach for health education practice.

Local advocacy for the medically indigent: strategies and accomplishments in one county

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.

An ecological perspective on health promotion programs

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.