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Abstract Social planners have begun to recognize that communities are an important resource for solving many problems. Understanding local norms and values is thought to provide insight into how issues are defined and what interventions might be considered practical. Communities in this framework are not just the physical locations at which programs are targeted, but are actively constructed spaces that must be properly understood. In many ways, the field of public health has been sensitive to this understanding and has elevated the community in importance, thus emphasizing that significant features are variable and locally defined. Even in the new public health, however, empirical indicators are still often relied on, thereby leading to the increasing standardization of communities, rather than to openness to neighborhood particularities. For this reason, a community-based focus should guide future public health endeavors. Most important, this strategy underscores the importance of getting to know the communities in which symptoms, illness and care are defined, and allows for full participation by community members that make interventions both relevant and sustainable. Introduction Nowadays communities are becoming increasingly important as the focus of social planning (Goodman et al., 2014; Sinclair and Whitford, 2015). In this regard, terms such as civil society, grass roots and civic participation are pervasive. The point is that in the past, planning was initiated most often from the top-down, and the result was the development of irrelevant and often harmful policies and practices (Murphy, 2014). To correct this situation, the claim is that planning must become community based. The field of public health has not been exempt from this trend. Many analysts believe that earlier models were abstract and reductionistic (MacKian et al., 2003). For example, communities were treated as if they represent clusters of socioeconomic traits. Furthermore, certain cultural features and psychological tendencies, such as motivation, were linked to these empirical properties. This web of assumptions, accordingly, is foisted on communities to predict the likely onset of social problems. Clearly the idea that data should be grounded in the life of a community, so that policies or interventions might be more relevant, has not always been given serious consideration (Kellehear and Sallnow, 2012). The so-called new public health arose against this backdrop of social indicator analysis, while suggesting that communities should be involved in data collection and program design and implementation (Baum, 1990). But for the most part, communities were still recognized as sources of disparate data and possible resistance to professional advice. In this regard, Tulchinsky and Varavikova (2009: p. 68) declare that new public health is merely an extension of traditional public health models. The strength of the new public health, on the other hand, is that communities are viewed to be dynamic and intricate, with rich cultures and knowledge bases that influence perceptions of health, illness and successful interventions. Planning, accordingly, is holistic and often guided by an ecological perspective (MacKian et al., 2003). The aim of this article is to illustrate this shift in thinking about health care and planning, along with discussing why the new public health has failed thus far to be truly community based. This failure is significant because of the importance accorded nowadays to community participation in the delivery and evaluation of health services. Particularly addressed are those readers who want to move public health closer to communities but are unfamiliar with the theoretical intricacies that are part of making this change. Not all community-based initiatives have been successful, but, in general, these interventions are thought to be sustainable options for reducing health disparities and improving population health (Cropper et al., 2007). Community-based programs, in short, tend to offer services in a relevant manner and thus garner public support. Specifically important is that a community is not identified with standard demographic, health, economic or other similar measures that are simply empirical. Communities, instead, are viewed to be the result of human agency and thus embody the discourse that unites their members. To become community based, accordingly, advocates of the new public health must begin to appreciate the embedded nature of all social phenomena (Zaner, 1964; Krieger, 2005). What this designation means at this juncture is that health behaviors are mediated thoroughly by interpretation, and thus, reliable observations or descriptions of community existence take into account this activity. Hence the biography of a neighborhood, along with the implied mores and proclivities, must be given serious attention (Berger and Luckmann, 1966; Hanna and Kleinman, 2013). In this way, how health and illness are understood by the members of a community becomes vital to sensible evaluation or the creation of effective interventions. In community-based public health dualism is challenged. Looking to objective societal or environmental features to locate health problems is thus passé, due to the pervasiveness of human action. The basic idea is that communities invent their worlds—referred to as ‘local worlds’ by Kleinman (1992)—that provide invaluable insight into how these persons define health and respond to illness. In traditional medicine, the aim is to overcome the error associated with such subjectivity. Community-based public health, on the other hand, elevates local participation, that is human action, in importance. This activity, accordingly, shapes health and all other behavior. This approach to public health, in the terminology provided by Thrift (2008), is a ‘non-representational’ philosophy. Other examples are symbolic interactionism and phenomenology. In fact, much of this discussion has been informed by phenomenology. But with human action mediating all knowledge, there is no autonomous reality available to represent, such as demographic traits. As a result, the various perspectives on health that are created by a community’s members vie for recognition as the relevant frame for understanding health. Traditional Public Health The guiding principle of the traditional model of public health is the identification of ‘high risk’ populations, and outlining the issues that have contributed to this condition (Frenk, 1993). The rationale behind this strategy is to channel interventions effectively while using resources in the most propitious manner possible. The determination of risk, however, is made on the basis of objective social indicators. Empirical referents such as age, education level, income and location, for example, are invoked to calculate the likelihood that a problem will emerge in a specific population. Objective data related to mortality, morbidity and related factors are thought to be very important. Associated with these empirical indices are assumptions about both the presence of pathogens and buffers to forestall the onset of illness. A neighborhood with a low level of education and high unemployment, for example, is considered to be a problematic location. In this regard, the potential impact of a particular pathological agent is calculated against the likelihood of resistance or successful remediation. A poor neighborhood with few preventive buffers is thought to be in dire straits, due to an unfavorable ‘risk ratio’ (Kellehear and Sallnow, 2012). Eventually a cause–effect onset matrix is established, along with the probable outcome of an appropriate intervention. This model is in effect at the outset of most health interventions. These projects are initiated regularly with a needs assessment (Patton, 2008). Most often the focus is gathering an array of data that describe a community. For example, a health status survey might ask, how many persons have had the flu or dengue fever in the past 6 months? Checklists are also often employed. The point is to establish a baseline that can serve a variety of purposes. But knowing how many households have contracted dengue does not tell much about how these persons have interpreted or responded to this illness. Their experiences are not often part of this style of assessment. The imagery that supports this orientation is very realistic (Besleme and Mullin, 1997). Terms such as barriers, structures, networks and systems, for example, are often used to describe communities. The implication is that the factors that influence the onset of illness, along with the promotion of health, are substantial and available for study and modification. In fact, in standard epidemiological assessments, the principle of ‘natural causality’ is thought to be operative. Furthermore, these linkages are mostly described in biomedical terms (Tulchinsky and Varavikova, 2010). As result of these portrayals, interventions can be pinpointed according to sound rationale. Both individual and collective correctives can be undertaken with the security and precision required to control risk. But eventually these models become very streamlined and focused, or the advantages of this general approach are lost. If variables are allowed to proliferate, in other words, the coherence that is sought is tempered by contingency. What is the point of creating a model, if increasingly concise statements are not advanced? Nonetheless, due to this parsimony, the resulting descriptions can easily begin to drift away from the reality of a community. And if researchers are not careful, these abstractions can begin to mask the actual disease process. In scientific parlance, this outcome is referred to as reductionism. What is overlooked by this imagery is the interaction or agency that constitutes and sustains a community. Using terms such as impact and outcome, for example, tends to obscure how perception mediates the onset of disease. Accordingly, how social indicators are socially constructed and interpreted, and thus inspire one response or another, is omitted from any analyses. In the end, the actual life of a community is replaced by concrete but uninformed descriptions of illness behavior. Causal statements are regularly provided that merely reify standard assumptions and behaviors, instead of providing insight into how persons perceive their health or decide to pursue care (Krieger, 1994). New Social Imagery The recent focus on community is accompanied by a significant change in social imagery. No longer is a neighborhood, for example, thought to be a collection of autonomous empirical traits. The dualism that sustains this position has simply lost legitimacy in many philosophical and planning circles (Gold, 1985; Bordo, 1987; Mehta, 2011). The assumption that persons must transcend the quotidian world, and the accompanying interpretation, and gain access to true or objective knowledge is considered dubious. This traditional trek has simply lost theoretical justification and practical relevance, in terms of non-representational philosophy. In the absence of dualism, human action is not treated as a barrier or impediment to the discovery of valid knowledge. With respect to research, this factor is not viewed to be a source of error that must be overcome. Diverse perspectives, instead, are recognized to mediate the pursuit of knowledge and pervade all findings. Correspondingly, writers who emphasize the creative role of language have become very important (Charon, 2006). Simply put, how speech is used in everyday life is thought to influence appreciably the nature of reality. Language use, accordingly, is not thought to simply reflect or highlight various aspects of social life. Those who have a community-based perspective contend, instead, that language is a game (Gergen, 2009). The point of this new descriptive is that language is a creative enterprise, and thus capable of deploying reality. Specifically, language use inundates existence and shapes whatever is known. The modality of language that is chosen, or put into play, influences how reality is created. Facts, accordingly, are always embedded in one perspective or another and never simply objective. For obvious reasons, the accompanying epistemology is referred to as ‘constructionism’ (Brown, 1995). Due to the pervasiveness and influence of language, reality is not simply encountered but constituted through human intervention. The traditional emphasis placed on empirical qualities, therefore, is eclipsed by a concern for meaning, or how facts are produced by everyday discourse. The dominant theme is that persons define themselves, their relationships and their social context. The thrust of constructionism is that social existence is shaped by human agency, including the nature of facts. Not everyone, however, is impressed by this claim. A number of constructivists hold on to dualism and never abandon the search for objective evidence (Lock and Strong, 2010). Others, such as Ian Hacking, contend that this position is trivial and adds little to discussions of knowledge (2000). Nonetheless, followers of the work of Kenneth Gergen, for example, have had significant impact on thinking about communities and how health services should be delivered to these groups (2009). They believe that overlooking how communities shape their realities through their interaction, perceptions and commitments is a serious omission in the provision of care. Specifically, in terms of public health, this change announces that communities are neither geographic areas nor composites of racial, ethnic or other empirical characteristics. Instead, these groups represent an ongoing construction, whereby various persons begin to adopt a range of positions, including views of health and illness, which provides them with an identity (Brown, 1995). And how persons recognize and respond to health threats, for example, depends on how they engage their worlds (Kleinman, 1986). This conclusion, however, does not necessarily subvert the discovery of knowledge, but changes the usual character of data. To acquire reliable information, researchers must now enter the interpretive world of a community and begin to appreciate the information pool that has been constructed and shapes the decision-making of persons. Within this framework of constructionism, persons do not evaluate and respond to objective facts but their perceptions of behavior or events. In the end, communities are somewhat elusive. Standard social indicator analysis may be able to specify, for example, the likelihood that children in a specific locale have been vaccinated against particular diseases. And such knowledge may be helpful when deciding to initiate a health campaign, but how persons understand this issue or might respond to any interventions is not necessarily an empirical question. This insight is revealed only in the biography of a community and the accumulated definitions and personal or collective recipes for dealing with illness. The New Public Health The aim of the new public health is to avoid reductionism and take the dynamics of communities into account. For this reason an ecological strategy is adopted, sometimes known as ‘eco-epidemiology’ (Kellehear and Sallnow, 2012). The general idea is that parsimony in model building may lead to clarity, but may also be misleading. Within an ecological framework persons are understood to be part of a seamless web of influences, including physiology, culture and the economy. Engel’s (1977) call for a biopsychosocial agenda is representative of this trend. The isolation of empirical risk factors, simply put, is no longer the guiding principle in any assessment of need or remediation. Explanations of behavior, accordingly, are expected to be holistic (Kelly, 2006). The point is to extend any investigation in at least two directions. At the individual level, persons are presumed to have agency and a life course (Elder, 1985). Accumulative effects are thus elevated in importance with respect to understanding the onset of and resistance to disease. As part of this life course, individual and communities are understood to examine themselves, make decisions on the basis of these determinations and, periodically, reflect on and modify these decisions. Additionally, persons are imagined to exist in an environment or context. Accurately describing disease onset, therefore, requires the introduction of a confluence of factors (Dakubo, 2011). A web or system of pathology is assumed to be operating. Causal imagery, in this sense, is thought to be overly simplistic, since a myriad of interactions are occurring at any time at different levels. Multiple descriptions and parallel interventions, accordingly, are required that are encompassing but textured and situationally or contextually sensitive (Tulchinsky and Varavikova, 2010). This attempt to add breadth to epidemiological analyses has been both welcome and productive. For example, the introduction of a sociological dimension that has an effect on explaining both health disparities and promotion has been very illuminating (Becker 1993; Phelan et al., 2010). The importance of a community’s history, among both academics and practitioners, is recognized nowadays with little fanfare. Indeed, variables related to life in the family and the workplace are included in most explanations of disease. Recognizing the importance of situational factors seems to make sense to almost everyone. There is little doubt that dynamism is introduced into the epidemiological descriptions generated by the new public health. Subsequent to the passage of the Community Mental Health Act of 1963, for example, the community was expected to be the focus of attention (Vega and Murphy 1990). Any illness should thus be described as the result of many factors and not merely faulty individual adjustment. In this sense, the point is to situate properly any problem in a community setting. Psychological and social-psychological factors, along with a multi-disciplinary orientation, were elevated in importance. But often the result of this strategy is that explanatory models are simply flooded by additional information (Kelly, 2006). More social indicators are often introduced to provide a comprehensive picture of a patient or community. Reductionism is thought to be avoided by this process. Nonetheless, neither individuals nor communities were necessarily better understood as a result of the increase in data. The point is that simply consulting communities, and amassing empirical data, does not necessarily result in grasping their biographies, or how they construct their lives. As part of the Community Mental Health Act, needs assessments were mandatory. A community mental health canter could not be established without data about the community in question. The problem, however, is that most of the methods adopted were ‘quick and dirty’ (Warheit et al., 1977). In other words, data were derived mostly from the US government or local area surveys, or agencies that were collecting general information about a catchment area. As a result, only very general data were available that described a community in abstract terms. Attempting to enter the ongoing discourse that creates and maintains a community is not usually a part of this agenda. Vital to this critique is the claim that process is not synonymous with biography. Specifically important is that a focus on the ecology of a setting may encourage holism, but biography provides insight into another dimension. Holism, in short, may not advance beyond the recognition of additional empirical traits. As a result, access to a real biography—the embodiment of construction and interpretation—is not a part of discussion and analysis. With regard to the new public health, holism did not lead necessarily to biography but instead to an expanded range of typical variables (Minkler, 1989). Becoming Community Based Key to becoming community based is the recognition that a community is not a place, structural framework or composite of empirical qualities, but a constituted reality (McMillan and Chavis, 1986; McLeroy et al., 2003). And subsequent to this realization, every aspect of social planning changes. Neither process nor social indicator analysis, for example, is sufficient to capture the experience of everyday life in a community. Now biography must be the focus of attention (Murphy, 2012). Fundamental to this change is that communities are thoroughly existential, or established through the ongoing dialogue between various persons. Norms, boundaries and membership are not only fluid, but defined and maintained through commitments (Lune, 2010). A biography of a community, accordingly, charts these definitions and their gradual accumulation and influence. In a word, a biography represents a confluence of perspectives and their arrangement in importance. While recognizing the work of Anderson (1991), such a biography reveals the self-image of a community. Key to understanding properly biography is that persons never construct their respective narratives alone (Gadamer, 1996). Persons interpret themselves and are interpreted by others. The result is a matrix of influences. Hence no personal biography is ever simple. A community’s biography, likewise, is seldom homogenous, but instead contains multiple perspectives and several plots. In this regard, the community is a fiction. Nonetheless, local knowledge is not necessarily convoluted and impossible to comprehend. Still, the flexibility must be present to integrate what may, at first, appear to be irreconcilable logics and themes. A community’s biography may be complex but is available to those who recognize the influence of these narratives. As is suggested, gaining insight into this biography requires a lot more than a periodic consultation with a community. Most important, instead, is that the effort be made to appreciate how behavior, events and even the environment, for example, are constituted and perceived by local persons. Acquiring this type of information, however, requires intense collaboration between the members of a community and social planners. For this reason, in community-based research persons are not merely studied as subjects or cases but participate actively in every phase of a project (Rifkin, 2009; Minkler and Wallerstein, 2011). After all, those who construct a community have privileged access to this reality. Given the emphasis placed on biography, for example, community health committees have become important lately when conducting needs assessments in community-based health care (Newman et al., 2011). These committees are composed of local persons who are considered to be ‘organic’ to a community. That is, they know the history, norms and how behavior and events are constructed. These persons, accordingly, can identify relevant data and their socially relevant use, so that interventions are attuned to a community’s definitions of health and proper care. Another example of this trend is provided by the use of local ‘care managers’ to help deal with chronic conditions (Ciccone, et. al., 2010). Similar to the ‘accompaniment’ movement in Haiti, sponsored by Partners in Health to treat HIV patients, the point is to have providers available who know local conditions and thus can support and encourage persons to adhere closely to their treatment plans (Farmer et. al., 2001). Through this intimate interaction, patients are empowered and services are sustainable. The aim of this involvement is to have the identification of problems, instrument development and data collection, for example, informed by the concepts and judgments used by community members to organize their daily existence. Data on health status, accordingly, are quite superficial if divorced from past experiences, perceived capabilities and future expectations (Conrad and Barker, 2010). Likewise, the prospect of pursuing treatment is not merely a matter of having information about disease onset or progression, or sufficient resources, but also relates to how symptoms and interventions are locally constituted and interpreted (Anderson, 1995). A biography, in this regard, includes an interpretive dimension that goes beyond holism. Indeed, process is not simply a natural progression or connection between events, but includes definitions, value judgments and willingness to act. How the onset of a disease is likely to occur, includes these and other existential considerations. This mediation is what community-based planners have in mind when they declare that the course of a disease depends on the character of a community (Kretzman and McKnight, 1993; Kretzman and McKnight, 1996). Barriers to health are thus not simply natural, such as a lack of resources, but reflect judgments about seriousness, probable impact and successful cure. Similarly, how the members of a community might respond to a health threat is not revealed merely by surveying a social setting and identifying its structural features. Table 1. Key features of different approaches to public health Focus of attention . Standard public health . New public health . Community-based public health . Knowledge Objective Contextual Constituted Project management Professional control Communities consulted Local control Communities Social objective indicators Holistic ecology Experiential Analysis Causal Ecological Biographical Focus of attention . Standard public health . New public health . Community-based public health . Knowledge Objective Contextual Constituted Project management Professional control Communities consulted Local control Communities Social objective indicators Holistic ecology Experiential Analysis Causal Ecological Biographical Table 1. Key features of different approaches to public health Focus of attention . Standard public health . New public health . Community-based public health . Knowledge Objective Contextual Constituted Project management Professional control Communities consulted Local control Communities Social objective indicators Holistic ecology Experiential Analysis Causal Ecological Biographical Focus of attention . Standard public health . New public health . Community-based public health . Knowledge Objective Contextual Constituted Project management Professional control Communities consulted Local control Communities Social objective indicators Holistic ecology Experiential Analysis Causal Ecological Biographical What has been created by the new public health is an awareness of how disease causation and prevention are influenced by contextual factors. The community, in this sense, is treated as a vital component in the planning process. Extending this point further, however, a community-based epidemiology approaches a community as a constructed reality rather than a source of additional input. The thrust of this shift is to confirm that the interpretive significance of any determination of a social behavior, such as health or illness, is taken into account. Most important, this realization requires that community members participate fully in planning and evaluating programs, thereby ensuring that interventions are locally relevant and sustainable. A comparison of these approaches can be found in Table 1. Fostering Community Participation Recognizing the need for this experiential-based knowledge, however, represents only half of the issue. The other side is that the conditions must be created whereby community members can participate directly and meaningfully in the planning process. Inclusion, in short, may be necessary but insufficient to secure this knowledge. Hence planning must be democratized to the extent that barriers to the adoption of novel knowledge and other insights are eliminated. For example, reflecting on and overcoming current beliefs held by professionals about the sources of valid knowledge or the skills of patients must be encouraged and fostered (Fairclough, 1992; Waitzkin, 1993). In this way, questions about health care and other issues can be addressed in a manner consistent with a community’s biography, which may or may not be aligned closely with dominant paradigms in public health. Often professionals may have difficult time dealing with this issue. These specialists, after all, are expected to have unique knowledge that gives them the right to survey situations accurately and fix problems. Community members, on the other hand, do not have this training and are thought to lack the insight required to solve health problems. Nonetheless, within the framework of community-based health care local persons, such as lay community health workers, are treated as having valid insights and pertinent knowledge (South et al., 2013). There is a movement nowadays to allow patients to consult their medical records and, if necessary, make changes (Leveille et al. 2012). At first, many physicians were skeptical of this change. After a trial period, however, many errors were found and physicians began to soften their original stance. In a similar vein, lay community health workers have been trained to undertake many tasks, even those thought initially to be very complex (Rosenthal et al., 2010). But in these and other examples, many biases had to be debunked and support provided, so that those not trained in medicine could gain the confidence required to have real input into these activities. The point is that acknowledging the existence of various knowledge bases may not be sufficient to ensure their inclusion in the planning process. The culture of planning must be democratized, so that a wide range of information can be given serious attention (Mannheim, 1971). If biases exist, for example, pertaining to who is likely to offer sound insight into a problem, planning is unduly truncated. Neither health committees nor lay health promoters will be taken seriously if this issue is not addressed. A community-based approach, accordingly, must deal with issues that prevent the introduction of novel knowledge or communal narratives into a project. In this way, the constituted reality that is operative can begin to inform every aspect of planning. Conclusion The new public health adds to understanding health and illness by envisioning the community to be the focus of any assessment or intervention (MacKian et al., 2003). A community-based approach, additionally, views the community to be a socially constructed reality. Having the persons who created this reality guide an investigation, accordingly, is an important additive. After all, operating according to the knowledge bases of those persons who know this situation best certainly increases the validity of any proposal. In the end, however, the new public health is not solely about improving health care. There is another facet that community psychologists have been championing for some time (Rappaport, 1981). That is, community participation in health care also empowers communities. When local persons participate in a significant manner in planning, evaluating and executing services, they begin to gain control of their lives. In other words, they acquire skills that enables them to improve their communities. Additionally, they begin to participate meaningfully in the operation of a significant institution, thereby illustrating their right to control these organizations. But in reality, local persons are not empowered by these processes. In a true community-based initiative empowerment is not viewed in this manner (Murphy, 2014). In fact, this term is often eschewed because communities have always had these skills and desires. The problem is that these persons were overlooked, and often manipulated, and thus their abilities were obscured. What a community-based strategy does, in this regard, is encourage these abilities to flourish. 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Public Health Ethics – Oxford University Press
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