By listening to and hearing the voices of the people we serve, public health researchers and practitioners can better understand the social issues that most significantly affect their lives and their health.
For example, one of us R. Figure 24—1 depicts the contrasts between the broad set of concerns voiced by community residents and the narrow focus taken by typical programs for prevention of infant mortality. The erosion of dignity, of self-worth, and of a useful role in society have led many people to believe that their lives and their communities will never p.
This lack of hope can also be seen when some people in groups in the community believe that other people or groups are beyond being helped. The loss of hope can be threatening to the survival of a sense of morality and community among African Americans. Paulo Freire, a Brazilian educator and philosopher, described the dehumanization that occurs as a result of oppression and social injustice and the impact of this dehumanization on self-esteem:.
Self-deprecation is another characteristic of the oppressed, which derives from their internalization of the opinion the oppressors hold of them. So often do they hear that they are good for nothing, know nothing and are incapable of learning anything—that they are sick, lazy, unproductive—that in the end they become convinced of their own unfitness. According to Paulo Freire, the first step in surmounting oppression is critically recognizing its causes.
In doing so, the oppressed can begin to see themselves and their humanity more fully. Public health strategies to restore dignity, self-respect, and regard for others are needed to repair the damage caused by societal oppression. Only when individuals see themselves as fully human can they act to end their oppression. Communities are built on strengths and assets—not on problems.
Public health workers are not the default source of information and advice regarding health in most communities. Local opinion leaders, trusted community members, and natural helpers tend to serve in this role. In African American communities, institutions parallel to those of the wider society have served as bases of belonging, self-esteem, leadership development, and social activism. These parallel institutions have facilitated the survival of African Americans, led the civil rights movement, and nurtured individual and community capacity.
Lay health advisor programs build on the strengths of African American churches and natural helpers to reduce health disparities. Addressing health problems through local institutions, networks, and community groups is an important strategy to help people to live healthy lives in their communities. Government public health agencies, as the backbone of the public health system, are clearly in need of support and resources, but they cannot work alone.
They must build and maintain partnerships with other organizations and sectors of society, working closely with communities and community based organizations, the health care delivery system, academia, business, and the media.
Although formal public health institutions are in need of resources and support, community-based institutions they partner with may have even greater needs. As public health professionals work with community-based institutions, they must bring resources from the wider public health system to build the capacity of these institutions.
Needs for capacity-building may include the development of basic technical skills, such as in budgeting and proposal writing, leadership, and financial and human resources. Strengthening local institutions, networks, and community groups makes it more likely that work to address health disparities will be sustainable. An important outcome of past community building has been the development of individuals who return to serve their communities after gaining additional training and education.
Social networks influence the health of individuals in many ways. Social networks may provide redundant types of social support with less access to the goods and services of society if the members of the network are relatively homogeneous in terms of education, occupation, and social class.
Rather, we encourage strategies that build networks of support for community and societal change and for greater access to the goods and services of society. Involving professionals from outside the churches helped create connections between the churches and these professionals. The connections were mutually beneficial.
Church networks developed larger pools of resources for assistance on important community issues and the network of service providers, including county health departments and nonprofit organizations, such as the American Heart Association and the American Red Cross.
As a result, they had greater access to the populations that they were seeking to serve. In order to effectively address health disparities, we need to use both ameliorative and fundamental approaches to public health practice. We need to use both of these approaches at the individual, community, and societal levels.
It should not be assumed that societal-level approaches will necessarily be addressing root causes. By maintaining a long-term vision while addressing immediate needs, public health workers and communities can contribute to reducing the social injustices that contribute to poor health. Communities may be better able to advocate and demand change when local public health work strengthens community leadership, expands social networks, and fosters community problem-solving. One of us J.
Small successes nurtured the belief that change was possible through collective action. Many who doubted the possibility of positive change began to attend meetings related to the health council and the farm cooperative. For many, this was a political awakening. People involved with these organizations were recruited by civil rights groups, such as Delta Ministry and the Mississippi Democratic Freedom Party, to lead voter-registration campaigns.
Organizing strategies used to educate, recruit, and involve people in the farm cooperative enabled organizers to develop skills similar to those required for political action. William Julius Wilson, a noted Harvard sociologist, contends that the political muscle needed to address some of the social problems facing the United States cannot be achieved without a broad-based, multiracial coalition—one that focuses on issues that are important to most Americans and emphasizes their interdependence.
Many economic forces that have disproportionately affected African Americans have arisen from global economic forces that are non-racial in origin.
Nearly half of recent job losses among less-educated blacks have resulted from the loss of manufacturing jobs. The importance of building bridges among citizens of the United States and those of other nations is particularly relevant for environmental issues and trade agreements.
Free-trade and investment agreements have undermined public health by increasing social inequalities, depleting natural resources, and increasing environmental pollution.
Partnerships among tobacco-control organizations in various countries have helped groups to frame tobacco issues in an international context and provide information, advice, and resources across borders. In addition, examples of egregious behavior by tobacco companies in other countries can be used sometimes to address their behavior in the United States.
See Box 21—3 in Chapter Community-based strategies to address public health problems are most effective when the population is mobilized and engaged in the identification of problems and the development of solutions. Developing broad-based coalitions of existing community-based organizations, agencies, associations, and concerned citizens can be a powerful way to mobilize and engage communities. See Box 24—1 , which addresses strengthening communities in low-income countries.
Box 24—1 Strengthening Communities in Developing Countries. Community capacity enables a community to reflect on its strengths and needs in order to improve its well-being and that of its residents. Strengthening community capacity can lead to better outcomes in health and social change. Participation in health and development programs can strengthen the voice of ordinary citizens and ensure their involvement in decisions that affect their lives and the life of their communities.
Participation of community members also increases the impact of health and development programs and can lead to long-term sustainability. In response, individuals and groups who are actively involved become committed to—and feel increasingly capable of—improving their health and living conditions.
The Community Action Cycle 2 CAC is a common method for strengthening community capacity and mobilizing communities towards collective action. Use of the CAC fosters a community-led process through which those people most affected by a problem organize, explore, set priorities, plan, and act collectively for improved health and development outcomes. Participation should engage people in the decisions that affect their lives and promote self-reliance. In the context of health and development programs, self-reliance means creating and strengthening appropriate forms of interdependence among communities and governments, service providers, or other external agents.
There is a continuum of levels of participation and self-reliance. Attending a meeting without expressing opinions, for example, can be an important first step—especially for those without experience in having their voices heard. Later, these people can become more actively involved. In some cases, involving those who are most marginalized is not possible at the start of a project; their involvement may require additional work to enable them to believe that they are capable of participating.
A step-by-step approach to participation may be more appropriate for individuals and groups who have been reluctant to participate in development programs or who mistrust external interventions. The following examples represent the application of these principles in projects sponsored by Save the Children, a nonprofit organization that works to strengthen p. In Ethiopia, a network of care and support for , orphans and vulnerable children was established by linking and building the capacity of six international organizations, 36 in-country non-governmental organizations, and community-based organizations.
Community-based groups were strengthened to explore the issues affecting vulnerable children; to plan and act together to access, demand, and deliver services; and to mobilize and manage financial and human resources. Community leaders receive training and support to facilitate dialogue within peer groups that enables participants to better understand why mothers and infants have been dying during childbirth, and to address local barriers by planning and acting together.
By strengthening community capacity, communities a learn how to apply political pressure to improve the quality of services, b generate and contribute additional resources not previously available to the health system, c facilitate changes in social strategies, structures, and norms to increase access to information and services for those who need them most, and d strengthen their ability to claim their right to respectful treatment.
The following measures for strengthening community capacity may also increase participation:. Involving those directly affected in health and development communication programs. Howard-Grabman L, Snetro G. How to mobilize communities for health and social change: A health communication partnership field guide.
Grey-Felder D, Dean J. Communication for social change: A position paper and conference report. New York: Rockefeller Foundation Report, Minkler M. Community organizing and community building for health.
Evaluating community capacity. Health Soc Care Community ; — Democracy in the United States is threatened by corporations and wealthy people who purchase access to government officials, especially since the Citizens United decision by the Supreme Court. As public health professionals working with disenfranchised communities to address health disparities, we need to use participatory strategies that maximize the potential for individual and community learning, empowerment, citizen engagement, and mobilization.
Lessons learned and power gained through such strategies—multiplied across communities—can help to strengthen democracy and address social injustices. Geni Eng, a professor of health behavior at the University of North Carolina, and her colleagues have found that communities with higher rates of participation in addressing health issues are more likely to address other community issues. This may mean that we become involved in issues not typically seen as part of public health.
The public health system does not always need to be the lead in local work to improve community health. Together, transdisciplinary groups representing environmental health, community planning, economic development, housing, transportation, social services, public health, justice, and community health could collaboratively address issues associated with low-income neighborhoods. Built-environment features that emphasize physical activity, such as parks and sidewalks, also strengthen community life by making social connections easier.
Parks provide contact with other people and with nature—features of our environment that promote health. Greater emphasis should be placed on participatory research strategies, such as community-based participatory research CBPR , that engage communities in the process of defining research priorities and developing research strategies. Funding for public health programs, likewise, should emphasize comprehensive and community-building strategies to improve the context in which people live. Changing behavior without changing the context in which it occurs is not likely to be sustainable.
State and national funding agencies should consider requiring research staff members and project personnel to complete an orientation to ethics of community-based research and practice—similar to the online training required for research involving human subjects.
The production of social injustice and health disparities is global. Addressing social injustice and health disparities therefore requires global coordination on such issues as environmental degradation, greenhouse gas emissions, biodiversity loss, water shortages, fishery declines, poverty, financial instability, taxation, food insecurity, trade in health-damaging products, and armed conflict—as well as governance.
For example, policies of the World p. As public health workers, we often do not live in the communities where we work. Therefore, our understandings of these communities are likely to be tinted by our own cultural lenses. Furthermore, if organizing efforts go awry, we can leave these communities and escape many of the physical and social consequences of our actions. Therefore, it is critical for us to:. Working with poor communities to eliminate social injustice requires that we, as public health workers, think reflectively about our own views of the community, our own privileges, and our own comfort level with different roles in promoting health.
Such reflection is critical when organizing or working with communities that are different than our own. Without intending to do so, we may demonstrate personally-mediated racism. Communities have a vital life force and ways of doing things that may not be apparent to us as outsiders. It takes concentrated and sustained listening over time to discover how things work in communities and the ways in which communities get things done. Given our education and training, we might not challenge our own views of what the community has to offer and might believe that our way of doing things is more informed and more effective.
All of these actions devalue what community members might be able to do. As public health workers with professional training, we have a different relationship with power than do members of the poor communities with whom we work. Examining our relationships with power will help us avoid unintentionally holding the status quo in place. We must develop an ability and comfort to work with community partners to conduct a structural analysis of the conditions that enable disparities to persist.
Powerful persons and institutions with which we p. But, without this analysis, we may not see the ways in which we have privileges not held by the community members with whom we work.
If we lack self-knowledge, our ability to work in partnership with the communities will be hampered. Because using community and social transformation for eliminating health disparities involves upsetting and changing routinized patterns of power, it is usually accompanied by conflict. Root causes of health disparities, such as income and wealth inequalities, racism, and sexism, persist because of powerful interests, which must lose some power if meaningful change is to occur.
As health workers and organizers, we face several dilemmas. Organizing is often dangerous, leading to backlash, exploitation, and oppression.
Historically, in the civil rights movement, local leaders sometimes were beaten, jailed, or forced to leave after outside organizers moved on. At other times, local leaders and organizers were killed. There are differing views about how the dangers in organizing should be addressed.
One approach would be to temper social activism by having the community decide how far to take confrontation-based tactics—because the community is often left to address the fallout from these tactics.
Building on an analysis of the root causes of injustice and of the powers that sustain it can enable us to enter situations with our eyes open and to anticipate potential backlash.
Not everyone is comfortable with this type of work. To grow as people and public health workers, we need to better understand ourselves and our work. Sometimes, we will recognize that we do not have the capacity for this work, or that, because of other circumstances, we must choose to work more indirectly with communities. In these roles, we still can choose to be supportive allies with communities and health workers. As examples, we can support community businesses, associations, and cultural activities; we can speak up for the rights and perspectives of communities in the organizations in which we work; and we can refuse to support or approve of organizations or individuals who undermine these communities.
Health disparities suffered by poor and minority populations are socially produced. They result largely from current and historical social injustice.
Addressing these disparities requires approaches that are both ameliorative and fundamental, addressing both current problems and root causes.
Comprehensive approaches are needed that work across the wide domain of social ecology—individuals, families, communities, organizations, institutions, and the broader society. Communities possess strengths and assets that can be used to address the health problems that they face. Communities can be strengthened in their capacity to address their current health problems and the root causes of these problems. Public health research studies and interventions in communities should be designed and implemented in ways that build community capacity and the skills p.
Engaged and critically conscious people are needed to sustain work for social change. Public health workers need new skill sets and intervention strategies to assist communities in meeting the challenges they face.
Our understanding of the effects of contexts on health must include insight into how health problems are experienced by people living within these contexts. From social integration to health: Durkheim in the new millennium. Soc Sci Med ; — Find this resource:. Coleman J. Social capital in the creation of human capital. Am J Sociol ; S95—S Putnam R. The strange disappearance of civic America.
Am Prospect ; 34— Social capital, income inequality, and mortality. Am J Public Health ; — Neighborhoods and violent crime: A multilevel study of collective efficacy. Science ; — Macinko J, Starfield B. The utility of social capital in research on health determinants. Milbank Q ; — Lynch J. Income inequality and health: Expanding the debate. Muntaner C, Lynch JW. Int J Health Serv ; 59— Kreuter M, Lezin N.
Social capital theory. Emerging theories in health promotion practice and research. San Francisco: Jossey-Bass, McLeroy K. Community capacity: What is it? How do we measure it? What is the role of the prevention centers and CDC? With contributions from leading experts in public health, medicine, health, social sciences, and other fields, this integrated book documents the adverse effects of social injustice on health and makes recommendations on what needs to be done to reduce social injustice and thereby improve the public's health.
It is the definitive resource for anyone seeking to better understand the social determinants of health and how to address them to reduce social injustice and improve the public's health. Post a Comment. Sidel Published on by Oxford University Press This second edition of Social Injustice and Public Health is a comprehensive, up-to-date, evidence-based resource on the relationship of social injustice to many aspects of public health.
This Book was ranked at 5 by Google Books for keyword Health. Labels: Medical.
0コメント