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Community directed interventions


A community directed intervention takes place, when the community takes an active part in distributing health commodities. NGOs or government agencies only have a facilitating role (e.g. supplying medicine and other health commodities as well as providing health education and other forms of outside support). A successful example for a CDI approach is the Onchocerciasis control program which was introduced in lecture week four. Further research into the efficiency of the CDI approach has revealed, that this approach can be successfuly applied in other areas (even outside of the health realm) as well (e.g. water sanitation, immunization, bednet distribution etc.)

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Coursera.org. Prof. Brieger blogs under www.malariamatters.org and can be found on twitter as @bbbrieger.

Case study: Onchocerciasis treatment


Two of the three lectures of the fourth week reflect on various attempts to combat Onchocerciasis – the so-called river blindness (see explanations below). This parasitic disease can be treated with the drug Ivermectin, which has to be applied long-term (for about 15 years) to be effective. This means, that any really successful treatment programme has to be sustained for 15 years (with one dose of the drug given per year and person) even in remote villages in sub-Saharan Africa. Against the background of this problem, Prof. Brieger examines the differences between a community-based and a community-directed treatment programme.

Community-based programmes: A community-based health programme follows the social policy planning approach discussed during the second week of this course. An outside NGO (such as the APOC – the African Programme for Onchocerciasis Control) basically plans the intervention from the outside and then comes into the community to carry it out. The members of the community are therefore simply recipients of an outside service, but have no “ownership” of the programme. This reduces the commitment to and the interest in the programme and therefore its effectiveness. It is also noteworthy, that outside health workers are usually under some pressure to present positive statistics to their superiors and are thus inclined to “push” measures on community members.

Community-directed programmes: A community-directed programme is initiated from outside the community by a NGO or government organization, but is then – sooner or later – gradually passed over to the community itself. Such community ownership means e.g. that the members of the respective community can decide among themselves, which community members shall receive health worker training by the NGO, who shall be responsible for the distribution of the drugs and when and how the drugs shall be passed out to the community members. The outside agency is simply acting as a facilitator to this process, providing the drugs itself as well as advice and outside resources needed for a successful project. Such community ownership practically guarantees that local issues and sensitivities are respected and that the programme is better accepted. Additionally, running a community-directed programme builds up skills and organizational structures within the community, that can prove to be very useful for future health- and non-health-related projects.

About Onchocerciasis / river blindness

The lectures of the fourth week center around efforts to combat Oncochericiasis in sub-Saharan Africa. Oncochericiasis – or river blindness – is a severe parasitic disease caused by a roundworm (Onchocerca volvulus). This specific parasites spreads to humans via the bite of the black fly and can cause severe infection in the eyes, leading – at least in some cases – to permanent blindness. The WHO estimates that about 18 million people worldwide are currently suffering from river blindness – with about 270.000 cases of actual permanent blindness caused by the disease:

http://www.who.int/water_sanitation_health/diseases/oncho/en/

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Coursera.org. Prof. Brieger blogs under www.malariamatters.org and can be found on twitter as @bbbrieger.

Community coalitions


While the lectures of the third week were all about different power imbalances within the Political Economy Framework, the fourth week centers around the dynamics of community coalitions, that form out of the need to correct such imbalances. Community coalitions can – for example – be focused on public health issues – such as the so-called Community Partnerships for Health (CPH).

A community coalition is basically a group of people who are combining their skills and resources to achieve a particular, clearly defined goal. As coalitions grow, they increase their visibility within as well as outside their respective communities and may reach a critical mass, attracting more and more supporters as well as help and attention from the outside.

There are three basic types of community coalitions:

(1) Grassroots coalitions: Grassroots coalitions usually form as (political) pressure groups that attempt to address or adjust a specific problem. They are usually just short-term formations.

(2) Professional coalitions: A professional coalition is a volunteer organization of professionals (e.g. physicians, nurses, engineers) that combine their know-how and influence. Professional coalitions are usually meant to last long-term.

(3) Community-based coalitions: In a community-based coalition, elements of grassroots and professional coalitions are combined in order to form an effective, long-term alliance.

Whether a coalition is successful, depends on a number of factors:

  • Successful communities need to have a clear set of realistic, reachable goals (motivation)
  • Successful communities depend on a clearly communicated set of rules and good leadership
  • Newly founded communities need some quick (low-level) successes which hold them together
  • Diversity makes communities effective – e.g. bringing together people with different resources, influence, skills, inside and outside contacts etc. for a combined effort
These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Coursera.org. Prof. Brieger blogs under www.malariamatters.org and can be found on twitter as @bbbrieger.

Levels of community involvement


Prof. Brieger differentiates between five levels of community involvement in (health) programs:

(1) Acceptance: Acceptance merely means passive cooperation, such as the use of health services provided by an outside agency. This level of involvement includes no active participation on the side of community members (e.g. putting up a mosquito net offered for free by an NGO).

(2) Mobilization: At the mobilization stage, the program is still run from the outside, but valuable input and ideas are provided by community members (e.g. obstacles with mosquito net use are actively discussed with the outside agency).

(3) Participation: Participation implies, that community members carry out parts of the program themselves and voluntarily contribute to it (e.g. community members with authority make the public case for mosquito net usage and see that nets are distributed within the community).

(4) Involvement/planing: At this stage, the program is not longer run completely from the outside. Community members plan and evaluate measures themselves, the community is given a high level of autonomy (e.g. a community health center is up that actively promotes distributes mosquito nets and has people regularly going from door to door to see if the nets are actually being used).

(5) Control/ownership: At this stage, the program is not longer run from the outside but is in total control of the community. Community members decide not only on the goals, which they are trying to reach, but also on the methods by which these goals should be accomplished. Outside agencies at this point only provided needed resources and outside contacts (e.g. a mosquito net program that is completely run within the community, whith local businesses buying and selling the nets with some help by outside agencies and local health centers advocating and controlling net usage).

When success and failure of a program are not seen as the success and failure of the outside NGO or agency by the community, but as success and failure of the community itself, an optimal level of involvement has been reached. Reaching that goal requires outside agencies to give up control over the program and accept local decisions, even if they are based on beliefs and customs that might not be shared by the respective agency.

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Coursera.org. Prof. Brieger blogs under www.malariamatters.org and can be found on twitter as @bbbrieger.

Community participation


Community participation in health projects increases community efficacy and usually leads to not only a better use of local resources but also to a higher acceptance of health measures by the local community members. Participation is – in this context – defined as the active involvement of community members in decision making processes as well as in the implementation of solutions. Higher levels of participation benefit the health of the community in various ways: people are more involved in spreading and implementing health solutions, local resources are put to better use, local needs are considered more aptly (no “one size fits all” solutions) and decisions are generally better accepted.

It is important to note, that even good ideas and valuable programs might not be accepted by a community if they are seen by people as being forced upon the community from outside NGOs or government officials. The better strategy often is to educate community health workers and then turn most of the outreach, implementation and evaluation over to them. This principle has been proven true in many primary health projects over more than three decades, ranging from water filtering (for preventing guinea worm desease) to well construction, child inoculation and use of contraception. An effective community health program can, however, still start out as a typical social policy planing effort (being initiated from the outside) and then be slowly turned over to more and more local control.

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Coursera.org. Prof. Brieger blogs under www.malariamatters.org and can be found on twitter as @bbbrieger.

The Political Economy Framework


Just like the Ecological Model from the first week of this course, the Political Economy Framework is yet another theoretical model for explaining community change processes. It is somewhat similar to the Ecological Model in that it is comprised of (three) layers, starting with the individual person (the intrapersonal layer in the Ecological Model) and ending at the level of national and even international government (the policy layer in the Ecological Model). The Political Economy Framework is comprised of the following three layers:

(1) Individual layer: Individual people and families
(2) Organizational layer: Local and supralocal organizations
(3) Political economy layer: National and international policy level

The model recognizes that communities can be comprised of higher and lower classes with very different access to power and resources. Such classes can be defined, for instance, by gender, wealth, ethnicity, land ownership, religion, family heritage or occupation.

The model differentiates between three different types of power as well:

(1) Situational power: The ability of individual persons to make their own decisions (e.g. regarding healthcare) within the given framework of political power (individual layer).

(2) Organizational power: The ability of local and supralocal organizations to influence the existing power framework in order to achieve their goals (organizational layer).

(3) Systemic / structural power: People who are holding actual structural power are able to shape the political framework and thus define how “the game is played” (political layer).

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Coursera.org. Prof. Brieger blogs under www.malariamatters.org and can be found on twitter as @bbbrieger.

Rothman’s model of community change


The lecture on community change models contained a comparison between the so-called functional view on community change and the so-called conflict view on community change:

Functional view: Communities change, when parts of their systems break down or massive external changes ocurr. These events force changes in social norms and thus changes in the community.

Conflict view: Change in communities is driven by the struggle for power between different interest groups. If new interest groups form or interest groups, who are not currently holding much power, do manage to ascend, they (re)form social norms which, in turn, leads to community change.

The rest of this lecture centered on Rothman’s model of community change. It differentiates between four different ways, in which community changes can take place: Change can either be initiated from the outside (social policy planning, community mobilization) or from within the community (community action, community development) with the necessary resources coming either from the outside (social policy planning, community action) or, again, from within the community (community development, community mobilization).

(1) Social policy planning (outside initiation, outside resources)
(2) Community action (inside initiation, outside resources)
(3) Community development (inside initiation, inside resources)
(4) Community mobilization (outside initiation, inside resources)

Social policy planning

– Outside experts design and implement models for communities
– The implementation is also forced from outside (laws, taxes…)
– Social policy planning often is a reaction to specific problems

Community action

– Members of a community identify power imbalances / missing resources
– Members organize themselves to get access to these outside resources
– Media help is important in getting the message to decision makers
– Any form of community action needs one or more strong leaders

Community development

– Members of a community self-mobilize internal resources to initiate changes
– This change process is completely under the control of the community
– New solutions are often built on indigenous knowledge and traditions

Community mobilization

– Outside experts design solutions but do not implement them from the outside
– Community members are expected to contribute via donations and work
– People are often encouraged to join the effort via social marketing

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Coursera.org. Prof. Brieger blogs under www.malariamatters.org and can be found on twitter as @bbbrieger.
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