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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.
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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.

What is a community?


Different kinds of communities can exist even within the boundaries of one city. But what exactly is a community? Most definitions of this construct include the following attributes:

  • same location (not always, e.g. online communities)
  • same basic values and social norms
  • same interests (e.g. economic or political)
  • a shared sense of belonging and identity

To identify, analyse and “cure” health problems within a community, the community must first be “diagnosed”. Just as a physician has to diagnose various systems within a patient (e.g. respiratory system), we need to look at five different systems within a community to come to a diagnosis:

(1) Social system: Defines basic units (e.g. family) and their roles in the community
(2) Political system: Defines power relations between groups and leadership roles
(3) Cultural system: Defines the basic beliefs, values and norms of the community
(4) Economic system: Defines how resources are distributed and incomes are generated
(5) Geographic system: Defines where resources are located and how available space is used

Community maps and Geographic Information Systems (GIS) today play an important role in community diagnosis. They can help to identify different social groups, find out who has access to which resources and what infrastructure is available. It is preferable to include the communities in the process of map-making to find out how people within the community see things.

Four important characteristics of communities are:

(1) Identity: Identity is defined as a sense of belonging and sharing a common destiny as well as a common set of values and norms. In a community with a strong identity, people tend to trust each other, get along well and are able to work towards common goals.

(2) Integration: A high level of integration is reached through interaction within a community. Such interaction can be observed on self-organized markets or at cultural festivals.

(3) Group orientation: In a community with high group orientation, the needs of the group take preference to the needs of single individuals. A sign for a high group orientation can be a strict system of social control.

(4) Linkages: Linkages are defined as the connections of the community to the outside world through individual or institutional channels. A community which is represented in the national government by representatives out of their own midst is, for example, a well-linked community. Thus, the linkage of the community defines whether they are more or less cut off from the outside world or whether they have the ability to communicate their needs to journalists and politicians.

By analysing these basic characteristics, we can identify six basic community types:

(1) Integral community: An integral community has a strong sense of identity and a high level of integration while also being highly linked to the outside world.

(2) Parochial community: A parochial community has a strong sense of identity and a high level of integration. Links to the outside world are, however, minimal, thus the community is cut off.

(3) Diffuse community: A diffuse community is characterised through a strong sense of identity and belonging as well as a low level of integration. In these communities, which often consist of a strong and homogeneous middle class, outside linkage takes preference to inside integration. As a result, diffuse communities exhibit a low intensity of community life and activities.

(4) Stepping-stone community: Most members of a stepping-stone community are looking to move forward to other communities with a higher socio-economic status. Thus, the identification with the current community is rather weak while outside linkage is high.

(5) Transitory community: A transitory community is a community where a population change is currently under way. Due to the changes within the community, there is usually little community organization and integration. If changes occur too fast, the community might break up into “newcomers” and people who have been living in the community for a longer period of time.

(6) Anomic community: An anomic community is pretty much a failed community. It is weak on all points: identity, integration, group orientation and linkage. Anomic communities are usually not able to mobilize strength for common action without outside intervention.

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 Ecological Model: five levels of change


The Ecological Model provides a framework for identifying reasons for public health problems as well as for planning interventions. The basis of the model is the recognition, that public health problems are rarely caused only by wrong individual behaviour but rather by a combination of factors from five different levels:

(1) Intrapersonal factors – individual level: What do individual people know about public health problems? What do they think about proposed solutions? What benefits and problems do they see?

(2) Interpersonal factors – social network level: Who makes family or household decisions? How much money is availably in households and families and how are spending decisions reached?

(3) Institutional factors – organizational level: Who has real influence in the community? Are there organizations that prevent positive changes or that could help bring about those changes? How do the local marketing and distribution systems work?

(4) Community factors – community level: Is there any institutional support for solutions to public health problems? Have public health problems even been identified as problems for the community by the formal and informal leadership? What roles are played by local businesses, schools, clinics, NGOs and other associations?

(5) Policy factors – national level: What influence do national policies (e.g. laws, tariffs, grants, taxes) have on the public health? Which parties and interests are involved in the policy-making process?

The Ecological Model is not just used to identify problems but also to identify key people, groups and resources that can help bring about positive changes.

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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