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The role of the social and physical environment
- the social and physical environment can
- serve as medium of disease transmission
- operate as a stressor
- function as a source of safety or danger
- serve as an enabler of health behavior
- serve as a provider of health resources
Working definition for HPEB 824
The social and physical environment can serve as a medium of disease transmission or a medium of diffusion of health promotion innovations; operate as a stressor or as a stress buffer; function as a source of safety or danger; serve as an enabler of health behavior or as an impediment to healthy behavior; and serve as a provider or health resources or as a barrier to health resources.
Working definition#2 for HPEB 824
"Structural interventions" (another name for social and/or physical environment interventions) involve a systematic and/or coordinated effort to influence or change the context in which people live, work, go to school or plat, etc.; can apply to programs, initiatives, innovations, advocacy, policy change, communication/media campaigns; this includes interventions that focus on changing the social and physical environments; and interventions that target factors beyond the control of an individual.
Elements of the Social and Physical Environment that Influence Health
- Blankenship et al. (2000) developed a framework to identify components or elements of "health-promoting environment" based on a comprehensive review of intervention strategies in the literature:
- Availability - includes behaviors, tools, equipment, materials, and settings
- Acceptability - alters social norms and social expectations
- Accessibility - addresses role of social, economic, and political power and resources.
Cohen et al. (2000) - Four Environmental Targets
- Availability/accessibility of consumer products that are associated with health outcomes (positive or negative)
- Physical structures - characteristics of structures or products that inherently reduce or increase opportunities for healthy behaviors and outcomes.
- Social structures - laws or policies that require or prohibit behaviors
- Cultural and media messages - messages that people see and hear frequently though large and small media and through stories and cultural practices
Change according to Cohen et a. (2000)
- Change is created through:
- Increasing/decreasing availability of protective/harmful products, services, and physical structures through influence social structures (such as policies, regulations, or laws)
- Increasing/decreasing accessibility of products, services, and physical structures through influencing social structures (such as social, economic, and political processes; access to resources)
- Increasing/decreasing acceptability of products, services, and physical structures through improving their characteristics (such as improving features of the physical environment, ensuring foods are appealing, culturally acceptable, etc).
- Increasing/decreasing acceptability of products, services, and physical structures though influencing cultural and media messages (such a social norms)
Benefits of Soc/Phys Env Interventions
- Environmental interventions have the potential for maximum public health benefits through:
- Changing the population behavior (versus individuals)
- Durability (versus short-term, time-limited gains; think sustainability, lasting change)
- Feasibility (versus reaching all individuals through cognitive-based strategies)
What Constitutes a Healthy Environment?
- Opportunity Structures
- Physical features of the environment shared by all residents in a locality
- Availability of healthy environments at home, work, and play
- Services provided, publicly or privately to support people in their daily lives
- Collective Social Functioning and Practices
- Socio-cultural features of a neighborhood
- The reputation of a neighborhood
McIntyre S, Ellaway A, Cummins S 2002
Three Types of Explanations for Geographical Variations in Health (Macintyre et al. 2002)
- Compositional - Characteristics of individuals concentrated in particular places
- Contextual - Opportunity structures in the local physical and social environment
- Collective - Socio-cultural and historical features of communities
Input vs. Output (Macintyre et al. 2002)
The number of places of worship locally as an environmental input because people may or may not choose to use this resource, whereas measures of religious participation reflect an output of the activities of local residents.
Public Health Impact Pyramid (Frieden, 2010)
Public Health Impact Pyramid Levels (Frieden, 2010)
- Socioeconomic Factors: social determinants of health, that help form the basic foundation of a society.
- Changing the Context to Make Ind.'s Default Decision Healthy: make healthy options the default choice, regardless of education, income, service provision, or other societal factors. The defining characteristic of this tier of intervention is that individuals would have to expend significant effort not to benefit from them.
- Long-Lasting Protective Interventions: Do not require ongoing clinical care; these generally have less impact than interventions represented by the bottom 2 tiers because they necessitate reaching people as individuals rather than collectively (e.g. immunizations)
- Clinical Interventions: ongoing clinical interventions, of which interventions to prevent cardiovascular disease have the greatest potential health impact. Although evidence-based clinical care can reduce disability and prolong life, the aggregate impact of these interventions is limited by lack of access, erratic and unpredictable adherence, and imperfect effectiveness.
- Counseling and Education: health education (education provided during clinical encounters as well as education in other settings), which is perceived by some as the essence of public health action but is generally the least effective type of intervention.
Linking the social environment to health (Anderson et al. 2003)
- To id the starting point of the research problem and to establish the vision to which the problem is directed.
- Determines and defines the focus and goal of the research problem.
- To test theories
- To make research findings meaningful and generalizable
- To establish orderly connections between observations and facts
- To predict and control situations
- To stimulate research
- Integrate the state-of the science about a particular public health issue/problem and relevant theoretical underpinnings to present the conceptualization of proposed research
- Depicted visually (diagram/figures)
- concepts are placed within a logical/sequential design
- Represents less formal structure
- used for studies in which existing theoretical models are insufficient or incomplete
- Based on specific concepts and propositions derived from empirical observations and intuition
- May (most often does) include representations of theory (theoretical underpinnings)
- Can provide a guide for intervention components
- Can provide a guide for measurement
- Can aid in interpretation of results and inform future directions
- Co-creating knowledge
- Shared power and resources
- Capacity Building focus
- Implementation/dissemination science
- How to understand, define, and measure
- Interdisciplinary - scholars speak different languages
- Implementation can be challenging
- Measurement challenges
- Ethics: Assignment to condition, sampling, time frame, stakeholder involvement, multilevel analysis (aggregate level changes vs. ind.)
Six Core Challenges Addressed by CBPR
- External Validity: Engages
- community stakeholders in adaptation within complex systems of organizational
- and cultural context and knowledge
- Evidence (the privileging of academic knowledge): Creates space for postcolonial and hybrid knowledge, including culturally supported interventions, indigenous theories, and community advocacy
- Language (incompatible discourse between academia and community): Broadens discourse to include ‘‘life world’’ cultural and social meanings
- "Business as usual within universities": Shifts power through bidirectional learning, shared resources, collective decision making, and outcomes beneficial to the community
- Sustainability: Sustains programs though integration with existing programs, local ownership, and capacity development
- Lack of Trust: Uses formal agreements and sustains long-term relationships to equalize partnership and promote mutual benefit
Social and Physical Environment Measurement Challenges
- Uses formal agreements and sustains long-term relationships to equalize partnership and promote mutual benefit and Context
- Secular Changes
- Synergies (e.g. Interaction with settings in which intervention(s) is completed)
- Timeframs/Appropriate time intervals
- Condition and assignment to condition
- Sampling/Participant "unit"
- Random allocation
- Multi-level analysis (e.g. aggregate-level changes v. individual level changes)
- Multi-sector focus/stakeholder investment
Environmental Conditions (Commers, 2007)
- Environmental conditions: A state of the environment (more specific than just the environment, similar to the difference between a weather condition and weather in general).
- Environmental conditions are linked to health through four pathways:
- Unmediated environmental influence via health-related behavior, in which a condition affects behavior largely without our awareness (food availability and diet)
- Perception-related mediated influence via health-related behavior, in which our awareness of some condition, such as social norms, may cause us to assume certain health-related behaviors, such as taking up or quitting smoking,
- Direct perception-mediated environmental influence, in which awareness of a condition has a direct impact on our health, and
- Direct environmental influence, such as a gas leak.