Coalition: A coalition is made up of groups and individuals who work together to achieve a goal. A coalition can be a powerful force for positive change in a community.
Health Disparities: Health disparities refer to preventable differences in health conditions and health status among groups.
Health Education: Health education is one health promotion method. Health education presents information to target populations on particular health topics and provides tools to build capacity and support behavior change.
Health Equity: Health equity is achieved when everyone can attain their full health potential and no one is prevented because of their social position.
Health Promotion: Health promotion aims to empower communities to improve their health outcomes not just through focusing on individual behaviors, but also through addressing social and environmental forces. Health promotion accomplishes this through building healthy public policies, creating supportive environments, and strengthening community action and individual skills.
Needs Assessment: A process for identifying top health needs within a defined target population and community.
Primary Data Collection: First hand data gathered by a public health researcher.
Secondary Data Collection: Already existing data gathered and analyzed by a previous researcher.
Setting: Anywhere people actively use and shape the environment. It is also where people create or solve problems relating to health by planning, implementing and evaluating health promotion programs. Examples of settings include schools, work sites, hospitals, cities, and even prisons.
Social Determinants of Health: Social determinants of health are the conditions of daily life and the environment that affect the health and well-being of different groups. They can either support or limit the health of a community or population.
Stakeholders: Stakeholders include all who are affected or have an interest or a “stake” in a program.
Welcome to the beginning of your journey in learning some of the most fundamental skills used in any public health career. In a hypothetical situation, you are training as a local health education specialist, and your supervisor has assigned you to a major project, in which you will do the following:
Compile secondary data to reveal the most pressing health concerns in your community.
Prioritize issues and determine which should be the target of the new program.
Discover which evidence-based practices best fit the needs of your community.
Create a budget allotting the $100,000 that has been given to support this one-year program.
In the road map below, each of the major points along your journey is a major skill in the program planning process. You will learn about and practice each of these skills.
Choose a location: You will have to choose a location for your project.
Where do you live? Do you have health districts? Do you have a ministry of health? You will need to have a specific location in mind for your project that covers a fairly small geographic location, like a city or county.
Planning Models: Over the years, people have created systematic planning models with step-by-step processes to plan, create, and implement a program of this scale.
Needs Assessment, Part 1: Your first step is to identify the health needs within the community. Professionals are required to collect empirical data to show the most important issues; they can not just choose what they think are most important. Each individual’s needs will not be the same, but we can identify more prevalent needs to make significant health improvements for the community. This data can come from both primary and secondary data collection. In this class, you will only use secondary data—that is data that other people have collected already.
Needs Assessment, Part 2: Once the most pressing health issues in your community have been identified, you will need to break each one down into the underlying causes to help you prioritize. Two things need to be determined: how much is each health issue impacting your target population, and how changeable the issue is. Will the health promotion program being made have the capability to make a change on this health issue?
Goals and objectives: Now that you know which health issue you are going to target, it is important to decide which changes need to be made. Setting specific goals and objectives will help you measure if you are successful or not.
Implementation: Implementation is a critical step. Before the program is started, you have to determine how you are going to run it. Who will be in charge of the program? Who will hire, train, and manage the staff? Where will you hold the program? These are critical questions that have to be answered.
Budget: Now you can start the administrative duties, including a budget. You have been given $100,000 to run your program over the course of the year. Where will that money go? Will that be enough? You won’t know until you create a budget showing the personnel, supplies, and equipment that will be needed.
Marketing Four Ps and Segmentation: The next step is to market the program. Advertising is just one part of marketing. It will also include targeting your intended audience and crafting your message to be culturally appropriate.
Evaluation: One of the last steps is to evaluate the program and determine how successful your program has been. During the planning phase, you need to determine how the data will be collected to measure how your goals and objectives will be met.
Conclusion
All of these steps will be broken down so that you will do them one at a time over the next few weeks. No matter which career you eventually choose, these skills will be helpful.
To begin the planning process, we will review the Health Promotion and Health Education professions and where they fit in the history of Public Health. We will also cover how program planners engage other stakeholders in coalitions to address health issues and how they determine health needs.
The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, n.d.-a)
Public health work involves promoting the health of individuals and communities. Health promotion aims to empower communities to improve their health outcomes not just through focusing on individual behaviors, but also through addressing social and environmental forces. Health promotion accomplishes this through building healthy public policies, creating supportive environments, and strengthening community action and individual skills.
The WHO has set Health Promotion priorities in these four areas:
Capacity, including finance and infrastructure
Urban health
Schools, workplaces, and other settings
Health literacy
(RHIH, n.d.)
One basic public health strategy is to educate the public by using classes or informal workshops. A good example are Community Health Workers who know the local people and work effectively with them. They are especially valuable in understanding cultural differences of the target groups.
According to the National Commission for Health Education Credentialing in the US, Health Educators are responsible for eight main roles: (NCHEC, n.d.)
Area I: Assessment of Needs and Capacity, to evaluate health needs of a specific population
Area II: Planning, developing policies, educating individuals or communities on health conditions, planning the desired outcomes and engaging priority populations
Area III: Implementation, producing materials, delivering health promotion interventions
Area IV: Evaluation and Research, monitoring implementation, aligning evaluation with the intervention goals and objectives, designing research studies, identifying current and emerging health issues and examining their underlying causes
Area V: Advocacy, engaging coalitions of stakeholders to address health issues and promote advocacy
Area VI: Communication, determining the factors that affect communication with the specified audience, developing messaging using communication theories and developing health communication delivery methods for varied stakeholders
Area VII: Leadership and Management, coordinating with partners and managing human, fiduciary, and material resources
Area VIII: Ethics and Professionalism, Applying professional codes of ethics, demonstrating ethical leadership and engaging in professional development to maintain proficiency
(WHO, n.d.-b)
"Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love" (WHO, 1986, p. 4).
Improving health can happen in many different settings. To build on the Ottawa Charter, the WHO presented Healthy Settings, a “Whole System” approach to health promotion, that encourages community participation, partnership, empowerment and equity.
What is a setting? A setting can be anywhere people actively use and shape the environment. It is also where people create or solve problems relating to health by planning, implementing and evaluating health promotion programs. Examples of settings include schools, work sites, hospitals, cities, and even prisons.
(IOM, 2003)
Throughout history, whenever people have lived together, there has been a need for public health. Ancient Romans built aqueducts to supply safe drinking water and dispose of waste. The earliest historical account of public health is in the Bible (Leviticus 11–20) where Moses gave the people rules for food safety.
Some of the notable public health efforts in more recent centuries were vaccinations. Vaccines were first developed by the Chinese a thousand years ago and later introduced in Europe in 1796 by Edward Jenner for smallpox. In 1854, John Snow investigated a cholera outbreak in London and discovered it was spread by contaminated water. In his now-famous public health intervention, he chained the central pump to prevent use of its water.
Such actions eventually led to developing public health associations, like in these examples:
UK Royal Society of Public Health, 1856
American Public Health Association, 1872
World Health Organization, 1948
World Federation of Public Health Associations, 1967
In the last two centuries, public health efforts have been used to:
Improve sanitation
Monitor and improve environmental health
Reduce and manage pandemics
Ameliorate the spread of disease and disease effects
Respond to disasters (both natural and human-made)
Create political policies that improve the well-being of the citizenry
In short, public health efforts work to protect against environmental hazards, prevent the spread of disease, encourage healthy behaviors, and respond to disasters.
(CTB, n.d.-a)
A key element in the health promotion process is the involvement of stakeholders. Any intervention will be more effective if all stakeholders are engaged in the process and all their interests are addressed.
[Note: This will be used in Section 1, Step 4 of the Term Project]
Stakeholders include all who are affected or have an interest or a “stake” in a program.
Primary Stakeholders are beneficiaries, those who stand to gain something from the program. Listed below are some examples of primary stakeholders:
A population – a racial or ethnic group, residents of a housing project, etc.
Residents of a neighborhood or city where a program is implemented.
People at risk for a particular condition, such as homelessness or an illness.
Secondary Stakeholders are those directly involved with beneficiaries, such as parents and family members, healthcare workers, community volunteers. Listed below are some examples of secondary stakeholders:
Schools and their employees – teachers, counselors, aides, and so on.
Social workers and psychotherapists.
Health and human service organizations.
Law enforcement agencies.
Landlords and employers.
Government officials and policy makers can pass laws and regulations that may either fulfill the goals of the program or cancel them out. From local board members to state and federal agencies or legislators, they can make or break public health efforts. An advisory board of appointed professionals may offer guidance and support.
Influencers are people that others listen to. They can be in respected positions such as church leaders, doctors, community organizers, and especially the media.
Others with an interest:
Businesses in the community
Academic or research teams
Potential funders
The community at large
In most cases, participation of as many stakeholders as possible and responding to their concerns will bring the greatest chance of success. Some advantages of identifying a wider list of stakeholders:
More perspectives and a clearer picture of the community.
Buy-in from all who participate.
Fairness to all who are affected.
Better awareness of obstacles and possible solutions.
More support in case of opposition.
It creates social capital, meaning the web of acquaintances, friendships, family ties and favors that can be used to cement relationships and strengthen community.
Creates connections among diverse groups that otherwise might not interact.
Increases the credibility of your organization.
The earlier in the process stakeholders can be involved, the better.
Brainstorm as long a list as possible from all different types of stakeholders.
Collect names from informants in the community, especially members of a group or area of concern.
Consult with partner organizations.
Get more ideas from stakeholders as you identify them.
If appropriate, advertise at community meetings, in newsletters, social media, religious gatherings, and through word of mouth.
It is important to monitor how well stakeholders are involved in your effort. The stakeholders themselves should help evaluate what did and didn’t work to recruit and keep them.
New stakeholders may need to be brought in as time goes on. You have to maintain stakeholders’ and supporters’ motivation, keep them informed, and continue to find meaningful work for them to do if you want to keep them involved and active.
(CTB, n.d.-b)
Whenever community problems are too large for any one agency to solve, the best approach is to put together a coalition of groups and individuals to work together to achieve the goal. A coalition can be a powerful force for positive change in a community.
Coalitions can work together in the short term or become permanent organizations with governing bodies and funding. Regardless of their size and structure, they exist to work together to reach specific goals.
Coalitions are often formed to accomplish goals. Some examples of possible goals are listed below:
Influencing or developing laws or public policy for a specific issue.
Changing people's behavior, such as reducing smoking or drug use.
Building a healthy community.
Responding to disturbing events such as a school shooting.
It helps to start with a core group and pull in all necessary stakeholders, as well as opinion leaders, policy makers, and community members. Early in the process, the elements below must be addressed:
Define the issue to be addressed
Create vision and mission statements with realistic goals
Develop a coalition structure and action plan
Identify resources needed and allocate what is available
As a coalition forms, it is essential to be inclusive and communicate well with all members. Acknowledge and take advantage of the diversity of coalition members.
Social determinants of health (SDOH) are the conditions of daily life and the environment that affect the health and well-being of different groups. They are often some of the root causes of health disparities and inequities. These social determinants can either support or limit the health of a community or population. Social determinants of health are grouped into five domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. For example, racial and ethnic minorities may have more health problems due to:
Hazards in poor housing and in workplaces
Poverty and poor education
Fewer health services
Racism, discrimination, and violence
Education, job opportunities, and income
Access to nutritious foods and physical activity opportunities
Polluted air and water
Language and literacy skills
(CDC, n.d.)
Many worldwide efforts address SDOHs. It will require a whole community approach in which different sectors all work together to assure conditions for health. Changes will be required by individuals, communities, and nations. Partnerships will be needed among public health, community organizations, education, government, business, and civil society.
SDOHs contribute to health disparities. For example, people who don't have access to grocery stores with healthy foods have higher risks of heart disease, diabetes, and obesity — and lower life expectancy.
Just promoting healthy choices won't eliminate health disparities. Instead, public health needs to take action with partners in education, transportation, and housing to improve the conditions in people's environments.
A basic principle of public health is that all people have a right to health. Health equity results when everyone can attain their full health potential and no one is prevented because of their social position. Health disparities refer to preventable differences in health conditions and health status among groups. Most health disparities affect groups that have been marginalized or excluded. They experience worse health, as well as less access to food, good housing, and health services. Health inequities are “avoidable inequalities in health between groups of people within countries and between countries” (CTB, n.d.-c)
Access the appendix for a description of this image
The Ten Essential Public Health Services were adopted by the US Centers for Disease Control in 1994 and strongly emphasize the theme of prevention. They are worth reviewing while communities assess their public health status.
Assess and monitor population health by collecting and interpreting health related data.
Investigate, diagnose, and address health hazards and root causes, identifying emerging health threats and combating both infectious diseases and patterns of chronic disease and injury.
Communicate effectively to inform and educate, including health promotion and social marketing efforts in your community.
Strengthen, support, and mobilize communities and partnerships. Health professionals join with other community sectors in effective coalitions.
Create, champion, and implement policies, plans, and laws. Review health-related laws and policies and advocate for changes as needed to promote optimal health for all.
Utilize legal and regulatory actions. This may include enforcement of sanitary codes, protection of drinking water and clean air, and monitoring healthcare services and supplies.
Enable equitable access for socially disadvantaged people. This should be done for clinical healthcare as well as culturally appropriate health education.
Build a diverse and skilled workforce with effective training for public health professionals.
Improve and innovate through evaluation, research, and quality improvement of health programs and community initiatives.
Build and maintain a strong organizational infrastructure for public health, including ties with higher learning and research.
The following examples illustrate how two cities planned and implemented health programs by gathering coalitions of community members and agencies.
Douala, Cameroon (WHO, n.d.-c)
With a population of 3 million, Douala, composed of six districts, is the largest city in the country, with 20% of the total urban population. The city is subject to various sources of pollution, as waste collection is hampered by the lack of motorized roads in disadvantaged neighborhoods. Public services are insufficient, are often located at the city center, and are provided by the private sector. Access to safe water remains a problem in many areas.
Under the leadership of the mayor, a multisectoral coordination committee was established to implement the City Action Plan 2023–2025. Douala 3rd district identified safe, good-quality water as an entry point for tackling health determinants, such as cholera, and, as a result of dialogue with the municipality, traditional rulers, civil society, community members, and the private sector, an intersectoral community committee for water management was established through a municipal act to improve access to safe water through community participation. Similar municipal acts for intersectoral community committees are expected to be passed in other municipalities of the city.
Bogota, Colombia (WHO, n.d.-d)
Bogota DC is the capital of Colombia; it constitutes 16.4% of the total urban population in the country. The project builds on two entry points: (i) Bogota is planning to become “the caring city” (ciudad cuidadora) by promoting an inclusive, sustainable, conscious city for population well-being through a participatory approach; and (ii) the “care promoters’ initiative” to improve integrated primary health care by developing a road map with the local community, civil society organizations, and stakeholders. The project is beginning in the Alcadia local de Kennedy, with a focus on promoting the participation of people with disabilities. It will make use of existing official intersectoral committees led by the Secretary of Health and Kennedy Local Council.
The first step of the planning process is the needs assessment. We can’t simply choose a health issue at random; we need to use credible data to show us what health issues are problems within our community.
Here is an example of data available about some prevalent health issues.
Access the appendix for a description of this image
Notice that we aren’t just gathering data about the most common causes of death. We are also looking at morbidity or the health issues that are not causing death but are upsetting the quality of life of the target population.
During the first part of the needs assessment, our job is to identify these health issues and collect data that will help us understand the underlying causes of each health issue.
Needs can be defined as the gap between what is and what should be. Resources, or assets, can include individuals, organizations, buildings, or anything that can be used to improve the quality of life. The mother in Chicago who volunteers to organize sports for neighborhood children after school, the Kenyan farmers' cooperative that helps farmers buy seed and fertilizer, the library that provides Internet access, the walking path where city residents can exercise -- all are resources that enhance community life. Every individual is a potential community asset.
1. Recruit a planning group that represents all stakeholders and mirrors the diversity of the community.
2. Determine what data is already available. Here are some commonly used sources of existing data. These link to external sources.
Centers for Disease Control and Prevention Global Health Center and Global Health Protection and Security.
Census data, ministries of health or departments of health of the country or community you are focusing on.
Assessments by local or state/provincial governments or government agencies.
Studies conducted by other agencies, hospitals, and local universities.
3. Determine what other information you need. Finalize the questions you'll ask your informants, as well as the questions you hope to answer with the assessment.
4. Decide what methods you'll use for gathering information. Choose among many methods of gathering assessment data. Some possibilities are listed below:
Use existing data. Secondary data is information that has been gathered by others.
Listening sessions and public forums. Learn about the community's perspectives on local issues and options. They give people of diverse backgrounds a chance to express their views, and are also a first step toward understanding the community's needs and resources.
Interviews and focus groups. These are less formal than forums and are conducted with either individuals or small groups. A focus group is a specialized group interview in which group members will be more likely to give answers that aren't influenced by what they think is wanted.
Direct observation. Direct observation involves seeing for yourself. One way to better understand an area is to become part of the culture you want to learn about.
Surveys. There are several different kinds of surveys, any or all of which could be used as part of a community assessment. Surveys often have a low return rate, and so may not be the best way to get information, but sometimes they're the only way.
Asset Mapping. Asset mapping focuses on the strengths of the community rather than the areas that need improvement. Focusing on assets gives the power back to the community members. When changes are made by the community and for the community, initiatives are easier to sustain.
5. Decide who will collect data. Who will do the work of interviewing, surveying, or carrying out whatever other strategies you've chosen to find information?
(CTB, n.d.-d)
There should be strong and effective representation for everyone involved, including the following:
The people whom the intervention is intended to benefit. There are two groups to be considered:
Members of the target community, both those on whom the intervention is specifically focused, and others who share their culture, age, language, or other characteristics.
People whom the target community sees as significant opinion makers - clergy, advisors, politicians.
People who make policy or influence public opinion. They can help or block an intervention by their support or opposition.
Policy makers
(CTB, n.d.-e)
Local elected or appointed officials
State or federal elected or appointed officials who have influence over the issue.
Local public agencies who administer policy in the community. If they're involved from the beginning, they may be able to smooth the way for the intervention.
Local researchers who are experts on the issue in question.
Influential people in the community
Members of the business community. They tend to be practical and conservative so their credibility may be high in the community. They are often directly affected by illiteracy and employee health, so they may see the need for an intervention. They also may have access to money, to help sustain the intervention over time.
Clergy and the faith community may wield great influence and see community issues as part of their spiritual mission. Faith-based groups can be powerful forces in a community.
The media or others who have a public platform.
Directors of other organizations affected by the issue.
These might include parents or school personnel for an intervention dealing with youth. Seniors may have the experience to be excellent community volunteers. People with a personal interest in the issue may want to participate, such as parents whose children have had drug problems.
(CTB, n.d. -f)
Quantitative information and data analysis provide a concrete approach for assessing, planning, and implementing community projects. It helps us compare community problems across geographic regions and across periods of time.
Primary data is information that you collect yourself. Although the information you need is often already available, sometimes you need to create it yourself. Methods of primary data collection include:
Surveys can be written, face to face, or done by telephone.
Focus groups, public forums, and listening sessions are better suited to finding qualitative information.
Secondary Data is information that others have collected. With access to the internet, countless sources are available for statistics on health conditions. One drawback is that we need to evaluate the accuracy of secondary data and ensure we use only reliable sources.
[Note: This will be used in Section 1, Step 5 of the Term Project]
The state or county health department or human service department can give many health and social determinant indicators.
Hospital admission and exit records give information on teen fertility, causes of death, and other things. Some of the data may not be a public record, but it may be possible to arrange to use it in some form.
Census data has demographic information for the U.S. on the Bureau of Census or on similar web sites for other countries.
Ministries of health or departments of health of the country or community you are focusing on.
Police records can tell you crime rates and the incidence of problems such as domestic violence or motor vehicle accidents.
Chamber of Commerce data discusses job growth, the unemployment rate, etc.
Nonprofit service agencies, such as the United Way, may have already conducted surveys.
School districts or regional departments of education can tell you graduation rates, test scores, and truancy rates.
Centers for Disease Control and WHO reportable disease files can give information on the rates of many diseases, such as AIDS.
Most libraries provide a reference librarian who is often very helpful.
Other professional contacts you have can lead you to sources of information particular to your interest.
Statistical Abstract of the United States and Our World in Data are good sources for national and global information.
AIHD. (n.d.). African Institute for Health and Development. An Africa where people live in dignity. https://www.aihdint.org/
CDC. (2022). Social Determinants of Health at CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/about/sdoh/index.html
CDC. (2023). 10 Essential Public Health Services. Center for Disease Control and Prevention. https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html
CDC. (n.d.) Social Determinants of Health. Healthy People 2030. Centers for Disease Control and Prevention. https://health.gov/healthypeople/priority-areas/social-determinants-health
CTB. (n.d.-a) Chapter 7, Section 8. Identifying and Analyzing Stakeholders and Their Interests. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/participation/encouraging-involvement/identify-stakeholders/main
CTB. (n.d.-b) Chapter 5, Section 5. Coalition Building I: Starting a Coalition. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/assessment/promotion-strategies/start-a-coaltion/main
CTB. (n.d.-c). Chapter 2, Section 17. Addressing Social Determinants of Health in Your Community. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/social-determinants-of-health/main
CTB. (n.d.-d) Participatory Approaches to Planning Community Interventions. Community Tool Box. Chapter 18, Section 2. https://ctb.ku.edu/en/table-of-contents/analyze/where-to-start/participatory-approaches/main
CTB. (n.d.-e). Chapter 33, Section 10. General Rules for Organizing for Legislative Advocacy. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/advocacy/direct-action/legislative-advocacy/main
CTB. (n.d.-f) Chapter 3, Section 4. Collecting Information About the Problem. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resources/collect-information/main
IOM. (2003). Institute of Medicine (US) Committee on Educating Public Health Professionals for the 21st Century. History and Current Status of Public Health Education in the United States. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. https://www.ncbi.nlm.nih.gov/books/NBK221176/
NCHEC. (n.d.). National Commission for Health Education Credentialing. Responsibilities & Competencies. https://www.nchec.org/responsibilities-and-competencies
RHIH. (n.d.). Rural Health Information Hub. Health Education. RHIhub. https://www.ruralhealthinfo.org/toolkits/health-promotion/2/strategies/health-education
WHO. (1986). The Ottawa Charter. World Health Organization. https://intranet.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.pdf
WHO. (n.d.-a). Health Promotion. World Health Organization. https://www.publichealth.com.ng/world-health-organizationwho-definition-of-health/
World Health Organization. (n.d.-b). Healthy Settings. World Health Organization. https://www.who.int/teams/health-promotion/enhanced-well-being/healthy-settings
WHO. (n.d.-c). Initiative on urban governance for health and well-being. Douala, Cameroon. World Health Organization. https://www.who.int/initiatives/urban-governance-for-health-and-well-being/work-in-cities-douala-cameroon
WHO. (n.d.-d). Initiative on urban governance for health and well-being. Bogota, Colombia. World Health Organization. https://www.who.int/initiatives/urban-governance-for-health-and-well-being/work-in-cities-bogota-colombia
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