Strategies for Community Health Promotion

Review of the Assessment

This plan for promoting community health was developed specifically for Gwinnett County, which is located in the northeast region of metropolitan Atlanta, Georgia. The plan is based on an assessment of the county that was previously undertaken. An essential component of a community assessment was obtaining facts and information on the community members’ opinions of their health needs and if their community is able to provide for those needs. The involvement of the community members (especially leaders of influential groups) will be more likely to guarantee that services that are put in place will be specifically targeted to and accepted by the community. The Community-As-Partner Model was used to conduct the community health assessment on which this plan is based. That model was derived from Neuman’s 1972 Systems Model as well as Seyle’s Stress Adaptation Theory, both of which adopt the nursing meta paradigm of health, environment, nurse and client (George, 2011). The aggregate group used for the assessment was identified as males and females, ages 20 to 79 years of age, who were admitted to the Intensive Care Units of Gwinnett Medical Center, Lawrenceville and Duluth, GA, with a diagnosis of drug overdose from January 1, 2013, until June 30, 2013. The focus of the overdose problem in the community includes those related to prescription medications and underlying issues such as depression and anxiety.

Following the initial assessment, it was determined that the same team members who were instrumental in collecting information would be used to administer the plan for promoting community health. The team includes physicians, nurses, social workers, case managers, chaplains, financial managers, hospital administration and community service workers, who all agreed to continue working on the intervention plan. The planning and implementing process will, therefore, be initiated with the collaboration of a cross-section of community service organizations throughout Gwinnett County—and especially in Lawrenceville and Duluth. In addition, similar formats and locations that were instrumental in the collection of information for the assessment will be utilized for the distribution of information for the health promotion plan, including town hall meetings. Based on the assessment, the major concerns that came to light from community residents were the increasing incidence and lack of management and treatment of substance abuse resulting in an overdose. Consequently, this strategic plan will rely largely on community collaboration in managing and treating behavioral and mental health issues, which the community members agreed to support.

Addressing Resources for the Targeted Population

This plan is designed to address the issue of drug abuse/overdose in the community at both a primary and tertiary prevention level. Specifically, while the assessment included a broad-based age demographic as the target members of the community (the primary group), it is understood that tertiary prevention must be directed toward younger members of the community as well. Specifically, younger members of the community will be provided with training and behavior modification techniques in school with the goal of eliminating (or, at least, significantly reducing) these problem behaviors in future adults. An initial step in designing prevention interventions is deciding who should be the target of the intervention. The school-based element of the plan will be based on similar programs that discourage smoking or drug use. In fact, many of the same agencies and groups that currently provide these services have agreed to expand their presentations to include the message of the health promotion plan and gear it toward the students. This pattern has proven effective elsewhere (Westmaas & Cohens Silver, 2007) and is considered a beneficial proactive step. At the same time, the primary aggregate group targeted by this plan (based on the assessment) are adults who have experienced (or may experience) a drug overdose.

The plan will take into consideration a wide variety of demographic factors, including age, gender, culture, and socioeconomic factors. The plan is designed to address certain groups and/or individuals at the personal, community, or societal level, depending on what is considered most appropriate and effective. For example, for those unable to commute regularly to attend support group sessions (due to financial or other reasons), a regular public service campaign will be developed and broadcast by radio and television stations available in the community. Similar programs have been undertaken to address health issues like smoking, and a good example is

Brandon and colleagues, who recruited individuals who had stopped smoking to participate in a series of newspaper, radio, and other media advertisements (Brandon et al., 2004). Following the pattern set by Brandon, this plan will similarly involve individuals from within the Lawrenceville and Duluth communities who have overcome drug abuse issues. A toll-free number will be promoted as well that residents may call to sign up for a support group and other assistance.

This plan addresses several issues specifically raised in the assessment. One of these issues is the need for an expanded level of health and social services, which Vollman, Anderson, and McFarlane (2012), described as the “social safety net” (p. 246). The plan, therefore, calls for the expansion of community resources and, in some cases, the implementation of new programs, to make sure that the needed resources are available and accessible in other neighboring communities in the county. An infrastructure with a large scope of health and social services can more easily assist community members in regaining a healthier lifestyle—physically, mentally and emotionally. Since many community members were unaware of available services, this plan addresses those issues.

Resources available within Gwinnett County communities, and which will be given a higher level of priority and promotion are The Gwinnett County Health Department (which offers services for those with or without insurance); The Gwinnett County Coalition for Health and Human Services (provides a helpline for information and referrals); MARR (a nonprofit facility that uses a Therapeutic Community Model for substance abuse); View Point Health (a public agency created by state law which offers mental health and addictive disease services on a sliding-scale fee determined by family size and income); and CEPTA (a team of bilingual, bicultural behavioral health clinicians and the only Latino agency licensed by the Georgia Department of Community Health). As part of the health promotion plan, all of these departments and agencies will be working proactively to educate community members about the warning signs of drug abuse—and potential overdose—beginning with informational campaigns targeting patients and clients (e.g., by displaying posters, providing flyers and other brief printed material, as well as notes included with statements and other correspondence).

The Collaborative Partnership

The assessment made it clear that a collaborative partnership was needed, and desired, by the community in order to successfully address the health concerns of residents. Therefore, this plan communicates a clear vision and mission: To provide the residents of Lawrenceville and Duluth and the broader Gwinnett County area with the resources and support necessary to limit the number of drug overdoses in the community, including medical, psychological, and environmental assistance. No individual—and no group—associated with this plan will ever place blame on an individual who is seeking assistance, and the plan will be structured in such a way that it does not discriminate regardless of a person’s history or current status. The core members of the collaborative partnership include recognized leaders from a broad range of agencies, groups, businesses, and organizations in the communities affected. With support from this cross-section of the community, it is much more likely that the plan will be embraced by members of the community, who are likely to respond to leadership from within their own peer groups.

To maintain organization and proper direction of the plan, staff will be assigned on a volunteer basis. Part of the staff’s responsibility will be to make sure that the activities of the health promotion plan are adequately advertised and obtain maximum publicity. This will include the production and distribution of a series of bulletins, leaflets, posters, signs, bumper stickers and other educational materials related to the theme of preventing drug overdoses. In some cases, such distribution may occur in workplaces or businesses, depending on the level of cooperation. The staff will also be involved in the organization and conducting of meetings designed to educate members of the community on healthy alternatives to drugs as well as ways to deal with stressors that may lead to drug use. The groups and organizations involved in these activities will include businesses, clubs, outreach agencies, schools, and any others willing to participate.

While providing educational information is necessary, it is understood that behavior does not always change based solely on access to information. In reality, what is most important is the ability to stimulate members of the community to act—to take definitive steps that will result in a change for the better. This plan, therefore, attempts to shape attitudes that will ultimately result in changed behavior. This can only be accomplished through the collaborative partnership, with members of the community supporting one another and encouraging one another to make decisions that will bring about a healthier community. Collaborative partnerships attempt to improve conditions and outcomes related to the health and wellbeing of entire communities.

Effectively Communicating the Health Promotion Plan

Effective communication is essential for building stronger participation and increasing education among community members. Duluth and Lawrenceville both have large multiculturally diverse populations and a significant percentage of Lawrenceville’s Central Gwinnett High School had limited English proficiency (based on the earlier assessment). Therefore, extra planning is put in place to communicate effectively with these populations. Communication with emergency services and workers will also be present to ensure that appropriate health care is being received. Both counties have bilingual 911 dispatchers. Upon arrival at either GHS facility, Spanish and Korean personal interpreters are present. Language lines are available and offer over 140 language interpreters. Multilanguage television is also present in patient rooms for daily entertainment as well as providing health education channels. Plans will be put into place to increase communication between community members, health care providers, educators, and community leaders to reverse the trend of increasing rates of overdose.

Perhaps one of the most critical elements of the plane is that health care providers will convey the importance of limited opioid use for non-terminal illnesses, single-user prescriptions, and curtailing multi-drug therapy such as antidepressants and opioids. Health care professionals, including public health nurses, will be an essential part of the communication system. Messages regarding drug abuse have already started in both cities in public schools due to increasing rates of depression, suicidal thoughts and attempts, and these efforts will be increased and reinforced.

Addressing the Social Environment

This community intervention will adopt a social-ecological perspective since it is accepted that changes in behavior typically are preceded by changes at the social and environmental levels. Significant components of the plan were developed based on research at the individual and group stages. The research included in the assessment, as well as identified for the development of this plan, proves that the elements selected for inclusion in this health promotion plan are financially justifiable (Sorensen, Emmons, Hunt, & Johnston, 1998). One of the sources utilized in the social-ecological model of behavior applied for this Health Promotion Plan is called “society and health” and described this way:

The society-and-health lens brings to the foreground cultural, social, economic, and political processes and aims to understand the ways in which these social structures influence differential risks. The social ecological model…offers a theoretical framework that integrates multiple perspectives and theories. This framework recognizes that behavior is affected by multiple levels of influence, including intrapersonal factors, interpersonal processes, institutional factors, community factors, and public policy. (p. 390)

The entire reasoning behind utilizing a social ecological model to promote healthier behavior in a community is based on the realization that influencing physical environments are critical. According to Stokols (1992), “the healthfulness of a situation and the well-being of its participants are assumed to be influenced by multiple facets of both the physical environment (e.g., geography, architecture, and technology) and the social environment (e.g., culture, economics, and politics)” (p. 7). Importantly, regardless of how effectively members of the community are educated regarding lifestyle changes and healthy choices, changes are not likely to occur if the social environment does not change as well. In other words, if the same influences and pressures remain in the social environment that caused members of the community to turn to drugs (and ultimately overdose), improved knowledge or coping skills may not be enough to maintain a changed lifestyle.

The reasoning behind this plan was based in part on the health belief model (HBM), which posits that behavioral change occurs once an individual understands that certain things negatively impact their health, and that realization was reached by members of the community, based on the results of the assessment. More precisely, once people see that the changed behavior is more beneficial than the behavior that was previously enjoyable (although detrimental from the aspect of their health), they are much more likely to pursue that behavioral change. The impetus for changed behavior includes symptoms (or, in the case of this plan’s focus, overdoses) in addition to the level of knowledge related to improved behavior—or something that can replace drugs in a person’s life (Rosentock, Strecher, & Becker, 1994). It is hoped that the inclusion of the HBM into this plan will provide additional real-life evidence that can add to the existing literature on the relationship between the social environment and changing health behaviors.

Wellness Initiatives and Methods

Wellness diagnoses work hand-in-hand with deficit diagnoses. While a deficit diagnosis illustrates the risk or ill health that an individual(s) may face due to certain factors (such as the overdosing problem in the target communities), a wellness diagnosis can be used to show the individual’s positive response that can result from the nursing intervention being carried out. An appropriate nursing diagnosis for this aggregate would be: Adults admitted to Gwinnett Health Systems ICU’s for overdose are at risk for powerlessness related to ineffective coping skills due to cultural factors and personal values. Indeed, allowing members of the community to overcome these feelings of powerlessness will be the main target of this plan.

As mentioned earlier, many members of the community may not be able to attend support groups or other regular meetings that are included as part of this plan. Therefore, another key element of this plan will be to utilize the Internet. Interventions accessible through the Internet also provide specific advantages, not only to community members but also to the funding needs of the staff. Other advantages of these interventions include greater access to data, standardization, personalization and/or customization of information, and more accurate reporting of details, especially if illegal drug use is involved (since anonymity can be maintained) (Westmaas & Cohens Silver, 2007). Many members of the community may only decide to participate in this plan because they can do so from home, in private. Furthermore, it is much easier to monitor program participation and success in an online format, rather than trying to track multiple meeting places and groups around the community. For example, there is significant evidence of the success of similar programs that address problems such as smoking, depression, and other health concerns (Copeland & Martin, 2004).

Of course, Internet interventions will be just one element of activity that the staff will establish and participate in. Many of the interventions will be determined by the skills and priorities of the agencies, individuals, agencies, and various institutions that are participating in the health promotion plan, and as such will vary—perhaps in different neighborhoods. The important thing to keep in mind, and the focus of this plan, was highlighted by Altman, who described four methods to ensure successful community-level interventions, namely: “(i) integrate interventions into the community infrastructure, (ii) use comprehensive, multi-level intervention approaches, (iii) facilitate community participation and promote community capacity-building, and (iv) conduct thorough needs assessment/social reconnaissance in order to tailor interventions to the community context” (cited in Westmaas & Cohen Silver, 2007, p. 62). As the plan proceeds, the priorities and needs of each member of the collaborative group will be monitored on a regular basis (ideally quarterly) and any necessary adjustments will be made.

Importantly, prior to the initiation of the plan, discussions will be undertaken between all stakeholders and group leaders, in line with the advice of Altman (1995), who noted that any issues related to control and decision-making must be sorted out in the opening stages of the process. The reason for this is to ensure “broad-based support from a cross-section of community constituencies” (p. 529). It is critical to maintain a high level of cooperation throughout the duration of the health promotion plan. Additionally, as the plan’s elements are implemented, it is expected that a mutually-beneficial exchange of skills will take place between a variety of staff and community members, including training and education.

Funding Issues

Finally, one critical element for this plan will be making sure that financial resources are available to sustain all activities. Realistically, good intentions and lofty goals will not pay for the classes, printed materials, and advertising that make up the plan. This plan is part of a long-term community commitment and will, therefore, require ongoing and renewable sources of funding. In addition, while many of the people working to support this plan will be volunteers, there is also a need to pay those individuals who are providing paid services and support. The level of human and financial resources required to maintain this plan is significant. Consequently, it is the goal of this collaborative partnership to obtain funding from a variety of sources, including donations, grants, state funding, etc. Also, community organizers will be used in many cases to actively engage various neighborhood activities and promotions. In particular, it is believed that, once the plan is recognized as bringing about positive results in the community, the level of financial support will increase and become consistently stable for the long-term.

References

Altman, D. G. (1995). Sustaining interventions in community systems: On the relationship between researchers and communities. Health Psychology, 14, 526-536.

Brandon, T. H., Meade, C. D., Herzog, T. A., Chirikos, T. N., Webb, M. S., & Cantor, A. B. (2004). Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: Dismantling the effects of amount of content versus contact. Journal of Consulting and Clinical Psychology, 72, 797-808.

Copeland, J., & Martin, G. (2004). Web-based interventions for substance use disorders: A qualitative review. Journal of Substance Abuse Treatment, 26, 109-116.

Easter, M. (2006). Obesity As A Cardiovascular Risk Factor: Assessment of the Community Services Related to Physical Activity in a Rural Midwestern Community (Master's thesis, University of Arizona, 2006). Masters Abstracts. Retrieved from www.nursing.arizona.edu/Library/Easter_MA.pdf

Elligers, J. (n.d.). Definitions of Community Health Assessment (CHA) and Community Health Improvement Plans (CHIPS). Retrieved from http://www.cdph.ca.gov/data/informatics/Documents/NACCHO%20CHA%20CHIP%20Definitions.pdf

George, J. (2011). Nursing theories: The base for professional nursing practice (6th ed.). NJ, NY: Pearson Education. http://www.euro.who.int/__data/assets/pdf_file/0018/102249/E73494.pdf

Rosentock, I. M., Strecher, V. J., & Becker, M. H. (1994). The health belief model and HIV risk behavior change. In R. J. DiClemente & J. L. Peterson (Eds.), Preventing AIDS: Theories and methods of behavioral interventions (pp. 5-24). New York: Plenum.

Sorensen, G., Emmons, K., Hunt, M. K., & Johnston, D. (1998). Implications of the results of community intervention trials. Annual Review of Public Health, 19, 379-416.

Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47, 6-22.

Vollman, A. (2012). Canadian Community As Partner (3rd ed.) (A. Vollman, Ed.). Philadelphia: Wolters Kluwer Health Lippincott Williams & Wilkins.

Westmaas, J. L., & Cohen Silver, R. (2007). Designing and Implementing Interventions to Promote Health and Prevent Illness. In H. H. Friedman & R. Cohen Sliver (Eds.), Foundations of Health Psychology (pp. 52-72). New York: Oxford University Press.