David G. Altman

Sustaining interventions in community systems: on the relationship between researchers and communities.

Important goals of research-based community interventions include the long-term maintenance of effects and fostering of collaboration between researchers and community leaders. This article reviews the challenges associated with transferring innovations to community systems, changing program delivery from an experimental context controlled by researchers to program delivery controlled by community organizations, and sustaining long-term effects of interventions. It is suggested that researchers who develop and implement community interventions in diverse health areas need to confront several issues: (a) fostering effective long-term relationships between researchers and the communities they study and in which they intervene and (b) designing and implementing interventions that are useful to community systems after the formal phase of research ends.

The relationship between tobacco access and use among adolescents: a four community study

The objective of this study was to examine the effectiveness of a longitudinal community intervention on the reduction of tobacco sales to minors and subsequent effects on tobacco consumption by youths. The study was conducted in Monterey County, CA. Four rural communities were randomized into treatment and comparison arms of the study and middle and high school students in each of these communities completed surveys assessing knowledge, attitude, and behavior. The main outcome measures were retail tobacco sales to minors as measured through store visits (tobacco purchase surveys) and self-reported consumption of tobacco. Over a three-year period, a diverse array of community interventions were implemented in the intervention communities. These included community education, merchant education, and voluntary policy change. In the treatment communities, the proportion of stores selling tobacco to minors dropped from 75% at baseline to 0% at the final post-test. In the comparison communities, the proportions were 64% and 39%, respectively. Although the availability of tobacco through commercial outlets was reduced substantially in intervention communities, youths reported still being able to obtain tobacco from other sources. Predicted treatment effects on reported use of tobacco among youths were observed cross-sectionally and longitudinally for younger students (7th graders). The intervention did not impact tobacco use among older students (9th and 11th graders) although the trends were in the predicted direction for 9th graders. A significant intervention effect was found for sex--females in the intervention communities were less likely to use tobacco post-intervention than females in the comparison communities. Tobacco sales to minors can be reduced through a broad-based intervention. To prevent or reduce tobacco use by youths, however, multiple supply-and demand-focused strategies are needed.

Health Education Intervention Strategies: Recommendations for Future Research

While the ultimate goal of health education interventions is to positively influence health status, more proximal indicators of success are changes in intermediate outcomes, or impact. Because health education interventions work through intermediate outcomes, the linkage to health status is often assumed to be at a conceptual or theoretical level. The term health education intervention strategy is a heuristic device used to conceptualize and organize a large variety of activities. There is a wide range of studies and reports in the literature that either test specific intervention strategies or report on larger health education efforts combining several strategies. This article organizes the discussion to focus on individual-, community-, and policy-level interventions. Mass communications are also considered, and the authors comment on program planning issues that cut across specific interventions at the individual, community, and policy levels. Eleven recommendations are offered for future health education intervention research.

Adherence in Social Context

Much has been written about adherence to interventions in older adults. What has not been discussed as extensively is how adherence is influenced and affected by the multiple interacting layers of the social context. Guided by an ecological or multilevel system model, this paper explores how social context may impact adherence. We conclude that when considering strategies to promote adherence to a particular regime, one must take into consideration the interplay between the social context and the adherence-related behavior. Control Clin Trials 2000;21:184S-187S

Teens as Advocates for Substance use Prevention: Strategies for Implementation

Substance use by adolescents is a growing public health problem, especially among youth in low-income neighborhoods. School-based substance use prevention programs can be effective but are compromised by the alcohol, tobacco and other drug (ATOD) messages that saturate the community environments. The Teen Activists for Community Change and Leadership Education (TACCLE) program engaged ethnically diverse high school students from low-income communities in advocacy activities that addressed environmental influences related to ATOD in their schools and communities. The intervention took place during the 1996-1997 school year and involved 116 students in the 9th and 10th grades at six sites. Using social learning and empowerment theories, teens identified an ATOD advocacy issue on which to focus. The program succeeded in engaging teens from at-risk communities in advocacy projects that successfully modified negative ATOD influences in their schools and communities. Ten guiding principles and their implications for practitioners are presented and discussed.

Creating Capacity: Establishing a Health Education Research Agenda for Special Populations

On Day 2 of the joint CDC/SOPHE conference on Creating Capacity: Establishing a Research Agenda for Health Education, the participants were asked to identify research needs or special issues in working with children and adolescents, the elderly, women, men, and underserved groups. This article presents the priority research areas across subgroups identified by the participants. The cross-group priorities are followed by research recommendations for each subgroup.

Churches, tobacco farmers, and community sustainability: Insights from the tobacco south

American tobacco farmers and the communities in which they live face an increasingly uncertain and tenuous future. In many rural American communities, churches function as the moral and social compass that guides community life. In North Carolinas rural communities, churches and tobacco are inseparable. Indeed, churches in tobacco-dependent communities are often referred to as tobacco churches. These churches experience tensions and contradictions that exist within the multiple cultures of which they are a part: denominations, banks, locally owned businesses, schools, and community centers. Ethical dilemmas abound as the moral dimensions of public health and livelihood are weighed against the backdrop of the common good. This article will give an overview of the conflict, then delve more deeply into the historical and societal components that have shaped the tobacco culture and the roles, past, present, and future, that churches have or could play. Current pressures related to public health and rural economic viability will be examined. Cases illustrating the possible central role of the church at both the local and regional level will be presented to build an argument for the constructive role of the church for communities undergoing radical social, economic, and cultural change.

Media coverage of tobacco diversification: tradeoffs for community health:

As part of a tobacco farmer diversification randomized intervention study in 14 eastern North Carolina counties, a media content analysis of 16 local newspapers was conducted. All available issues of each of the newspapers from the period 1 November 1996, through 31 December 1999, were reviewed, and all relevant articles were clipped, coded, and entered into a database. Media coverage intensity was compared, qualitatively, with data from interviews with local civic, health, and religious leaders. There was, on average, only one tobacco diversification article in every 100 newspaper issues. The hypothesis that coverage of tobacco diversification and tobacco control would become more favorable in the intervention counties over time was not supported. Interview data showed that organizational leaders placed a higher priority on tobacco diversification policy issues than evidenced by media coverage.

A Primer on Tobacco Production: Implications for Health Promotion Practice

In the late 1990s, there has been unprecedented attention to issues that affect tobacco farmers and tobacco-dependent communities. During this time, relationships between public health professionals and organizations and tobacco producers have been established. At the same time, some growers have questioned tobacco company loyalty to the American tobacco farmer. Despite these burgeoning relationships, most public health professionals know little about tobacco production and the host of factors that play a role in shaping the tobacco culture. This overview article attempts to fill this gap in knowledge so that health professionals are in an informed position when they speak about intersections between public health and tobacco farming. An increased understanding of these background issues will enable the public health community to achieve the dual goals of reducing disease caused by tobacco products and ensuring the prosperity of rural farming communities historically dependent upon tobacco.

An Interview with Jeffrey Koplan, MD, MPH, Director, Centers for Disease Control and Prevention

H ealth Promotion Practice editor Randy Schwartz and associate editor David Altman were pleased to have the opportunity to interview the Centers for Disease Control and Prevention (CDC) director, Dr. Jeffrey Koplan, for this issue of HPP. Dr. Koplan is widely known to many in the health education and health promotion community for his long-term support of health promotion and education at the CDC. Dr. Koplan was the first director of the National Center for Chronic Disease Prevention and Health Promotion at the CDC. SOPHE was honored to have Dr. Koplan serve as the keynote speaker at its recent 50th Anniversary Annual Meeting held in Chicago, November 1999.