Lisa D. Lieberman

Structural Approaches to Health Promotion What Do We Need to Know About Policy and Environmental Change

Although the public health literature has increasingly called on practitioners to implement changes to social, environmental, and political structures as a means of improving population health, recent research suggests that articles evaluating organization, community, or policy changes are more limited than those focused on programs with individuals or their social networks. Even when these approaches appear promising, we do not fully understand whether they will benefit all population groups or can be successful in the absence of accompanying individually oriented programs. The role of this broad category of approaches, including both policy and environmental changes, in decreasing health disparities is also unclear, often benefiting some communities more than others. Finally, the political nature of policy and environmental change, including the impact on personal autonomy, raises questions about the appropriate role for public health professionals in advancing specific policies and practices that alter the conditions in which people live. This article addresses these issues and ends with a series of questions about the effectiveness and ethical implementation of what we have termed “structural initiatives.”

Upending the Social Ecological Model to Guide Health Promotion Efforts Toward Policy and Environmental Change

Efforts to change policies and the environments in which people live, work, and play have gained increasing attention over the past several decades. Yet health promotion frameworks that illustrate the complex processes that produce health-enhancing structural changes are limited. Building on the experiences of health educators, community activists, and community-based researchers described in this supplement and elsewhere, as well as several political, social, and behavioral science theories, we propose a new framework to organize our thinking about producing policy, environmental, and other structural changes. We build on the social ecological model, a framework widely employed in public health research and practice, by turning it inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthy policy and environmental development. We conclude by describing how health promotion practitioners and researchers can foster structural change by (1) conveying the health and social relevance of policy and environmental change initiatives, (2) building partnerships to support them, and (3) promoting more equitable distributions of the resources necessary for people to meet their daily needs, control their lives, and freely participate in the public sphere.

A Theater-Based Approach to Primary Prevention of Sexual Behavior for Early Adolescents.

Early adolescence is a crucial period for preventing teen pregnancy and sexually transmitted infections. This study evaluated STAR LO, a theater-based intervention designed to affect antecedents of sexual activity among urban early adolescents (N = 1,143). Public elementary/middle schools received the intervention or served as a wait-listed comparison group in a quasi-experimental study. Students completed pretest and posttest questionnaires. Multivariate regression models were used to examine treatment effects. Comparison students showed significantly greater increases in sexual intentions and decreases in pro-abstinence attitudes and intended age of first sex than treatment group adolescents. Comparison girls showed significantly greater increases in desire to be a teen parent than STAR LO girls. Treatment group adolescents exhibited greater increases in sexual knowledge than comparison group adolescents, with stronger effects for boys than girls. The results suggest that this theater-based prevention program can help early adolescents develop knowledge, attitudes, and intentions that may prevent future sexual risk behavior.

Pregnant Teens in Foster Care: Concepts, Issues, and Challenges in Conducting Research on Vulnerable Populations

Teens in foster care give birth at over twice the rate of other teens. Unique challenges exist for these vulnerable teens and babies, yet research on such populations, particularly within the systems that serve them, is limited. A demonstration project at Inwood House, a residential foster care agency in New York City, from 2000 to 2005, at the same time that the Administration for Childrens Services was exploring policy and practice changes for this population, is described. Research design and implementation issues, descriptive data, and experiences provide lessons for improving the evidence base to meet the needs of pregnant teens in care.

Impact of the Choosing the Best Program in Communities Committed to Abstinence Education

States vary in standards for sex education, some requiring an emphasis on abstinence. Schools seek to identify curricula that reflect local community values and meet state standards. Choosing the Best (CTB), a classroom-based abstinence education curriculum, has been implemented in 75 Georgia school districts since 1995. CTB Inc., sought to determine if this popular program had an impact on abstinence attitudes, intentions, and behavior. Six Georgia public schools (1,143 ninth graders) participated in the study in 2009-2010. Four randomly assigned schools received the CTB curriculum, taught by trained CTB staff. Two control schools received their usual textbook-based abstinence lessons. Surveys were conducted at the beginning and end of 9th grade, and the beginning of 10th grade. Data demonstrated significant impact of CTB at the end of 9th grade on commitment to abstinence, proabstinence beliefs and attitudes, intentions to maintain abstinence, and lower onset of sexual intercourse, and at the beginning of 10th grade on proabstinence attitudes. In two communities that sought an abstinence education approach, CTB had a short-term impact on abstinence attitudes, commitment, and behaviors, and a longer term impact on abstinence attitudes only.

Silence and Censure: A Qualitative Analysis of Young Adults’ Reflections on Communication With Parents Prior to First Sex:

Seventy-four first- and second-year students, participating in focus groups at a northeastern U.S. university, discussed recollections of messages received at home, prior to sexual debut, about sex and sexuality. Responses were categorized as Characteristics of Communication (nature of interactions participants had at home about sexuality) and Major Message Content (actual themes of those conversations). Commonly reported characteristics were trouble talking with parents; most conversations happened with mothers; participants feared parents’ reactions; and among lesbian, gay, bisexual groups, feared parents’ discovering their nonheterosexual orientation. Commonly reported message content included use protection and, among women, wait. Women reported messages that were at best, mixed, and at worst, threatening or moralistic. Men reported fewer conversations, and those recalled were more neutral or encouraging, especially from fathers. Parental messages to males and females differed qualitatively, reflected stereotypical assumptions about gender roles, desire, and appropriate conditions under which to have sex, and lacked support for nonheterosexual orientations.

Reflections on Structural Change Where Do We Go From Here

As the guest editors for this supplement issue, we sought to provide evidence of whether and how policy and environmental approaches are being used to improve the public’s health. We wanted to know what type and amount of evidence are needed to demonstrate effectiveness, as well as whether poorly resourced communities benefited equally from such approaches. Together, the 12 articles in this issue suggest that, to have meaningful impact, we should think broadly about policy and environmental change to include all efforts to modify the physical, social, political, and economic environments in which people make health-related decisions. So-called structural strategies, as defined in Lieberman, Golden, and Earp (2013), include price modifications, social norm alterations through media advocacy and other mechanisms, community empowerment efforts, resource redistribution, expanding social networks, and more. Manuscripts submitted for the issue provided some response to the questions raised. That only a small number, however, offered empirical demonstrations of effective structural interventions provided its own “data.” The nature of structural change appears to be ill-suited to the kinds of evaluations that are most feasible or most often funded. In addition, while the call for papers sought to expand beyond nutrition, tobacco, and injury—three topics already most associated with structural-level interventions—these topics were central to the majority of manuscripts received in response to the call for papers. Key themes illustrated in this issue include the following: the importance of partnerships and coalitions outside of traditional public health; the substantial amount of time and resources (financial and otherwise) needed to implement and study structural changes; the challenges of evaluating multilevel approaches and building evidence for effectiveness; the need for multi-level approaches that link income, institutions (such as housing), and health outcomes; the importance of historical context for interpreting cultural changes; the role of theories that place individuals as stakeholders or nodes in social networks that drive organizational change; and the power of market forces to make health-directed policies less effective than they might otherwise be. The articles collected here also raise new questions about structural approaches. For example, to be effective, how many aspects of individuals and environments need to be engaged? Are more levels automatically better than fewer? Do interventions prioritizing the social, political, and economic environments need to be implemented simultaneously for best results, or will sequential adoption still produce the desired population health outcomes? Traditional evaluation methods, like randomized control trials, may not answer these kinds of questions. To that end, there is a need for an a priori, replicable, logical method of determining which aspects of structure need to be addressed for each health problem. Furthermore, to what extent do shifting norms and perceptions precede structural changes or result from them? How should champions, the media, policy advocates, and health promotion researchers work most effectively to “denormalize” previously accepted behavior, and how do these efforts intersect with other structural actions? Public attention to an issue may further public health goals, by increasing the likelihood of structural change, or may elevate issues perceived as controversial or limiting to autonomy, thereby providing opportunities for opposition. Although it is clear that partnerships, alliances, and coalitions are central to structural-level change, the exact types of linkages, and the resources they can leverage, remain less well understood. In short, are linkages that emanate from outside the community, or across different networks within a community, more effective than those from within closely connected social networks? Or do they serve different functions, but all of them necessary? Can we get beyond piecemeal or time-limited approaches to funding and evaluation so that they account for the complexity and actual length of time necessary for significant social change? Tobacco control outcomes, often championed as a structural change success story, both elsewhere and in this issue, have been more than 50 years in the making. We cannot ignore that such structural change processes are dependent on research inputs, champions, policy responses, normative changes, media glamorization or de-normalization, stakeholder 575099 HEBXXX10.1177/1090198115575099Health Education & BehaviorLieberman and Earp research-article2015

Evaluating programs that address ideological issues: ethical and practical considerations for practitioners and evaluators.

There are important practical and ethical considerations for organizations in conducting their own, or commissioning external, evaluations and for both practitioners and evaluators, when assessing programs built on strongly held ideological or philosophical approaches. Assessing whether programs “work” has strong political, financial, and/or moral implications, particularly when expending public dollars, and may challenge objectivity about a particular program or approach. Using a case study of the evaluation of a school-based abstinence-until-marriage program, this article discusses the challenges, lessons learned, and ethical responsibilities regarding decisions about evaluation, specifically associated with ideologically driven programs. Organizations should consider various stakeholders and views associated with their program to help identify potential pitfalls in evaluation. Once identified, the program or agency needs to carefully consider its answers to two key questions: Do they want the answer and are they willing to modify the program? Having decided to evaluate, the choice of evaluator is critical to assuring that ethical principles are maintained and potential skepticism or criticism of findings can be addressed appropriately. The relationship between program and evaluator, including agreements about ownership and eventual publication and/or promotion of data, should be addressed at the outset. Programs and organizations should consider, at the outset, their ethical responsibility when findings are not expected or desired. Ultimately, agencies, organizations, and programs have an ethical responsibility to use their data to provide health promotion programs, whether ideologically founded or not, that appropriately and effectively address the problems they seek to solve.

Relationships and Context as a Means for Improving Disease Prevention and Sexual Health Messages

In many ways, the HIV epidemic changed the discourse about sex in the United States and worldwide (Ehrhardt, 1992; Everett, 1986) and continues to drive approaches to sex education. After a period of rapid growth in the late 1980s (approximately 150,000 new infections per year), by the late 1990s HIV rates in the United States slowed to some 40,000 new infections annually (Centers for Disease Control and Prevention [CDC], 2001), and new HIV infections continue to hover around that number. The first successful examples of behavior change that resulted in decreased HIV transmission emerged from communities of men who have sex with men (MSM; Coates, Richter, & Caceres, 2008). However, although the past decade has been marked by longer survival rates, and significant reductions in new infections in some population groups, MSM remain the largest HIV transmission category in the United States and the only one associated with an increasing number of HIV/AIDS diagnoses (CDC, 2008). In 2010, some 61% of newly diagnosed HIV infections were attributed to male-to-male sexual contact (CDC, 2012). Over this same period, school-based sex education programs have varied widely in focus and content (Kirby, 2007; Santelli et al., 2006). The political landscape from the 1990s through 2008 yielded the largest investment of federal funds in abstinence-only-until-marriage programs. In 2009, however, funds awarded in the Teen Pregnancy Prevention initiative were primarily for comprehensive sex education programs, with some funds for abstinence education programs appropriated in the 2010 health reform legislation (Boonstra, 2010), despite their limited effectiveness. Currently, state standards for school curricula vary widely, with 18 states requiring instruction on the importance of engaging in sexual activity only within marriage, whereas 19 others require instruction on condoms and contraception (Guttmacher Institute, 2011). Within this highly politicized context, questions remain as to how to stem the tide of disease and teen pregnancy, while addressing the needs of both youth and adults, heterosexual and non-heterosexual, as they seek healthy sexual relationships and protection from harm over their life course. It may be that our very efforts to point lasers at disease, with abstinence (Guttmacher Institute, 2011) or condoms (Warner, Gallo, & Macaluso, 2012) as a central focus, rather than at the context in which sexual behavior occurs, has limited our vision to find messages that more effectively lead to the kinds of outcomes we seek. This issue of Health Education & Behavior carries six articles focused on sexuality within the context of various types of relationships, providing important implications for sex educators and others addressing risks related to sexual activity. The articles highlight several specific population groups and the unique aspects of their sexual relationships and risk taking. Together they suggest the limitations of prevention messages that focus solely on sexually transmitted infections and HIV, that promote either abstinence or condom use as their nearly universal emphasis, and that do not take relationships and other social contexts into account.

Evaluating Structural Change Approaches to Health Promotion: An Exploratory Scoping Review of a Decade of U.S. Progress:

Structural change approaches—also known as policy and environmental changes—are becoming increasingly common in health promotion, yet our understanding of how to evaluate them is still limited. An exploratory scoping review of the literature was conducted to understand approaches and methods used to evaluate structural change interventions in health promotion and public health literature. Two analysts—along with health sciences librarian consultation—searched PubMed, Web of Science, and EMBASE for peer-reviewed U.S.-based, English language studies published between 2005 and 2016. Data were extracted on the use of evaluation frameworks, study designs, duration of evaluations, measurement levels, and measurement types. Forty-five articles were included for the review. Notably, the majority (73%) of studies did not report application of a specific evaluation framework. Studies used a wide range of designs, including process evaluations, quasi- or nonexperimental designs, and purely descriptive approaches. In addition, 15.6% of studies only measured outcomes at the individual level. Last, 60% of studies combined more than one measurement type (e.g., site observation + focus groups) to evaluate interventions. Future directions for evaluating structural change approaches to health promotion include more widespread use and reporting of evaluation frameworks, developing validated tools that measure structural change, and shifting the focus to health-directed approaches, including an expanded consideration for evaluation designs that address health inequities.