On paradigms, community participation, and the future of public health.

Abstract

In the Journal's recent series of articles on the future of public health, Pearce argues that epidemiology has become overreductive, attending to personal behaviors at the expense of social and historical factors; he proposes instead a "postmodern epidemiol- The paradigm underlying these efforts was the reductive-objective paradigm of science, which aims at "objective" and "universal" truths, as determined by the scientist. It has clearly evolved, from simple models of cause and effect to complex ecological "webs" of causation," but the search for objective, universal truths has not changed, and the processes of research and intervention are still controlled by the scientist. An ecological approach does help solve some problems, overconcentration on personal behaviors, for example. Complex social factors are indeed also determinants of health and disease. But this complexity can also immobilize; there are so many potentially relevant variables! To work more effectively, and to constitute a new paradigm, we need something more. Community participation-the involvement of people in designing and implementing research and interventions intended to benefit them-emerges from public health practice to satisfy this need. We first became aware of its possibilities from the North Karelia Project, Finland's major coronary heart disease intervention in the 1980s. Although similar in scale and methods to the US interventions, it differed from them in two important ways.

Promoting well-being: Time for a paradigm shift in health and human services

“…This has been a major gap in previous efforts to sustain individual well-being through strictly psychological means such as cognitive reframing, positive thinking, information sharing, and skill building. This is in line with recent thinking in public health, articulated forcefully by spokespersons such as Syme [10,18] and Labonte [19]. Individuals cannot significantly alter their level of well-being in the absence of concordant environmental changes [9].…”

“…Conversely, any strategy that promotes well-being by environmental changes alone is bound to be limited. There is ample evidence to suggest that the most promising approaches combine strategies for personal, relational, and collective change [10]. It is not one or the other, but the combination of them all that is the best avenue to seek higher levels of well-being in our three sites of interest.…”

“…There are many aspects of the psychosocial, economic, political, and physical environment that influence the state of well-being; and there are many aspects of well-being that reach far beyond health and encroach into the realm of values, thriving, meaning, and spirituality. My definition of well-being is in line with comprehensive conceptualizations of health promotion put forth by the WHO [7], by the Canadian government [8], and by the new public health paradigm [9][10][11], all of which emphasize the values of self-determination, participation, community capacity-building, structural determinants, and social justice.…”

Local Health Department Capacity for Community Engagement and Its Implications for Disaster Resilience

“…19 The emphasis in public health emergency preparedness on community partners resonates with the broader historic shift among public health professionals toward working alongside-not independent of-community members and their top health concerns. [20][21][22][23][24][25][26] It parallels, too, developments in the field of emergency management to adopt a more participatory and collaborative approach to reducing the impacts of natural and technological disasters. [27][28][29][30] More broadly, the value now placed on the public's role in the public health emergency preparedness enterprise represents an additional chapter in a much longer, complex history, wherein US citizens are taking a more active role in shaping the public systems, policies, and programs that affect them-the subject of a large literature dispersed over many disciplines.…”

Challenges in Replicating Interventions

“…They are also hypothesized to be ″community-based,″ [2] and ″culturally sensitive,″ reflecting the needs, values, and cultures of the targeted individuals Yet there is also the expectation that interventions should be replicable and able to be "scaled up" for much wider use [3,4). Issues relating to the tensions between specificity and generalizability seem to occur across a wide range of innovations [5].…”