Voice of the Public in Public Health Policy and Planning: the Role of Public Judgment, The
Scutchfield, F Douglas
Key words: Public Health Policy and Planning, Deliberation, Community Involvement, Community Health Assessment Models
COMMUNITY health is the ultimate responsibility of public health agencies and community involvement is an absolute core value of effective public health practice. However, creating public involvement in public health is a cumbersome task. Improving the public’s health demands citizens that feel connected to the decisions being made. How we proceed with that task and the mechanisms used to engage and involve the community in improving its health are evolving. Through the last several years a number of techniques have been developed to engage the community and obtain its input on how best to improve the community’s health.
Professionals must be prepared to guide this process, not to dominate it. Community capacity for improving health will be most effective if the community takes ownership of local dialogue and feels connected to the decisions being made. Citizens will become engaged when a connection is made between what is most valuable to them and the problems facing their community. Dewey, decades ago, concluded that deliberation, in the search for ways to act, leads to providing people, and thus, their communities, with choices (1).
Dan Yankelovich, the social scientist, and David Mathews, of the Kettering Foundation, describe a political process that includes the public in community decisions and connects ordinary citizens to governmental organizations and agencies (2,3). We lay out some theoretical underpinning of this deliberative process, examine several frequently used models for community health planning, and judge how well those models do or do not conform to this political process, that is infusing public deliberation into public health. We illustrate our analysis with developments in one Kentucky community that encouraged the public to take a more active role in its health care planning and implementation.
Experts have created a culture of technical control that results in elites talking with other elites when problems arise. An alternative to this contemporary form of elitism would be citizens coming to public judgment., which means, “the state of highly developed public opinion that exists once people have engaged an issue, considered it from all sides, understands the choices this leads to, and accepts the consequences of the choices they make” (2).
Because everyday citizens can utilize empirically base information and contribute to collective wisdom through this process, developing public judgment becomes a priority issue. How do we encourage the public to come to judgment about health-related issues? How can public judgment be incorporated into the professionally driven health planning and development milieu? Work at the Kettering Foundation over the last several years has shed some light on these questions and how they could be addressed (3).
Mathews suggests that the first step in the process is seeking a public name for the problem. seeking a public name means identifying an issue in language of ordinary citizens, linking it to other problems in community life and results in a better departure point for deliberation and dialogue. The second step is framing the issue in the meaningful context of everyday life. This will sort out the pros and cons, advantages and disadvantages, as well as the trade offs and weigh moral/ethical issues. Public deliberation can begin once the problem is named and framed (3). As a community deliberates and comes to public judgment, it can move to public acting, “a sense of direction and an appreciation of interrelated purposes that promotes complementary, mutually reinforcing initiatives from different groups in the community” (3).
There clearly is a role for government and its agents in the deliberative process. Public action can and does complement institutional action. Listening to citizens weigh trade-offs and think through tough choices could and should improve officiai programmatic decision-making. Administrative forums, such as a local board of health deliberations, can be made aware of the community’s perception and judgment. In one Kentucky community feedback from public deliberation motivated a County Judge Executive to adopt the goal of 100% access and o% disparity.
There are also international examples of deliberation in health related issues. Recently a Kettering Fellow, who had returned to South Africa, has named and framed an issue book around HIV/AIDS and is convening forums in South and Sub Sahara Africa around this issue book. Similarly, Kettering has been working with Botswana and a US non governmental agency to help women in Botswana address, with governmental officials, HIV/AIDS.
Recently, Israel’s Ben Gurion University of the Negev has also expressed interest in using this technique to more effectively engage the Bedouin tribes in the Negev region about their health care. One of us (DS) will discuss use of deliberation with senior health leaders in the Negev with the opportunity to use the notion of deliberation to bring the Bedouin community more appropriately into the planning of their health care system.
COMMUNITY HEALTH ASSESSMENT MODELS
Currently, local health entities use various models to facilitate community participation around health issues. These models include 1) Assessment Protocol for Excellence in Public Health (APEX/PH), 2) Mobilizing Action through Planning and Partnership (MAPP), 3) Planned Approach to Community Health (PATCH), and Healthy Communities. The following is a brief description of each model and how citizens are engaged.
Assessment Protocol for Excellence in Public Health
The Assessment Protocol for Excellence in Public Health (APEX/PH) emerged from collaboration between the Centers for Disease Control and Prevention (CDC) and a number of public health partner organizations (5). The focus on community primarily involves a stakeholder analysis. Representatives from organizations and agencies concerned with health issues convene to identify, prioritize and design solutions to community health problems. Stakeholders may include local government, the local board of health, special interest groups, health provider representatives and educational institutions. APEX encourages a role for the larger community, calling for involvement of “the general public, as represented by some form of community health committee or advisory body.” APEX specifically states that citizen participation and sustained community involvement is key to ownership of the collective health of the community and is critical to improving health status. Health agency staff’s role is to facilitate and clarify information, and act as an information resource.
APEX encourages collection and analysis of “objective” data, in the form of surveys and key informant interviews to identify perceived health problems. Using these data, a dialogue between the committee and health department staff can begin to identify, prioritize, and analyze resources and map community assets. Finally a community health plan is developed and presented to the appropriate decision-makers for adoption.
Mobilizing for Action Through Planning and Partnership
Mobilizing for Action Through Planning and Partnership (MAPP) resulted from a cooperative agreement between CDC and NACCHO to provide a community-wide strategic planning tool to improve the community’s health status. There are a series of steps and four assessments that comprise the model. Steps, in order, include: organizing for successful partnership development, creating a vision, conducting the four assessments, identifying strategic issues, formulating goals and strategies and, finally, developing an action step. This final step involves planning, implementing and evaluating. The four assessments include community themes and strength assessment, local public health system assessment, community health status assessment and forces of change assessment.
A steering committee guides the process, supported by subcommittees that represent the broader community. MAPP is a community-driven process that emphasizes community ownership and collective thinking. Voices of numerous organizations and individuals that contribute to the community’s health are heard. The broader partners play a critical role in developing a community vision.
Planned Approach to Community Health
Planned Approach to Community Health (PATCH) is a community health planning and program activity developed by the CDC’s National Center for Chronic Disease Control and Health Promotion to assist communities in planning, conducting and evaluating health promotion programs, particularly those focused on chronic disease prevention. PATCH tries to “increase the capacity of communities to plan, implement, and evaluate comprehensive, community-based health promotion programs targeted toward priority health problems” by mobilizing the community, collecting and organizing “objective” health data, choosing health priorities, developing a comprehensive intervention plan, and evaluating PATCH. Citizens guide the process of community mobilization, using a working group formed from a larger community group to provide guidance for day-to-day maintenance of the mobilization efforts. The community group and working group have the responsibility to collect objective health data, set priorities for action design community interventions and evaluate the programs developed by the PATCH process.
Healthy Cities, originating in 34 European cities, initiated the global Healthy Communities movement that spread to a number of US communities. The principles of Healthy Communities-broad definition of health, focus on root causes, system change-compel citizens to view community challenges holistically, thereby drawing people away from the trap of issue-specific fragmentation and competition (12). The core of the movement is building communities capable of addressing their own health problems by engaging the voices and talents of the community. Healthy communities could and should be seen as a civic and democratic movement.
Based on the framework of public judgment suggested in the introduction to this paper, we find several problems in existing community health planning and development models. First, experts continue to be responsible for organizing, leading, presenting, implementing and evaluating in the models we discuss. Although most of the models call for participation of the community, unfortunately, the community usually is represented by those who are from kindred organizations and agencies, in the parlance of public health, stakeholders. The result is that elites discuss the problem and working through solutions with other elites, not citizens. We do not intend to suggest that individuals representing stakeholders are not citizens, but they bring an organizational perspective and scientific expertise with them. Were they to participate without overemphasizing their expertise or stifling the discussion, putting forth their own experiences and the trade-offs they are making in deliberation, then they can certainly be a part of a public deliberative process.
Generally, the models discussed here also call for smaller groups to represent the community and to guide the process, diminishing the potential for broader involvement of citizens and the potential for public acting that might result from the involvement of larger numbers of individuals. The role of public judgment is severely limited in the processes described here. The predominant information used in most of these models is objective information: facts about the community’s health status, risk factors, and morbidity and mortality data. Some of the models do call for more qualitative data, such as key informant data, which brings us back to elite discussions.
Instead of these approaches, a series of deliberative forums might be used to facilitate give and take discussion, weigh risks and opportunities and come to some public judgment. Citizens need ownership of the results of their judgment and deliberation to move to the next step of public acting. For example, consider how the MAPP process might be improved with minor modifications suggested by Yankelovich’s and Mathew’s work (2,3). A part of the community visioning activity could be “naming and framing” public health issues in public terms, as described earlier. Deliberative forums could be held to encourage this naming and framing and result in broader communication to the community. Were these two additional steps added to the MAPP model, the process might improve the connection between citizens, the government and its agencies. It might increase the potential for public acting, as there would be a broader sense of community ownership of the process and its outcomes. Public judgment would add an additional dimension to the knowledge that could be used to improve the public’s health.
A Better Way
Efforts in Owensboro and Daviess County, Kentucky, a rural community of 100,000, exemplify an improved approach. Community health improvement resulted from efforts of the Public Life Foundation, a local foundation, that supported a survey/focus group process to identify health-related concerns as expressed by citizens. The community picked access to and cost of health care, plus lack of community participation in major health-related decisions. The Foundation contacted us at the University of Kentucky for assistance in further eliciting community health concerns. The resulting community/academic partnership first organized a series of focus groups to identify topics of interest to the community. Using the emerging themes, the university designed a questionnaire to collect more information from the community, employing a random-digit dial telephone survey. A survey of major health care providers gathered additional insights. The resulting community health profile was shared in a town hall meeting.
We continued the process into the next phase: naming/framing major health issues. Two major themes appeared in the data collection and analysis-health behavior and access/cost/quality issues. The deliberative process focused on access/cost/quality issues. We informed participants who deliberated through a booklet containing local data on health care and discussions of the necessary trade-offs for considering these issues. Over 11 months, 52 public forums engaged more than 575 citizens. For each forum, we collated and examined the major themes and the demographics of the participants. Ongoing analysis of participant characteristics assured the inclusion of voices from all segments of the community. Themes from the process were summarized in a “consumer-friendly” booklet written by a journalist, All is Not Well: Citizens Speak Out About Health Care in Daviess County (13).
The forums sparked several public actions. Most notable was the formation of Citizens Health Care Advocates, a group of forum participants committed to maintaining community dialogue, citizen deliberation, and a community voice in health decisions. Based on this experience, other Kentucky communities looking to improve their health status have begun similar projects (13).
Additional thought should be given in each of these models about the best method of incorporating naming and framing health issues that lends itself to public deliberation and results in public judgment and public acting. If it is possible to rethink the four models to incorporate these activities, then the process of improving communities’ health can be better informed and facilitated. As new iterations of these models are developed we encourage the responsible groups to incorporate more direct citizen involvement to assure a wider range of citizens are involved in community health improvement activities.
Acknowledgment: This paper was completed while Dr. Scutchfield was a Visiting Scholar at the Kettering Foundation. Their support and encouragement have contributed to the results reported here. I would also like to acknowledge Dr. Julie Fisher and Neil Carlson for their early reading and suggestions.
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Community involvement with public health planning and implementation are vital to improving community health. There are a variety of community health models that are available. We describe these four models from the perspective of how they involve the broader community. These models are evaluated from a different perspective about linking the community and politics and agencies, that involves naming issues, framing options, public deliberation and public acting. We suggest ways that these models can be further refined to connect citizens to the processes that we use for community health improvement.
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