COMMUNITY ACTION FOR HEALTH PROMOTION: A STRATEGY TO EMPOWER INDIVIDUALS AND COMMUNITIES E. Richard Brown Health status is directly affected by environmental conditions and by personal health-related behaviors, and it is indirectly affected by environmental conditions that themselves influence health behaviors. A comprehensive approach to health promotion, therefore, should encourage individuals to adopt and maintain personal behaviors that would prevent disease and promote health; discourage healthdamaging personal behaviors by individuals and facilitate people engaging in health-promoting behaviors; and eliminate health hazards from the physical and social environment and make that environment more health-promoting. This comprehensive approach would require social and community action to change environmental conditions as well as efforts to change individual behavior. A model of health promotion interventions is developed within which community action plays a central role. The author then presents a model of community organization to influence public policy to achieve health promotion goals. The community organization model, previously tested in comparative case-study research, is illustrated with examples drawn from appropriate health promotion programs.

Health educators frequently discuss the virtues of community-based programs to change physical and social conditions to improve health, the importance of avoiding victim blaming, and the desirability of giving people a greater sense of their power to make changes in their lives. But health promotion programs usually focus on getting individuals to change their personal health-related behaviors and seldom broaden their objectives to empowering people beyond arenas of their individual lifestyles or to changing environmental factors that shape behavior and influence health status (1).This article focuses on the use of community action to promote the health of populations. I will develop a model of health promotion interventions within which community action plays a central role, then present a model of community organization to influence public policy to achieve community health promotion goals. This article is part of the Special Section on Health Promotion Strategies, edited by Dr. I. Warren Salmon. The article is based on a paper presented at the International Symposium on Community Participation and Empowerment Strategies in Health Promotion, Center for Interdisciplinary Research, University of Bielefeld, Federal Republic of Germany, June 5-9,1989.

Intwnetional Journal of Health Services, Volume 21, Number 3, Pages 441456, 1991 0 1991, Baywood Publishing Co.,Inc.

441 doi: 10.2190/AKCP-L5A4-MXXQ-DW9K http://baywood.com

442 I Brown A COMPREHENSIVE STRATEGY OF HEALTH PROMOTION “Health promotion” includes actions intended to prevent specific diseases (that is, to reduce the risks of particular types of morbidity and causes of death, defined clinically or biomedically), to prevent sickness (that is, to reduce the likelihood of functional incapacity, predominantly defined according to social criteria), and to promote an optimal level of physical and social functioning (that is, striving to reach the World Health Organization’s definition of health as “a state of complete physical, mental and social weil being”) (2, 3). These three components together define the goals of health promotion, whether programs are targeted to improve the health of individuals, groups of people, communities, or whole populations. Changing Individual Behavior

It is clear that many personal behaviors contribute to morbidity and mortality while others contribute to improved health. Smoking and heavy drinking, for example, may contribute to a variety of acute and chronic illnesses and death, while regular exercise and appropriate eating may reduce the incidence of illness and actually increase longevity (4). Programmatic interventions may help individuals to stop, or not start, health-damaging behaviors and to adopt health-promoting ones by providing them with information about the health effects of various behaviors and by giving them cognitive and affective tools that are useful in changing such behaviors. Health education programs, for example, may help teenagers not to start smoking and to learn to drink in moderation by educating them about the hazards of smoking and alcohol abuse, helping them develop resistance to advertising and social pressures, and teaching them alternative ways of coping with emotional stress. To reduce the incidence of cardiovascular disease, programs may educate people about healthy dietary practices that would reduce cholesterol levels or other risks. To improve the health of infants and mothers, pregnant women may be educated to enroll in prenatal care early in their pregnancies, to eat appropriate diets, and to avoid alcohol and most drugs. In workplaces, educational programs may inform workers about occupational hazards and instruct them to use personal protective equipment (such as protective gloves or respirators) to protect themselves from exposures. The specific behavioral targets thus may be habits or practices that should be avoided (for example, not smoking, drinking heavily, or eating high-cholesterol foods) or those that should be adopted and maintained (for example, obtaining medical monitoring and adopting especially healthful practices during pregnancy, getting young children adequately immunized against preventable diseases, wearing seatbelts, using protective equipment and following safe work practices). While resisting blaming individuals for illnesses related to harmful behaviors, we must recognize the role that personal behavior does play in determining health status. It is important to inform people about how their own personal actions affect their health and to help them make desired changes in their health-related behaviors, even though this individual empowerment strategy is likely to be effective only for a minority of highly motivated people with well-developed “self-efficacy.”

Community Action for Health Promotion I 443 Unfortunately, most health promotion programs, particularly in the United States, begin and end with efforts to get people to change their personal health-related behaviors. Although such interventions may help some people change from healthdamaging behaviors to health-promoting ones, many individuals find it difficult to adopt healthful behaviors because their physical or social environments impose many obstacles to engaging in these actions. Indeed, rather than holding individuals responsible for their lifestyles, it is important to recognize the central role that physical and social environments play in shaping personal behavior. Virtually no behavior is under the complete and voluntary control of individuals. In addition, individual behaviors are not sufficient to prevent illness and death in the face of hazards in the physical and social environment that increase risks of disease or death. Environment is a vitally important influence on behavior as well as a direct influence on overall health status (5-8). A comprehensive health promotion strategy thus would help individuals adopt healthpromoting behaviors as well as strategies targeted to the larger environment. Changing Environmental Influences on Behavior Many environmental influences discourage people from changing health-damaging behaviors to health-promoting ones in at least two ways. First, the social environment may encourage or reinforce health-damaging behaviors and discourage people even from desiring to engage in healthful behaviors. Advertisements for cigarettes and alcoholic drinks, for example, often make smoking or drinking look like the road to success and popularity. Second, the physical and social environment may discourage people from engaging in health-enhancing actions, even when they want to do so, by providing innumerable obstacles to such behaviors. For example, low-income pregnant women who want to enroll in prenatal care may find it very expensive, or they may have to wait many weeks for the first available appointment. People who want to lower their cholesterol intake may find low-cholesterol foods unavailable at local markets and restaurants or available only at prices they cannot afford. Workers who try to use personal protective equipment may find that the equipment is uncomfortable and that it interferes with the demands of production. Programs may help people change their health-related behaviors by eliminating barriers to behaving in healthful ways, by creating an environment that enables people to engage in health-promoting actions, and in some cases, by changing the environment to make it more difficult to engage in health-damaging actions. To encourage pregnant women to use prenatal care, a health promotion program may, for example, ensure that prenatal care services are readily available, free or at least affordable, and culturally sensitive. In the case of diet, actions might be targeted at encouraging markets and restaurants to offer more low-cholesterol food items at low prices. In occupational settings, this strategy might involve developing more comfortable personal protective equipment or slowing down the pace of work to enable people to use such equipment and safe work practices. To discourage smoking and drinking, especially among adolescents, a health promotion strategy might work to ban advertising of tobacco products and alcoholic beverages and to increase taxes on them, although increased taxes would have a disproportionate impact among low-income populations. An important goal of such programs is to make healthful behaviors “the easy choice” (9), a central

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programmatic strategy in the health promotion programs encouraged by the European region of WHO.

Changing Environmental Influences on Health Status In addition to targeting changes in personal health-related behaviors, communities can directly influence health status by changing health-damaging environments to health-promoting environments. These changes are designed to reduce individuals’ and populations’ risks for disease or injury and to improve their health, independently of their own individual behavior. Historically, changes in the physical and social environment have been responsible for more improvement in mortality and morbidity rates than medical care (8, 10) and, probably, than any other factors. Such changes are needed to protect the health of populations from many hazards that are not of their making. Social justice, as well as good public health practice, requires that we eliminate hazards at their source, rather than expecting individuals to cope with risks for which they are not responsible. For example, redesigning dangerous roadways and improving the safety engineering of cars (such as improving their “crash worthiness” and installing automatic seatbelts) can reduce automobile accidents and fatalities, independently of the actions of drivers. Regulation of the food industry could increase the likelihood that most foods that consumers buy are relatively low in saturated fats, as well as free of contaminants, independently of consumers’ own selection decisions. In workplaces, employees’ health can be protected by substituting nontoxic substances for toxic ones or by creating an enclosure for toxic substances that protects workers from being exposed, without requiring workers to use personal protective equipment (11). Communities can protect themselves from exposure to toxic substances by eliminating them from their environments (12). The strategy of changing health-damaging environmental conditions to healthpromoting ones requires effective community and societal action. In sum, a truly complete health promotion approach would: (u) encourage individuals to adopt and maintain personal behaviors that would prevent disease and promote health; (b) discourage health-damaging personal behaviors by individuals and facilitate health-promoting behaviors; and ( c ) eliminate health hazards from the physical and social environment and make that environment more health-promoting. This is the strategy advocated by the Ottawa Charter for Health Promotion (13). A Model ofIndividual and Community Health Promotion

These three intervention strategies-directly changing personal behaviors, changing environmental influences on health-related personal behaviors, and changing environmental conditions that directly influence health status-can be depicted in a model of health promotion (Figure 1).In Phase 1, public health workers and community members identify health needs and risk factors that contribute to disease or death or that reduce positive health functioning, and plan programs to deal with them. These factors may be in the physical or social environment, or they may be personal health behaviors, or some combination. However, it is important to remember that how the problem is definedthat is, in terms of the voluntary behaviors of individuals, environmental factors that

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influence the health-related behaviors of individuals, or environmental factors that directly influence health status-essentially determines the intervention strategy that will be chosen. This phase is the needs assessment and planning stage typically found in public health programs. If community participation truly is intended to empower the population, then the community must be substantively involved in this process of assessing health problems and needs, deciding priorities, determining the causes of health problems, and developing strategies and programs to solve them (14). In Phase 2, a health promotion intervention is implemented. Depending on the source of the problem-that is, the risk factors identified in Phase 1-the intervention may target a hazardous environment or high-risk personal behaviors. Environmental hazards would be targeted directly, while personal health-related behaviors may be influenced indirectly by changing the social or physical environment or directly by trying to influence individuals themselves, depending on the factors that have been identified as primary sources of the problem. As in Phase 1,active community participation in Phase 2 is essential if community members are to gain the necessary skills, experience, and confidence to overcome other health problems. The outcome of these interventions, it is hoped, will be reduced risks and improved health status, as Phase 3 suggests (Figure 1). A few programs combine more than one strategy. For example, community-wide interventions to reduce cardiovascular disease risks among whole defined populations have been established in Finland (15), the United States (16, 17), and Wales (18). They

446 I Brown educate people to change their own behaviors, and they help people to make the “healthy choice” by making appropriate changes in the environment. In general, these programs use social marketing and community-based communication networks to encourage people to change high-risk behaviors (such as smoking and high-cholesterol diets), and they try to modify the social environment to discourage such behaviors (for example, by getting support for smoke-free workplaces) and to lower barriers to engaging in appropriate behaviors (for example, by encouraging food producers, markets, and restaurants to offer low-cholesterol food items at low prices). In Sweden, this approach has been adapted to the prevention of cancer (19). Some community-wide interventions target high-risk individual behavior and also try to correct hazardous conditions in the environment. An accident prevention program in a Stockholm suburb, for example, at the level of individual behavior, educated community members about how to reduce their own risks for accidents and, at the level of changing environmental hazards, helped improve the safety of consumer products and sent teams of inspectors throughout the community to identify and force the correction of community conditions that were likely to cause accidents (20). Similarly, a community organizing effort in a hillside slum, or favela, in Rio de Janeiro educates local community members about healthful behaviors and organizes them to demand sanitation, water, and health services from the city and changes in the environmental conditions that cause illness, injury, and social problems in the community (21). Similar emphases on educating workers as a group and changing health-damaging environments can be found in most government occupational health protection programs in Scandinavia and Western Europe, as well as in programs of many labor unions and voluntary committees on occupational safety and health (COSH groups) in the United States (22). To sum up, it is important to keep in mind the limited power that individuals have. People should be encouraged to assert whatever personal control they can over their lives, including altering their own behavior or changing their immediate conditions to improve their health or other aspects of their lives. For most people, however, factors outside their individual control are greater determinants of their lives than are factors that they individually can control. Collective action at the level of the school or workplace, the community, and larger populations is far more effective in changing these environmental factors, and thus in improving the health of whole populations, than is a strategy that focuses primarily on changes that individuals can make by themselves. The remainder of this article focuses on empowering communities to take effective action to change environmental conditions that directly affect personal health-related behavior and/or health status. COMMUNITY ACTION FOR HEALTH PROMOTION Community action involves deliberate organization of community members to accomplish some objective or goal. As a deliberate and formal activity, community action is distinguished in this article from purely informal activities, such as a picnic or baseball game among friends or neighbors that does not involve some formal organization, and from nondeliberate action, such as a riot that arises spontaneously. Community organization includes any effort to form temporary or permanent organizational structures involving members of a community. In the case of health promotion, community

Community Action for Health Promotion / 447 action may be directed at changing environmental conditions to improve health directly or to change health-related behaviors. The specific objectives of such community action might involve bringing about a change in public policy (for example, getting a county clinic to make prenatal care free, culturally sensitive, and more accessible), getting a private organization to change its practices (for example, forcing a battery factory to stop its emissions of lead into the community), or altering other aspects of the physical or social environment (for example, starting a community garden on available land). Sometimes new programs may be initiated or desired changes in organizational policies or practices may be brought about as the result of cooperative discussions among diverse elements of a community, including community members or representatives and officials of relevant organizations and agencies. This is a community development approach, in which a cross-section of the community participates in problem-solving and reaches a consensus decision that all can support, or at least live with (23). Community development is useful to change environmental conditions and personal behaviors where the main obstacle to desired changes is a lack of social cohesion or inadequate organizational resources, such as basic organizations, leadership, and organizational skills. Such collective community resources, however, may be only gradually developed through organizational processes that involve a high degree of participation by community members and groups. Community development is thus a gradual process, and its results cannot be realized quickly. The consensus decision-making process limits community development to those situations in which different constituencies are not polarized around an issue and are fairly easily unifiable. Moreover, the consensus process allows dominant interests in the community to exercise a veto power over collective decisions simply because their support is usually viewed as critically important to community efforts (24). In many cases, however, more persuasive action is required to get a more powerful organization or official to make changes desired by people who have fewer resources and less power. Where changes are controversial or conflict with the interests of powerful groups or social classes, more forceful action is usually required. This more forceful advocacy of a particular position is a social action strategy, in which cornmunity members are mobilized to use organizational, political, and economic pressure to correct an injustice (23). Like community development, social action organizing can help powerless people develop organizational skills and experience and a greater sense of their own ability to change both their community and their own lives, changes that are consistent with any conception of health promotion. Social action, however, uses popular power in an effort to coerce often recalcitrant dominant economic and political institutions and agencies to meet people’s expressed health and other needs. A strategy developed by the Brazilian adult educator Paulo Freire even more fully emphasizes the importance of empowering oppressed people (25). Because of the emphasis in this health promotion model on active participation of community members, the concept of community action used here excludes some forms of community organization that are conducted by experts as a service for the benefit of community members without their active participation. This criterion would exclude social planning and social reform approaches, which are controlled by

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experts, and some community development programs that pay only lip service to community participation.' A Model of Community OrganizationProcess and Factors That Influence It

Health promotive changes in a community's social and physical environment may thus be achieved by community development or social action strategies, depending on the community's particular needs and circumstances. In some cases, it may be appropriate to use both strategies, emphasizing one during an early phase and the other at a later stage, or using both strategies simultaneously in different community contexts. Regardless of whether community development or social action strategies are being employed, however, changing the environment will ultimately involve changing aspects of public policy, usually at the local level. And such changes will require a process of deliberate community organization to influence the policy process. The model presented in Figure 2 describes the elements of a successful process of community organizing to achieve objectives of community change, identifying variables that are important in the process and how they relate to one another. This model was first developed and tested in a comparative case study of community actions to influence local government health care policy (26) and was later applied to health promotion actions (27). The San Francisco Tenderloin Senior Outreach Project (TSOP) (later renamed the Tenderloin Senior Organizing Project) will be used to illustrate the various elements of the community action model and their interrelationships. TSOP employs both community development and social action strategies with low-income elderly residents of single-room occupancy hotels in an inner-city neighborhood to overcome their social isolation and increase their political power, as well as to improve their physical health. The community, its problems, and TSOP have been described by Minkler (28-30). The model comprises four phases: pre-organizational conditions, the organizing phase, policy influence, and the policy decision. Phase 1 involves the basic preorganizational conditions of community organization, including three categories of factors that lay the basis for whether community organization efforts will be successful. 1. Need or conditions. Relevant health, economic, political, and/or social factors indi-

cate whether a community's problems are sufficient to sustain an interest in community action. These needs should be measured independently of the attitudes of the commrrnity population. Having a substantial need helps motivate organized action. It is often communities with higher levels of economic development, however, rather than those with severe needs, that are more likely to achieve new policies or programs. In the San Francisco Tenderloin area, indicators of need include low per capita income and high rates of alcoholism, hypertension, suicide, homicide, and assault. Phase 1 of this community

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450 / Brown organization model is related to the assessment of health needs and risk factors in Phase 1 of the health promotion model. 2. Predisposing factors. A community population’s receptivity to being organized is affected by its attitudes, including its beliefs about the importance of the issue being raised, the legitimacy of the issue as a focus of group action, previous experience with organized action, and community perceptions of the probabilities of success and failure of organization and action. A community is more highly predisposed to organization and action if its members believe a given issue is important and is a social issue that can legitimately be addressed by collective action, rather than just a personal problem to be suffered individually. They will also be more predisposed to participate in community action if they have had previous successful organizational experiences or know other people who successfully used community organization. In the Tenderloin, elderly residents’ fear of crime kept them socially isolated, and thus unable to act collectively on their concerns. However, most residents articulated their personal concerns about crime, and many expressed great interest in doing something about it.

3. Enabling factors. The potential for community organization is influenced by the availability of organizational resources, including the level of existing organization of the community constituency, the presence and effectiveness of an organizer, the emergence of leaders and the extent of their support, the degree of unity among organizations and leaders involved in the organizing effort, and the availability of material support for the effort. Community organizing efforts are greatly facilitated if there is a network of organizations, agencies, and leaders already present. These organizations and leaders can enable community action to develop if they support the organizing effort, if they provide an organizer to prod and give direction, and if they supply material resources (for example, photocopying, mailing, and other expenses). The Tenderloin area is an especially difficult one in which to organize because of the extreme absence of social networks and organization among the elderly residents. This lack of opportunities for social participation was apparent to residents and organizers alike. These deficiencies in enabling factors were gradually overcome, however, by other enabling factors-namely, the intervention of volunteer TSOP organizers, initially based at a nearby university, who brought residents together in each of several hotels, assisted by some material resources provided by a small foundation grant. As the arrows in Figure 1 suggest, actual need influences predisposing variables. That is, objective conditions influence individual perceptions of need, attitudes concerning the importance or legitimacy of the issue, and the perceived likelihood or success. Predisposing and enabling variables also influence each other. An intensely perceived need and strong receptivity to organization may, for example, encourage people within the community to provide needed resources, while an effective organizational process or one supported by prestigious leaders may encourage community members to have greater faith that organizational efforts will successfully achieve their objectives. This

Community Action for Health Promotion / 451 phase is characteristic of any kind of community organization effort, including community development and social action interventions. The TSOP’s efforts were made more difficult because, although the serious threat of crime (need factors) provoked great concern by the elderly residents (predisposing factor), most residents had little positive experience with community organization and felt quite powerless to change social conditions (predisposing factors). They also had few informal social ties, few places in which to socialize, and few formal community organizations or agencies (enabling factors) that could help them act together to deal with this problem. However, volunteer organizers helped them overcome these obstacles by bringing them together and providing an opportunity for leaders to emerge among residents (enabling factors). Collective social and political action at the neighborhood, municipal, county, state, and/or national levels is often necessary to change conditions that themselves adversely affect health or that discourage individuals from engaging in health-promoting actions. Phase 2 depicts the stage in which community organization takes shape and action is implemented to affect those decision-making units that make relevant policies (Figure 2). Phase 2 of this community organization model includes the intervention programs in Phase 2 of the health promotion model. In community organization, this phase includes three categories of factors.

1. Community organization and action. This important component is the process of organized action-that is, the adoption of objectives, development of structure, and organizational participation by units and individuals to achieve the group objective. It includes activities intended to strengthen the organization itself, such as improving the group’s internal functioning, reaching out to additional community members and groups, and obtaining support from other constituencies. This component also includes externally directed actions, such as those designed to encourage a policymaking unit to adopt the desired changes or actions that would bring about other changes in the community that would lead to improved health status or changed health-related behaviors of community members. As Figure 2 indicates, the predisposing and enabling variables together influence community organization and action. This component may involve community development or social action strategies to change health-damaging conditions and develop health-promoting ones. Some organizational activities may be directed at obtaining support from technical experts and from units and leaders outside the constituent community. Other community actions may be used to mobilize support, neutralize opposition, and encourage policy makers to adopt the desired changes. Although many different objectives, structures, and actions may be appropriate, depending on the community conditions, perhaps the most important caveat is that community participation should be as central as possible in this process. This participation is vital to build organizational skills and leadership in the community and to assure that the community “owns” the organization and action that emerges.

2. Technical support. Another component applies the technical expertise of organizations, agencies, and individuals in support of the community objectives. This

452 1 Brown component includes the use of health planners to document problems and needs, housing specialists to help develop community-sponsored plans, and lawyers to interpret statutes and initiate legal action, etc. Technical support can influence the kinds of actions a community organization implements, as when attorneys encourage a strategy of change using judicial processes or when budget analysts provide information to community leaders that they can use in their arguments in public hearings or negotiations. Technical experts may also formulate arguments used by community organization leaders in their efforts to secure other support or neutralize opposition-for example, when researchers present findings in support of community proposals for expanded, publicly provided prenatal services. Such technical support is very useful to community efforts, but it is important not to let technical experts dominate the community process because their domination would discourage active participation by community members. A strategy that relies on experts to define and lead change efforts is a social reform approach, not primarily communitycentered action. This emphasis on community participation and empowerment is not meant to denigrate the importance of health professionals or other experts in this process. Communities may look out for “number one” in ways that few public health professionals would support. As Labonte put it, “what communities do for their own health may be inimical to public health” (31). If community action is being organized on behalf of racist or reactionary goals, health professionals have a responsibility to voice their own views and values and not blindly or slavishly support the community. 3. Expanded support and opposition. Actions by groups and individuals outside the immediate constituent community being organized may support or oppose the community action objectives, thereby having a substantial impact on its outcome.

Winning the support and involvement of “outside” leaders or groups with their own constituencies and the support of media can make a difference between a successful and unsuccessful effort. Support from leaders outside the constituency may have a substantial reinforcing effect on the attitudes of the community constituency, as when a well-known public official, labor or business leader, or other popular figure publicly endorses a community’s objectives or actions and thus lends his or her legitimacy to the effort. Similarly, media coverage may generate wider interest in an issue, publicize a community organization effort, and further legitimize an issue as a social and community concern. Because many of the communities most in need of health promotion efforts are also economically poor and politically weak, such communities may find it particularly valuable to win support from media, political leaders, and more powerful groups to achieve their objectives of changing environmental conditions. TSOP organizers first focused on the issue of crime because of the strong sentiments of the hotels’ elderly residents. The fear of robbery or assault kept residents indoors and isolated, limiting their opportunities for social participation. Initial police department presentations angered residents because they emphasized what individuals must do to ensure their own safety, rather than focusing on the social environment that fostered crime in the neighborhood and on community action that could reduce it or protect

Community Action for Health Promotion / 453 residents. Organizers encouraged residents to visit Project meetings on the issue in other hotels being organized, and the most activist among the residents organized a formal inter-hotel coalition, Tenderloin Tenants for Safe Streets. They used the media to publicize their problem and to demand (and get) a meeting with the mayor and the chief of police. They demanded that the police increase the number of foot patrols and regularly visit the hotels to get to know the elderly residents. They also organized a Safehouse Project in which they recruited local businesses, agencies, bars, and restaurants to serve as places of refuge, designated by a sign in their windows, where residents could go when they felt they were in danger or had a medical emergency. These actions reflect the process of adopting objectives, initiating action to influence city police policy (a social action strategy) and to improve conditions within the neighborhood (a community development strategy), using technical support provided by volunteer organizers and generating support through the media and from local businesses and agencies. Phase 3 identifies and describes the target of these community actions. 1. Policy-muking body. The receptivity of the policy-making body (or person) to the changes or developments being proposed is, of course, important to the kinds of actions that may be necessary to achieve the community’s objectives. The relevant characteristics of the public or private body include its composition, its authority and autonomy, its relationship with the community constituency, and its vulnerability to influence from the community. 2. Noncommunify context. Factors outside the community-including external resources available, fiscal factors, legislative action, judicial action, and regulatory enforcement-provide the broad backdrop within which the body makes policy.

The availability of external funding, the threat of legislative inquiry or legal action, or tough enforcement of regulations may facilitate, limit, or compel the actions of the local policy-making body and the decisions they make. The types of actions taken by the community in Phase 2 should be influenced by the anticipated receptivity of policy makers (Phase 3), by support from forces “above” the community (Phase 3), and by support or opposition from groups outside the community constituency (Phase 2). For example, when policy makers are believed to be very receptive to the change objectives and there is little or no opposition to changes from other powerful interests, then necessary changes may occur as a byproduct of the consensus process of the community development strategy. Under such conditions, nonconfrontational tactics may be perfectly adequate even in a social action strategy. When policy makers resist, however, more militant and challenging actions may be necessary. Such actions, together with an alliance between the community constituency and more powerful community leaders and groups, have proved to be very important determinants of the willingness of officials to meet the needs or demands of less powerful constituencies (27). The success of TSOP was facilitated by the political appeal of elderly residents of a high crime area asking the Mayor of San Francisco to increase police patrols. The Mayor, who is politically ambitious in a generally liberal city, quickly responded with a visit to the neighborhood and by agreeing to increase police activity. In this case, the

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impact on fiscal resources was small, and the policy maker had the authority and the political inclination to respond positively. Finally, Phase 4 represents the culmination of the whole process: the extent to which policies have been changed in accord with the community’s objectives. As depicted in Figure 2, the policy is determined by the policy-making body but under constraints directly or indirectly imposed by contextual factors. The policy may then have a presumably measurable effect on the indicators of need. It may also directly affect the predisposing indicators by changing the perceptions and attitudes of community members and thus reduce or increase their commitment to further organizational action. Successful actions that result in desired changes in the health-related environment may reduce the needs to which community members originally responded, but they may also increase community members’ organizational skills, experience, leadership, and feelings of empowerment. They thus may encourage further action for more far-reaching goals of social change. Alternatively, policy changes that are more cosmetic than substantive may decrease the perceived relative importance of the desired change, and repressive actions may reduce the perceived prospects for success. (In the health promotion model, the effect of the intervention on health status in Phase 3 may have parallel effects on health needs and readiness to engage in additional health promotion actions.) During the first year of TSOP’s crime prevention program, crime in the area dropped 18 percent, a reduction that the police attributed in part to the program. The 48 Safe Houses were a visible achievement of the Project, which assisted community people in 56 medical or police emergencies and which encouraged residents to believe that their community organization could improve community conditions. New projects have been launched to improve the nutrition of hotel residents. Social isolation has, in turn, been reduced as residents spend more time in their hotel lobbies, socializing and engaging in daily living activities. Thus, the Tenderloin Project has resulted ultimately in policy changes (increased police presence) and new institutions (Safe Houses) that have improved the need conditions (reduced crime rates), changed residents’ attitudes (given many of them a feeling of power over their community environment), and improved enabling factors (reduced their social isolation, produced leadership among the residents, and developed a new and effective community organization). These changes have led to reformulation from a predominantly community development strategy to a more explicitly social action strategy, even involving a change in TSOP’s name (as noted above) to reflect the social action emphasis (32).

CONCLUSION Together these four phases and nine components describe community action efforts to influence local public policy for health promotion and for other issues. The first two phases are generic to all community organization strategies, while Phases 3 and 4 are relatively more specific to efforts to influence policy. This model is applicable to a wide variety of community action strategies to turn health-damaging environments into health-promoting ones, fostering healthful behaviors of community members and empowering communities to alter the social and physical conditions that directly affect the health of the community. It is intended to provide a general guide to action; it

Community Action for Health Promotion / 455 is not a cookbook. Beyond any practical value it may have, it is also intended as a conceptual model to stimulate further research on effective methods of community action. The ultimate objective of community action for health promotion must be to empower people to improve their individual and collective health. Health promotion thus can be most effective when it fully involves community members in a community-organizing process of assessing health needs, deciding which needs should receive priority attention, determining the causes of problems, and deciding on strategies to solve them. This process has been used by others, including efforts by the Center for Health Promotion/ Disease Prevention of the University of California, Los Angeles, to work with lowincome minority communities in that city. Although some changes at the individual, community, and societal levels can be made administratively by concerned reformers and behavior-change experts, such changes may not be broad or long-lasting. They are likely to affect only those narrow sets of conditions to which they are targeted and to be dependent on the goodwill and commitment of those immediately involved. Developing organization and leadership among the people who are affected by the conditions or behaviors, and involving them in every aspect of creating necessary changes, it is likely to result in a broader and more firmly rooted social and political base that will ensure wider impact and greater staying power. Groups and communities that are empowered through organization and active participation develop the ability to attack other conditions to further improve their lives and their health.

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