575099 research-article2015
HEBXXX10.1177/1090198115575099Health Education & BehaviorLieberman and Earp
Endnote
Reflections on Structural Change: Where Do We Go From Here?
Health Education & Behavior 2015, Vol. 42(1S) 141S–142S © 2015 Society for Public Health Education Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1090198115575099 heb.sagepub.com
Lisa D. Lieberman, PhD, CHES1, and Jo Anne L. Earp, ScD2 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 1
Montclair State University, Montclair, NJ, USA Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA 2
Corresponding Author: Lisa D. Lieberman, Department of Health and Nutrition Sciences, Montclair State University, Montclair, NJ 07043, USA. Email: [email protected]
Downloaded from heb.sagepub.com by guest on November 13, 2015
142S
Health Education & Behavior 42(1S)
reactions, capacity building, coalition formation, and planning for sustainability. Yet limited numbers of agencies or groups are dedicated solely to funding and evaluating public health or community-level health promotion outcomes at the same level that the National Institutes of Health is dedicated to biomedical research or the National Science Foundation to physical, chemical, biological, and engineering research. Even foundations with impressive resources, such as the Robert Wood Johnson Foundation, tend to prioritize their resources toward one or two major public health or social issues at a time. Finally, given variations in access to power and resources by interventionists themselves, how do we guarantee that structural changes actually reach communities most in need? To what extent are the problems we prioritize, and the language used to advocate for them, a consequence of unequal access to power and, ultimately, resources? To target resources more equitably, we must find a way to reframe issues vital to the success of most social change efforts as controversies that result from the unequal distribution of power, rather than from exposure to a health threat. The articles in this issue, and the questions they generate, thus imply a need to avoid false dichotomies. The future of structural-change practice and research in health promotion can rely neither on process nor outcome evaluation alone, nor on RCTs, at the expense of what can be learned from natural experiments. Conceptual and analytic debates between intervening on one or multiple levels, or through normative versus regulatory approaches, moreover, fail to illuminate the complexity of intervention work, much less the importance of attending to
interactions between different structural strategies within different contexts. In the end, as these articles demonstrate, no gold standard exists for designing or evaluating structural change. Creative approaches, however, undergirded by both empirical and “lived” evidence, and guided by social and behavioral theory, hold the promise to expand the boundaries of structural change in the service of public health. Supplement Issue Note This article is part of a Health Education & Behavior supplement, “The Evidence for Policy and Environmental Approaches to Promoting Health,” which was supported by a grant to the Society for Public Health Education (SOPHE) from the Robert Wood Johnson Foundation. The entire supplemental issue is open access at http://heb.sagepub.com/content/42/1_suppl.toc.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References Lieberman, L., Golden, S., & Earp, J. (2013). Structural approaches to health promotion: What do we need to know about policy and environmental change? Health Education & Behavior, 40, 520-525.
Downloaded from heb.sagepub.com by guest on November 13, 2015
HEBXXX10.1177/1090198115575099Health Education & BehaviorLieberman and Earp
Endnote
Reflections on Structural Change: Where Do We Go From Here?
Health Education & Behavior 2015, Vol. 42(1S) 141S–142S © 2015 Society for Public Health Education Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1090198115575099 heb.sagepub.com
Lisa D. Lieberman, PhD, CHES1, and Jo Anne L. Earp, ScD2 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 1
Montclair State University, Montclair, NJ, USA Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA 2
Corresponding Author: Lisa D. Lieberman, Department of Health and Nutrition Sciences, Montclair State University, Montclair, NJ 07043, USA. Email: [email protected]
Downloaded from heb.sagepub.com by guest on November 13, 2015
142S
Health Education & Behavior 42(1S)
reactions, capacity building, coalition formation, and planning for sustainability. Yet limited numbers of agencies or groups are dedicated solely to funding and evaluating public health or community-level health promotion outcomes at the same level that the National Institutes of Health is dedicated to biomedical research or the National Science Foundation to physical, chemical, biological, and engineering research. Even foundations with impressive resources, such as the Robert Wood Johnson Foundation, tend to prioritize their resources toward one or two major public health or social issues at a time. Finally, given variations in access to power and resources by interventionists themselves, how do we guarantee that structural changes actually reach communities most in need? To what extent are the problems we prioritize, and the language used to advocate for them, a consequence of unequal access to power and, ultimately, resources? To target resources more equitably, we must find a way to reframe issues vital to the success of most social change efforts as controversies that result from the unequal distribution of power, rather than from exposure to a health threat. The articles in this issue, and the questions they generate, thus imply a need to avoid false dichotomies. The future of structural-change practice and research in health promotion can rely neither on process nor outcome evaluation alone, nor on RCTs, at the expense of what can be learned from natural experiments. Conceptual and analytic debates between intervening on one or multiple levels, or through normative versus regulatory approaches, moreover, fail to illuminate the complexity of intervention work, much less the importance of attending to
interactions between different structural strategies within different contexts. In the end, as these articles demonstrate, no gold standard exists for designing or evaluating structural change. Creative approaches, however, undergirded by both empirical and “lived” evidence, and guided by social and behavioral theory, hold the promise to expand the boundaries of structural change in the service of public health. Supplement Issue Note This article is part of a Health Education & Behavior supplement, “The Evidence for Policy and Environmental Approaches to Promoting Health,” which was supported by a grant to the Society for Public Health Education (SOPHE) from the Robert Wood Johnson Foundation. The entire supplemental issue is open access at http://heb.sagepub.com/content/42/1_suppl.toc.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References Lieberman, L., Golden, S., & Earp, J. (2013). Structural approaches to health promotion: What do we need to know about policy and environmental change? Health Education & Behavior, 40, 520-525.
Downloaded from heb.sagepub.com by guest on November 13, 2015
