Community psychology

The founding of community psychology in the United States in the 1960’s was motivated by many psychologists’ wish to contribute to the reduction of social inequalities of the times, and to right social wrongs that festered in American society. A founder of the field, Julian Rappaport, wrote: «…community psychology is concerned with the right of all people to obtain the material, educational, and psychological resources available in their society. In this regard community psychology is a kind of reform movement…and its adherents have advocated more equitable distribution of the resources that psychology and the helping professions control» (Rappaport 1997).

Community psychology’s ideological synchrony with the new public health is reflected particularly well by its ecological orientation (Catalano 1979), having these main features, again according to Rappaport (1997, pages 2–3):

• the notion that there are neither inadequate persons nor environments, but the fit between the two may be in relative accord or discord;

• the conviction that action for change emphasises the creation of alternatives by developing existing resources and strengths, rather than looking for weaknesses;

• the embracement of a value system based on cultural relativity and diversity.

In its content, community psychology bears a striking resemblance to the new public health, with emphases on person-environment fit in community settings, coping and social support, promotion of social competence, stimulation of citizen participation and empowerment, and organising for community and social change (Dalton, Elias and Wandersman 2001).

The research methods of community psychology are highly participatory and action research is common in the field. Participatory action research involves practitioners and community members in the research process from the initial design of a project, to data gathering and data analysis. Together, community members, practitioners and researchers draw conclusions about what action and change priorities arise from the research findings.

A critical difference between traditional public health research and action research is that the community are equal partners with professional researchers in deciding what the research question is. Community priorities and concerns are often set before researcher’s academic interests, but ideally, over the long run issues of importance to both the community and theresearchers receive sufficient emphasis. In some cases, action research includes no professional researchers at all. Instead, research happens as a natural part of working. For example, a public social services work group might engage in a constant cycle of doing-learning-doing-learning, paying careful, systematic and critical attention to the learning (research) parts of the cycle, and communicating what is learned to other groups involved in the same kind of work. Researchers who help organisations develop the skills for such action research are truly engaged in capacity building, by weaning practitioners of total dependency on professional researchers.

Popular epidemiology

A particularly good example of how the principles of research that characterise community psychology research can be incorporated into public health is found in the emerging arena of popular psychology (Leung, Yen et al. 2004). This emerging arena in epidemiology melds the interests and research methods of epidemiology and community based participatory research in order to: (1) understand the social context in which disease outcomes occur; (2) involve community partners in the research process, and (3) insure that action is part of the research process.

The success of this hybrid of old and new is already evident in the specialty of environmental epidemiology, so much so that Leung, et. al. (2004) call on all of epidemiology to seek ways incorporate community based participatory research methods alongside the standard research methods of the field. The benefits, they claim, would be improvement in epidemiology’s ability to understand complex community health problems, to enhance the policy and practice relevance of the research, and to identify and implement structural changes needed for health improvement.

An example from Tasmania, Australia, illustrates the possibilities.*Abstracted from Mittelmark MB, Gillis DE, Hsu-Hage B. Community development: The role of health impact assessment. In: J Kemm, J Parry and S Palmer (Eds.) Health Impact Assessment: Concepts, Methods and Application, Oxford University Press, London, 2004, pp 143-152. There, residents of two rural townships were concerned about increased respiratory illnesses in the winter months. This prompted an investigation which concluded that the main cause was pollution from the use of woodfired heating in winter, exacerbated by unfavourable topographical and meteorological conditions. Other factors were forest fires, poor waste incineration practices in the timber industry, and rural and domestic outdoor burning. The increase in the use of domestic wood heaters followed the surge of world oil prices during the 1970s. The improper use of wood heaters played a significant role in the high level of air pollution.

The community and government agencies worked hand-in-hand to identify the causes of pollution and develop strategies to reduce pollution levels. A community action group stimulated involvement of the media and school and academic leaders, to publicise the issue and educate the community about the effect of wood burning on the atmosphere and of the need to improve techniques of fuel combustion.

Technical reports were prepared that advised more stringent emission stipulations for new wood heaters, subsidies for upgrading of heaters, quality controls on firewood, continuing community education, and encouragement of homeowners to properly insulate their houses. The local government worked in partnership with the Australian Solid Fuel Heating Association Inc., in a proactive way to educate the community by offering a free advisory service to any domestic consumer who had a problem with smoke from a wood heater. The local Council improved a local law that controlled the construction and use of incinerators, restricted the operation of domestic incinerators to two days a month, and banned on-the-ground burning.

This case study illustrates the feasibility of real partnership between environmental epidemiology, local government and citizens, leading to changes in local government policy in respond to community advocacy about a health issue raised by citizens. Critically, the advocacy initiative was armed with evidence from an impact assessment that identified the determinants of the health problem. The community demonstrated its willingness and ability to tackle a complex problem in partnership with government and industry. The three-year process undoubtedly strengthened the community’s confidence and ability to take concerted action on a wide range of issues that might arise in the future. Thus, while the impetus for action was the problem of respiratory illness, the problem solving process resulted in community capacity building.

Cultural epidemiology

The term ‘cultural epidemiology’ seems an oxymoron, given the differences between epidemiology and anthropology. Nevertheless, experience in as diverse places as India, England and Canada shows that when epidemiology and anthropology combines forces, public health research can enjoy successes that would be hard to imagine otherwise (Weiss 2001). The need for anthropologic perspectives and research methods stems in large part from the increasing complexity of the social context in which epidemiology operates in our modern times. Social processes such as migration, modernisation, urbanisation and globalisation add social elements to epidemiological problems that cannot be approached with classical public methods alone. People’s concepts of health, and what it means to be healthy, or ill, vary from place to place. If epidemiological intelligence is to lead to local public health policy and practice that is culturally sensitive and appropriate, the social context of a health problem is perhaps best addressed as part of the epidemiological work, not as an afterthought.

At the community level, where the translation of policy into planning and action often takes place, two kinds of information, developed in a coordinated way, are essential. On the one hand, local public health workers need an epidemiological portrait of the community. On the other hand, they need information about the local experience of illness, its meaning, risk and risk aversion culture, and patterns of help seeking and problem solving in the community (Weiss, 2001). A research project that combines epidemiology and anthropology places priority not just on the objective risk factors and outcomes, but also on clarifying the nature and distribution of illness experiences and meanings. Such a project combines qualitative and quantitative methods, and the data from these complementary investigative processes are mutually enriching.

Recent reports in the literature show how cultural epidemiology can be used to investigate clinical problems such as depression. In an example from India, people reporting for the first time to a public psychiatry screening clinic and screening positive for depression participated in interviews focused on their personal experience, ideas and activities related their patterns of distress, perceived causes of their problems and help-seeking activities (Raguram, Weiss et al. 2001). Also, diagnostic assessment using standard clinical methods was undertaken. Nearly half the participants had co-morbid conditions, calling into question the validity of ‘Western’ psychiatric diagnosis standards in non-Western settings. From the interview data, the most troubling aspect of their health for many respondents was various kinds of aches and pains. Social problems were cited by many as the main cause of their problems, and ‘nerves’ were the most frequently reported cause. Participants reported seeking help from private allopathic doctors as well as public clinic physicians, and not being very satisfied with allopathic treatment.

The researchers concluded that to address the needs and expectations of persons with positive depression screening results, health professionals should attend to diagnosis and clinical formulation, but also to the experience and meaning of their patients’ problems. Culturally sensitive inquiry might in this way stimulate treatment strategies that are congruent with the cultural concepts and needs of patients (Raguram, et al. 2001).

The above example is from clinical epidemiology, but it is not difficult to imagine how epidemiology in the general community would benefit from closer connections to social sciences general and especially qualitative methods of investigation. For example, at the University of Bergen, population-based, quantitative investigations of chronic social stress and associated psychological distress have been complemented by qualitative investigations, with useful results (Mittelmark 2004). The survey research showed that chronic social stress levels in the general community were high, and significantly associated with depression symptoms, anxiety and loneliness. But no quantitative survey can illuminate what is like to experience chronic social stress on a personal basis, and to struggle to cope. The in-depth interviews that complemented the survey research in the Bergen studies revealed that when survey respondents indicate they experience chronic social stress, it was not merely normal daily social hassles that stimulated their affirmative responses. Rather, virtually all respondents in the qualitative studies indicated that very burdensome, long lasting and seemingly insoluble interpersonal problems had stimulated them to report affirmative responses on the survey questionnaires. The qualitative studies enriched the interpretation of the quantitative data and suggested refinements for further quantitative research.

Conclusion

The research described above illustrates how public health is enriched by expanding its academic ‘watershed’ to social science approaches and methods that are not today part of mainstream public health research. Other areas of social science that have much to offer include environmental psychology (Booth and Crouter, 2001), economic development (Jack, 1999), political ecology (Stott, 2000), and information technology and pedagogy (Loveless, 2001). This paper has made the point that the tasks of the new public health require innovative thinking in the public health research community, and that social science approaches and methods are available that could strengthen public health research’s capacity to innovate. However, practical mechanisms are required to activate the potential. The expansion of university-based, interdisciplinary research centres presents an obvious partial solution. Cross-cutting conferences, research journals and training programmes are other bridge-building mechanisms with promise. Finally and quite obviously, schools of public health and medical departments devoted to community health have great potential to create the needed environments, by the strategic recruitment to their faculties of top notch social science scholars, around whom hybrid research environments would grow.