Wednesday, January 26, 2011

Reframing "Public" Health: Considering the dynamic community identity

In reading Dutta’s “Communicating Health” chapter on culture, identity, and health, I was prompted to critically evaluate a number of conflicts I’ve encountered in my study of rural health disparity. From the traditional perspective I’ve been exposed to in prior courses, it seems as though the primary focus of public health intervention is that of diagnosing the health status of a population, identifying contributors to negative health outcomes, and consequentially crafting programs that address these contributors. Just as in the biomedical model, this system propagates the view that the sick population is a site to be acted upon by an all-encompassing “medicalizing logic,” broadly applicable to any community in need of intervention. Such a viewpoint shifts the attention away from questions of resource inequities or structure. Ultimately, the health of the individual is the site by which change at the population level occurs, such that many interventions focus on encouraging a change in lifestyle rather than recognizing how the health structure in a community constrains positive outcomes.

In conducting a number of community needs assessments, I’ve reviewed literature published by well-regarded national health organizations relating to the kinds of questions necessary to ask individuals when crafting such reports. These materials fail to take into account the diversity present within individual communities, such that needs assessment questions posed to schools, government workers, churches, work sites, and individuals in one community are suggested to be the same for EVERY community. The mass marketing of these programs, without failing to consider the cultural and structural diversity present within individual communities, can prove detrimental to the creation and implementation of public health interventions based on such an approach.

It seems as though this traditional approach to public health could benefit the use of narratives as a tool for understanding community culture and identity. In this, the narratives of health articulated by community members may take focus away from the dominant viewpoint of individual lifestyle decisions to instead locate such voices in the context of structural constraints. These sentiments have been echoed in the narratives of a variety of rural citizens I’ve spoken with, reflecting the unique characteristics of each community. Such a repositioning of focus may also lend more credence to the American Public Health Association’s recently claimed interest in structural improvements, such as community environments, transportation, and access to services (APHA’s Agenda for Health Reform, 2009). However, considering the quantitative methodological foundation of epidemiology, it will take a significant interest by those in the field to use narratives, a more qualitative approach, as a way of assessing and understanding the health of a community or population. Nonetheless, this seems to be a necessary step in encouraging community mobilization in favor of structural changes, which ultimately may be of the best chances we have at successfully improving the health of those living in disadvantaged communities.

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