INTRODUCTION

The existing policies, systems, and environments that impact community health can be a confusing maze of physical attributes, organizational systems, and rules that govern behavior. This document will help Cooperative Extension agents and health advocates to tease apart the complexity of community living and use a Policy, Systems, and Environment (PSE) approach to identify assets and barriers to community health and explore the importance of engaging community members in the process.

POLICY, SYSTEMS, AND ENVIRONMENT

Health is impacted by individual behavior as well as influenced by relationships, culture, and environment. The socio-ecological model of health illustrates how the connections between family patterns, shared culture, and access to resources can affect behavior. A Policy, Systems, and Environment (PSE) approach brings focus to community influencers of healthy behaviors. The elements of PSE can be used together to improve community health.

The elements of PSE can be used together to improve community health: 

Policies 

are shared rules, laws, or regulations that govern activities in a community. Formal policies are often documented, approved, and openly implemented. Examples of formal health-related community policies include public smoking or drinking regulations, curfews, exclusive club memberships, and rules about public facility use. Policies can be inclusive or exclusive. Informal policies are not documented and include prevailing attitudes or beliefs of the “right” way things should be done.

Community systems 

include the networks of organizations and programs invested in the function of a community. Community systems include efforts that address health, education, business and economy, and government. In some communities, subsets of the health system may include recreation, mental or physical health programs, and emergency care. Likewise, education systems may be divided into specialized types or by client age.

Environment 

refers to any built or natural physical aspects of the community, including the location of buildings and services and the accessibility to those resources. When addressing community health, the term environment may also refer to cultural and social environments, which includes celebrations, foods, and traditional culturally accepted norms or attitudes that influence health.

SOCIO-ECONOMIC MODEL

(source: www.CDC.gov)

Individual 

Individual attitudes, beliefs, knowledge, and behavior.

Interpersonal

Individual relationships, support groups, social networks, cultural context.

Institutions and Organizations

Schools, health care administration, businesses, faith-based organizations, institutions.

Community

Relationships and communications between organizations and institutions.

Structures and Systems

Federal, state, and local regulations, laws, the built environment (public works, infrastructure, etc.).

ASSESSING A COMMUNITY

Communities may have developed complex systems to address community needs such as transportation, communication, or housing development. Assessing community systems can include identifying the interaction of these services and programs, program availability, and connections between organizations within a location. Community systems may be coordinated to function well together or may function independently of one another.

Physical environmental assessments may help identify areas where services are needed or ways in which barriers to facilities or resources may be eliminated. A primary focus of PSE is exploring availability and access to physical resources or programs that support health. Identifying and addressing environmental change is important for sustained health impacts. 

Assessing the social environment can include looking at how social relationships and attitudes support or inhibit healthy activities. Of the types of environment, the physical environment is usually easier to change than the social or cultural environments of a community. Physical changes are often more immediate and limited in scope, while social and cultural change often involves broad shifts in norms or behaviors. 

Other methods of assessment created through CEDIK include environmental mapping or walking assessments, applied leadership programs, and topical public discussions. These tools allow Cooperative Extension to serve as the catalyst and facilitator of health assessments and to initiate activities to engage community members in understanding community access to health.

A KENTUCKY EXAMPLE

In 2016-17, the Community and Economic Development Initiative of Kentucky (CEDIK) and University of Kentucky Cooperative Extension began a project in Madison, Bourbon, Lincoln, Boyle, Knott, Jackson, Breathitt, and Owsley Counties to better understand community health. The project began by listening. 

In each county, agents pulled together a focus group of stakeholders and asked them to talk about health. Participants identified and prioritized issues, which resulted in identifying changes that could improve access to health resources. By listening to those who would be impacted by community health change, agents learned what was important to participants—what was working in their environment, and what was not. By guiding the assessment, reflection, and planning, Extension supported residents in taking action to improve their community health situations.

PSE EFFECTS ON HEALTH 

By involving community members in the exploration of the community environment, they are better able to make informed individual choices on health-related decisions. In addition, leaders can facilitate groups of community members to move beyond issue identification to action. Pursuing priority projects identified by community members ensures that the work is relevant and important to the participants. Selfdetermination theory studies have shown that levels of commitment and investment in community change, including health change, is most effective when it involves people working toward their own desired outcomes.

THE BEST APPROACH

Beginning community discussions with an assessment of assets starts the conversation on a positive note as residents identify strengths and resources in their community rather than focusing on what is lacking. The asset-based approach builds on existing resources and motivates participants as it leverages existing community capacity. Beginning with a needs-based approach is a deficit focus and can be defeating. 

This is not to say that the two approaches cannot be used together. After mapping the assets in the community, a needs assessment will be helpful. Using combined approaches to community development can have powerful results. If a group starts by looking at the assets in their community, followed by prioritizing existing needs, they can leverage the identified strengths and resources available to address community issues.

PROCESS AND PRODUCT

When a community development process is done well, short-term goals of citizen education, strengthening community cohesion, and building relationships can be achieved in conjunction with the project. 

When working for community change, agents must differentiate between the product (the end goal) and the process. In other words, they must recognize the difference between what gets done, and how it gets done. The way a project leader goes about achieving community goals can frustrate and alienate others, or it can expand perspectives, build relationships, and strengthen social networks. 

While exploring local community policies, systems, and environments that impact health, Cooperative Extension or community leaders can engage community members in the process. When people are engaged in the discovery and problem-solving process, they increase their knowledge of health opportunites, foods, and services, and become actors in decisions that affect community health.

REFERENCES AND RESOURCES

Deci, E.L., and R.M. Ryan (2008). Self-determination theory: A macro-theory of human motivation, development, and health. Canadian psychology/Psychologie canadienne 49(3):182. 

Green, G.P., and A. Haines (2015). Asset building and community development. Sage publications. 

Kretzmann, J.P., and J. McKnight (1993). Building communities from the inside out. Pp. 2-10. Center for Urban Affairs and Policy Research, Neighborhood Innovations Network, Evanston, IL. 

Krile, J.F., G.J. Curphy, and D.R. Lund (2006). The community leadership handbook: Framing ideas, building relationships, and mobilizing resources. Fieldstone Alliance. 

Ryan, R.M., H. Patrick, E.L. Deci, and G.C. Williams, G. C. (2008). Facilitating health behaviour change and its maintenance: Interventions based on selfdetermination theory. European Health Psychologist 10(1):2-5.

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