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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences 6 Organisations, Communities, and Society: Models and Interventions Individuals and families are embedded within social, political, and economic systems that shape behaviors and constrain access to resources necessary to maintain health (Brown, 1991; Gottlieb and McLeroy, 1994; Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; McKinlay, 1993; Sorensen et al., 1998a; Stokols, 1992, 1996; Susser and Susser, 1996a, b; Williams and Collins, 1995; WHO, 1986). The impact of social and environmental conditions is most visible in the growing gap between the health behaviors and health status of rich and poor, white and non-white (Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; Lillie-Blanton and LaVeist, 1996; Lynch et al., 1997; Williams and Collins, 1995). There is a need to better understand the role of organizational, community, and societal factors in determining health. This chapter continues to explore the ecologic framework, describing theoretical concepts and sample interventions at the organizational, community, and societal levels. ORGANIZATIONS AND HEALTH Formal and informal organizations constitute another framework for describing interactions between behavior and health. Organizations are important components of social and physical environments, and they exert considerable influence over the choices people make, the resources they have to aid them in those choices, and the factors in the workplace
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences that could influence health status (e.g., work overload, exposure to toxic chemicals). As employees, consumers, customers, clients, and patients, people are influenced by the organizations to which they belong. Porras (1987) and Porras and Robertson (1992) suggest four major categories of work settings that are targets for change: organizing arrangements, social factors, technology, and physical settings. Organizing arrangements include organizational goals and strategies for progressing toward them, organizational structure (e.g., formal division of labor, authority relationships, lines of communication), policies and procedures (the formal rules that govern the organization), and reward systems. Social factors include management style, informal social networks, and interaction processes (e.g., problem-solving, decision-making, conflict resolution). The technology category includes job design factors, work flow design, and technical systems. Physical settings include spatial configuration, interior design, and physical ambiance factors such as temperature, lighting, and noise. In their original typology, Porras and Robertson (1992) included individual attributes under the social factors umbrella. However, given the emphasis placed on individual beliefs, attitudes, and skills in health behavior research, those individual factors are suggested as a fifth category in the work setting for targeting change interventions. Organizational Culture and Change Organizational culture is the base upon which organizational and related individual behavior change occurs. The culture prescribes the “right way” to do things (Schein, 1990). An organizational culture that supports health is likely to adopt policies, procedures, and priorities that facilitate the healthy behaviors of employees; enhance employee health by reducing environmental risk factors; facilitate healthy behavior on the part of clients, customers, or members; and facilitate linkages to other organizations for health-enhancing purposes. The more health-enhancing policies an organization adopts, the more likely it is to be perceived as having a health-conscious culture (Basen-Enquist et al., 1998). Organizational development (OD) is a set of behavioral-science-based theories, values, strategies, and techniques aimed at planned change in the organizational work setting (Porras and Robertson, 1992). Three important foundations are briefly described here: systems theory, employee participation in change efforts, and action research. Systems theory (Katz and Kahn, 1978) says that a change in one part of the system will influence
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences other parts, and so there is a need to vigilantly monitor unexpected (and often undesired) changes. Increased involvement and participation of organizational members in decision-making and problem-solving processes enhances the quality of decisions and solutions, increases members’ commitment to following through on plans, reduces organizational stress, and enhances employee well-being (Cotton et al., 1988; Ganster, 1995). The action research involves outside change agents working with organization members in a cyclical process of diagnosing problems, planning, implementing plans, monitoring, and evaluating progress (Argyris and Schon, 1989). Planned-Change Models Lewin (1951) developed an early and influential model for conceptualizing the change process. He posited three stages: first is unfreezing the old behavior, second is moving to a new behavior, and third is refreezing or stabilizing the new behavior. Thus, change was conceptualized as moving from one equilibrium point to another. To begin the process, the balance between opposing forces (those that facilitate and those that hinder change) must change, Lewin’s “force field analysis” was instrumental in the development of subsequent models of change. For example, organizational theorists such as Lippitt and co-workers (1958) and Schein (1987) built on Lewin’s three stages and linked them to psychological mechanisms for change and to action steps that change agents should take to facilitate progress through the stages. INTERVENTIONS TARGETED AT ORGANIZATIONS Organizational change is an integral component of a comprehensive ecologic approach to health behavior change that emphasizes how individual decisions and behaviors are influenced by the multiple layers of systems within which individuals are embedded (Stokols, 1996). As important components of the social and physical environments, organizations exert considerable influence over the choices people make, the resources they have to aid them in those choices, and the factors in the workplace that could affect health status (e.g., work overload, exposure to toxic chemicals). People are influenced by organizations as employees, consumers, customers, clients, and patients.
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences Changing Employee Health Behaviors National surveys of work organizations clearly document a burgeoning interest in worksite health promotion programs (see McGinnis, 1993). These programs focus either on a single behavioral risk factor (e.g., smoking) or on multiple risk factors (e.g., behavioral risk factors associated with cardiovascular disease). Because many of these interventions are aimed primarily at individual behaviors, they are reviewed in Chapter 5. Here the organizational context for these programs is addressed. In a review of 47 studies of health promotion programs that addressed multiple risk factors, Heaney and Goetzal (1997) found that almost all provided health education to employees. A smaller number of the programs (25%) incorporated modifications in organizational policy or the work environment to facilitate employee behavior changes. Such modifications included policies restricting or banning smoking on the premises, removing cigarette-vending machines, providing on-site exercise facilities, and providing healthier cafeteria food. A survey of health promotion programs funded by the Canadian Ministry of Health showed that more than half the programs reviewed reported modifications of health-compromising aspects of the organization (Richard et al., 1996). Most of the organization-level interventions addressed organizing arrangements. With the exception of providing on-site fitness facilities, few programs attempted to change physical settings, social factors, or technologies. Programs integrated into the culture of the organization were more likely to have multiple components and last longer than did those that had less support from top management and were less a part of the underlying fabric and culture of the organization (Heaney and Goetzal, 1997). Heaney and Goetzal (1997) concluded that providing opportunities for individual risk reduction counseling was necessary but not sufficient for effective worksite health promotion programs. Studies of programs aimed at individual risk factors also provide some support for the importance of changing the organizational context to support employee health behavior change (Glanz et al., 1996; Hennrikus and Jeffery, 1996). The example of smoking-control efforts at the workplace is illustrative. In their review, Eriksen and Gottlieb (1998) concluded that there is consistent evidence that smoking-control policies reduce cigarette consumption at work among smokers and reduce all employees’ exposure to second-hand smoke. However, they found mixed evidence for policies aimed at prevalence of smoking and overall consumption of cigarettes (including during non-work hours). They also point out that many
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences evaluation studies lacked the methodologic rigor necessary to permit confident causal inferences. And although several investigators have suggested the importance of looking at the degree of management support for smoking-control programs, the extent to which the organizational climate is consistent with control efforts, and the design and implementation of programs, few studies have done so. Some worksite health promotion programs use organizational change theory to inform their strategies. More specifically, current standards of practice include employee participation in planning the efforts. This ranges from incorporating employee input into the assessment of employee health needs (e.g., through surveys or focus groups), to having employee advisory boards guide the planning process, to having employee groups take full responsibility for implementation. Although several large, randomized trials incorporated at least one strategy (Glasgow et al., 1995; Sorensen et al., 1996), a direct comparison of health promotion programs with and without planned employee involvement has not been made. In addition, results from randomized trials that incorporate employee involvement have been mixed. Another strategy for incorporating organizational change into health promotion programming relies on training key figures in the organizations in methods for creating a supportive organizational culture and developing a comprehensive health promotion program. For example, Golaszewski and colleagues (1998) devised a seven-session curriculum for human resource managers who wanted to develop programs for employee heart health. The training addressed such issues as how to generate support among senior management; how to develop employee wellness committees; and how to conduct needs and resource assessments, diagnose organizational culture, and use employee benefits plans to support health promotion. Student interns were provided to the organizations, faculty from an academic medical center were available for consulting, and potential vendors for health promotion services were identified. Evaluated with a quasi-experimental design, the intervention organizations exhibited a significantly greater increase in organizational support for employee heart health than did the comparison organizations. Reducing Environmental Risk Factors Traditional worksite health promotion programs focus on individual change of personal risk factors. Occupational safety and health (OSH)
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences programs address the influence of physical (e.g., noise, extreme temperatures), chemical, ergonomic, and psychosocial work hazards on employee health. According to Goldenhar and Schulte (1994), OSH programs can involve three strategies: engineering, administrative, and behavior change, used to address the different targets for organizational change presented in Figure 6-1. Engineering strategies modify technology or physical setting; administrative strategies modify the organizing arrangements or social factors; and behavior change strategies target beliefs, attitudes, and skills. Examples of behavior change interventions in OSH include training to increase compliance with safety practices (Parkinson et al., 1989), use of personal protective equipment (Ewigman et al., 1990), and exercise to prevent occupationally related back injuries (Silverstein et al., 1988). Those interventions tend to focus almost exclusively on individual-level change (Goldenhar and Schulte, 1994). Strategies to enhance compliance with universal precautions among health care workers provide a case in point. Although descriptive research clearly indicates the influence of organizational safety climate and work task design on compliance rates, most interventions have targeted only individual employee knowledge, attitudes, and behaviors for change (DeJoy et al., 1995; Gershon et al., 1995). Few OSH interventions address more than a single type of environmental exposure or use more than a single intervention strategy. However, no matter the exposure or strategy used, organizational change principles are needed to initiate, implement, and maintain OSH programs. Programs oriented to reducing adverse psychosocial work exposures illustrate that point. A voluminous literature documents the consequences of occupational psychosocial stressors such as work overload, role conflict, job insecurity, unpredictability, ambiguity, responsibility for the work of others, and poor relationships with supervisors and co-workers (Hurrell and Murphy, 1992). Much research supports the benefits of psychosocial resources, such as social support and control or decision latitude over how one’s job is done (Baker et al., 1996; House, 1981; Israel et al., 1989; Karasek and Theorell, 1990). These psychosocial resources can directly affect employee well-being, and they can buffer employees from the negative effects of stress. Baker et al. (1996) give a comprehensive presentation of the stress process in occupational settings. Strategies for reducing the harm caused by psychosocial stressors most often entail individual behavior change strategies or administrative change strategies. Those efforts focus either on developing personal strat-
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences FIGURE 6-1 Potential Targets for Organizational Change Interventions. SOURCE: Modified and reproduced by special permission of the Publisher, Cnsulting Psychologists Press, Inc., Palo Alto, CA 94303 from Handbook of Industrial & Organizational Psychology, 2nd ed., vol. 3, by Marvin D.Dunnette and Leatta M.Hough (Eds.). Copyright 1992 by Consulting Psychologists Press, Inc. All rights reserved. Further reproduction is prohibied without the Publisher’s written consent.
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences egies for alleviating stress-related symptoms (e.g., relaxation techniques, biofeedback, exercise) or on increasing employees’ coping capacity (e.g., cognitive restructuring, problem-solving skill building, stressor recognition). (See Murphy  for a review of these strategies.) Administrative strategies involve changing the way work is organized, distributed, supervised, and rewarded, for example by using clear job descriptions (to reduce uncertainty or unnecessary conflict), providing for flexible scheduling, and holding regular work team meetings so that employees can voice concerns and engage in group problem solving. Members of work teams that meet regularly or that have leaders trained in facilitating group problem solving report receiving more social support from their supervisors and experiencing less role ambiguity and higher job satisfaction (Heaney, 1991; Jackson, 1983). In addition to these behavior change and administrative strategies, environmental psychologists suggest that changes in the physical setting can reduce occupational stressors and enhance psychosocial resources (Sundstrom and Altman, 1989). For example, the physical proximity of employee work stations and the presence of “gathering places,” such as mailrooms or lunchrooms, have been associated with the quantity and quality of employee social interactions. Behavior change strategies are usually “expert guided” (Karasek, 1992) in that they depend on health professionals or other outside consultants to counsel, train, or educate employees. The administrative strategies described here either were expert guided or were guided by the employees themselves. An example of the latter was the formation of an agency-wide labor/management stress committee in a study of stress among social workers in a child protective services agency (Cahill, 1992; Cahill and Feldman, 1993). Working with outside researchers, this committee developed goals to reduce sources of worksite stress, such as poor communication, and strengthen psychosocial resources, such as decision-making latitude over job tasks. Workers, management, and researchers then collaborated to develop, implement, and evaluate different interventions. For example, a computerized information system was introduced to reduce the workload and frustration associated with intake and tracking of clients. Economically correct computer workstations were provided. All employees were trained to use the new system and had easy access to technical assistance. Evaluation of the project suggested that the staff who were most involved in the intervention experienced gains in job decision latitude, productivity, and job satisfaction.
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences Karasek (1992) reviewed 19 case studies of occupational stress reduction programs gathered from countries around the world. He concluded that the programs that focused solely on individual-level coping enhancement—even when they involved substantial resources—were not effective. Programs that attempted to change work organization, task structure, or communication patterns in worksites were more likely to be effective. Karasek (1992) concluded that this was particularly true when participatory strategies (e.g., worker discussions in quality circles or “health circles” to identify stressors and develop plans to reduce them) were used. Several intervention studies attempting to increase employee participation in and influence over work-related decisions have shown positive effects on employee stress and well-being (e.g., Israel et al., 1992; Jackson, 1983; Landsbergis and Vivona-Vaughan, 1995; Schurman and Israel, 1995; Terra, 1995; Wall and Clegg, 1981). Participatory action research (PAR) has been proposed as a promising approach to occupational health interventions (see Israel et al., 1992; Schurman, 1996; Schurman and Israel, 1995). PAR entails collaboration between researchers and members of an organization in a data-guided, problem-solving approach to enhance an organization’s ability to provide a safe and healthy work environment. PAR builds on many of the tenets of organizational development and it has been used as a stress reduction intervention with some success, particularly in Scandinavia (DiMartino, 1992; Israel et al., 1992; Lindstrom, 1995; Schurman and Israel, 1995; Terra, 1995). No direct empirical comparisons of individual behavior change approaches with organizational-level change approaches to stress reduction have been conducted. Indeed, an either/or approach is not likely to enhance understanding of the stress reduction process. The ecologic approach, models of the stress process, systems theory, and the organizational development literature suggest that stress reduction approaches that use several points of intervention are likely to be most effective. Thus, comprehensive programs that address both changing the organizational processes that are causing stress and strengthening employees’ skills and resources for coping with stress could be most promoting of employee health. Some efforts along these lines are promising (see Monroy et al., 1998), but more research is needed to elucidate fully the potential of these interventions.
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences Lessons From Organizational Change Interventions In 1988, the observation was made that the “most striking feature” of studies examining the effects of organizational-level interventions to enhance worker control is “the sheer lack of them” (Murphy, 1988). This observation still applies today to the broader arena of organizational change strategies intended to enhance health. Although more studies are being done now, the scarcity of well-evaluated interventions is still apparent. A few recurring themes emerge from the findings of existing studies. First, they address a relatively narrow set of organizational targets. Few interventions attempt to modify social factors, technology, or physical setting. The results of studies that do address these factors (see, e.g., Cahill, 1992; Heaney, 1991; Sundstrom and Altman, 1989) have been encouraging. Second, many studies did not consider the organizational culture of their participants. Given the potential importance of organizational culture to the success of change efforts (Schein, 1990), future studies should routinely assess and diagnose this factor. Several validated instruments for measuring organizational climate (the more superficial manifestation of organizational culture) and its receptivity to health innovations are available (Basen-Engquist et al., 1998; Steckler et al., 1992). Third, many studies found that when the external change agents terminated their involvement with the target organizations, intervention benefits quickly dissipated. Efforts to build capacity for sustaining organizational changes among organization members can address this problem. The same critique applies to the areas of worksite health promotion and occupational health and safety programs. Over the past decade, it has become clear that generic programs are not likely to be optimally effective because they do not consider organizational culture or the beliefs, attitudes, needs, and resources of organization members. The prescription for this challenge is two-fold: strong formative research, and participation of all relevant stakeholders in the planning and conduct of health-promoting activities. Careful formative research is likely to illuminate important local issues and challenges, and stakeholders’ participation is likely to enhance the program quality and increase commitment to follow through with the program activities. COMMUNITIES AND HEALTH Individual-level risk factors, families, and organizations influence health behavior and health status, and so do social and environmental
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences conditions. This phenomenon is most visible in the growing gap between the health behaviors and health status of rich and poor, White and non-White (Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; Lillie-Blanton and LaVeist, 1996; Lynch et al, 1997; Williams and Collins, 1995). There is a need to better explain how the broader community and societal factors help determine the health status of individuals and groups. Some important conceptual constructs regarding the nature of communities as they relate to health outcomes are discussed below. Communities of Identity There are numerous definitions for and considerable confusion about what is meant by “community” (Heller, 1989; Klein, 1968; Rogers-Warren and Warren, 1977; Sarason, 1984; Steuart, 1993; Warren, 1975). Particularly important for this discussion of community-level change is the recognition that a “catchment area” or “population” is not a community but a geographic entity (e.g., city, county) that has a population aggregate with numerical but not a functional meaning (Steuart, 1993). Here, community means “unit of identity” created and recreated through social interactions (Hatch et al., 1993; Steckler et al., 1993; Steuart, 1993). A community in this sense is characterized by the following elements (Israel et al., 1994): Its membership has a sense of identity and belonging. It has common symbol systems: similar language, rituals, and ceremonies. It has shared values and norms. It offers mutual influence—community members have influence and are influenced by one another. It has shared needs and a shared commitment to meeting them. It has a shared emotional connection—members share common history, experiences, and support. Thus, a community of identity can exist within a defined geographic neighborhood or as a geographically dispersed group among whose members there is a sense of common identity. A city or catchment area might not be a community as defined here, or it might include numerous different and overlapping communities of identity (Israel et al., 1998).
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences this issue is reflected in the concerns it has raised from the World Health Organization (WHO), the World Bank, and the European Community (Whitehead, 1998; Gwatkin, 2000). Many efforts have been implemented to review the evidence and to search for solutions to the problem (see Gwatkin, 2000). The concern goes beyond providing equitable access to health care to addressing the basic links between social inequality and health. In 1992, WHO set the following target: “By the year 2000, the differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups” (Dahlgren and Whitehead, 1992). Approaches were aimed at reducing poverty (e.g., compressed income scales or progressive tax systems), decreasing unhealthy living conditions (e.g., urban renewal programs), improving working conditions (e.g., legislation to eliminate physical health hazards at work or organizational reforms for less stressful working arrangements), decreasing unemployment (e.g., creation of new jobs or minimizing the impact through increased public awareness of available assistance), improving lifestyle (e.g., targeting the most disadvantaged groups for smoking or nutrition education or interventions), and providing access to health care (e.g., availability of insurance and culturally appropriate training for health care providers). More recently, an Independent Inquiry (Acheson et al., 1998) examined the health inequalities in England and put forward several recommendations. Three areas were considered critical: improving the health of families with children, reducing disparity in income while improving the living conditions of the poor, and assessing all relevant public policies for their effect on health inequalities. The report pointed out that many areas not normally associated with health have an impact on the social inequities that influence health; these include poverty, income, tax and benefits, education, employment, housing and environment, transportation, pollution, and nutrition. Others in the international community have participated in the discussions concerning how to address the problem of health inequities. Gwatkin (2000) suggested directing efforts toward reducing differences between the rich and the poor rather than improving societal averages. Barzach (2000) recommended a focus on prevention and control of certain priority pathologies with the expectation that these efforts would later provide a framework that could be generalized to broader issues. Dahlgren (2000) emphasized progressive financial strategies for health in-
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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences surance with access to services based on need rather than on ability to pay. Tarlov (1999) proposed a framework for thinking about interventions classed as either ameliorative or corrective and directed toward five objectives: enhancing child development, strengthening community cohesion, providing opportunities for self-fulfillment, increasing socioeconomic well-being, and modulating hierarchical structuring. This is just a sampling of the perspectives from the international community. While there seems to be no consensus on the optimal approaches to rectify the health impact of disparities in socioeconomic status, there does seem to be agreement that the issue deserves attention. REFERENCES Acheson, D., Barker, D., Chambers, J., Graham, H., Marmot, M., and Whitehead, M. (1998). Independent Inquiry into Inequalities in Health Report. London: The Stationery Office. Accessed on line January 16, 2001. http://www.official-documents.co.uk/document/doh/ih/contents.htm Aday, L. (1993). At Risk in America: The Health Care Needs of Vulnerable Populations in the United States. San Francisco: Jossey-Bass. Amick, B.C., Levine, S., Tarlov, A.R., and Walsh, D.C. (Eds.) (1995). Introduction to Society and Health. Oxford: Oxford University Press. Anderson, N. and Armstead, C. (1995). Toward understanding the association of socioeconomic status and health: A new challenge for the biopsychosocial approach. Psychosomatic Medicine, 57, 213–225. Argyris, C. and Schon, D.A. (1989). Participatory action research and action science compared. American Behavioral Scientist, 9, 612–623. Baker, E., Israel, B., and Schurman, S. (1996). The integrated model: Implications for worksite health promotion and occupational health and safety practice. Health Education Quarterly, 23, 175–188. Barzach, M. (2000). Overcoming inequity means finding approaches that work. Bulletin of the World Health Organization, 78, 77–78. Basen-Engquist, K, Hudmon. K, Tripp. M, and Chamberlain, R. (1998). Worksite health and safety climate: Scale development and effects of a health promotion intervention. Preventive Medicine, 27, 111–119. Berkman, L.F. and Syme, S.L. (1979) Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. American Journal of Epidemiology, 109, 186–204. Brown, E.R. (1991). Community action for health promotion: A strategy to empower individuals and communities . International Journal of Health Services, 21, 441–456. Cahill, J. (1992). Computers and stress reduction on social service workers in New Jersey. Conditions of Work Digest, 11, 197–203. Cahill, J. and Feldman, L.H. (1993). Computers in child welfare: Planning for a more serviceable work environment. Child Welfare, 72, 3–12.
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