COMMUNITY PSYCHOLOGY

1. INTRODUCTION

KEY PRINCIPLES OF COMMUNITY PSYCHOLOGY

There are other key features of the field of Community Psychology, as will be described in the subsequent chapters, and
below we briefly review them.

Respect for Diversity

Community Psychology has a respect for diversity and appreciates the views and norms of groups from different ethnic or
racial backgrounds, as well as those of different genders, sexual orientations, and levels of abilities or disabilities.
Community psychologists work to counter oppression such as racism (white persons have access to resources and
opportunities not available to ethnic minorities), sexism (discrimination directed at women), heterosexism (discrimination
toward non-heterosexuals), and ableism (discrimination toward those with physical or mental disabilities). The task of
creating a more equitable society should not fall on the shoulders of those who have directly experienced its inequalities,
including ethnic minorities, the disabled, and other underprivileged populations. Being sensitive to issues of diversity is
critical in designing interventions, and if preventive interventions are culturally-tailored to meet the diverse needs of the
recipients, they are more likely to be appreciated, valued, and maintained over time.

Active Citizen Participation

The Brazilian educator Freire (1970) wrote that change efforts begin by helping people identify the issues they have
strong feelings about, and that community members should be part of the search for solutions through active citizen
participation. Involving community groups and community members in an egalitarian partnership and collaboration is one
means of enabling people to re-establish power and control over the obstacles or barriers they confront. When our
community partners are recognized as experts, they are able to advocate for themselves as well as for. Individuals build
valuable skills when they help define issues, provide solutions, and have a voice in decisions that ultimately affect them
and their community. This Community Psychology approach shifts the power dynamic so that all parties collaborate by
participating in the decision-making. Community members are seen as resources who provide unique points of view about
the community and the institutional barriers that might need to be overcome in social justice interventions. All partners are
involved equally in the research process in what is called community-based participatory research.

Grounding in Research and Evaluation

In striving to understand the relationship between social systems and individual well-being, community psychologists
base advocacy and social change on data that are generated from research and apply a number of evaluation tools to
conceptualize and understand these complex ecological issues. Community psychologists believe that it is important to
evaluate whether their policy and social change preventive interventions have been successful in meeting their objectives,
and the voice of the community should be brought into these evaluation efforts. They conduct community-based action-
oriented research and often employ multiple methods including what are called qualitative, quantitative, and mixed
methods research (Jason & Glenwick, 2016). No one method is superior to another, and what is needed is a match
between the research methods and the nature of the questions asked by the community members and researchers.
Community psychologists, like Durlak and Pachan (2012), have used adventuresome research methods to investigate the
effects of hundreds of programs dedicated to preventing mental health problems in children and adolescents, and the
findings showed positive outcomes in terms of improved competence, adjustment, and reduced problems.

Interdisciplinary Collaboration

Social issues are complex and intertwined throughout every fiber of our society, as pointed out by the ecological
perspective. When working with individuals who have been marginalized and oppressed, it is important to recognize that
issues such as addiction and homelessness require expertise from many perspectives. Community Psychology promotes
interdisciplinary collaboration with professionals from a diverse array of fields. For example, a community psychologist
helped put together the multidisciplinary team evaluating Oxford House efforts to help re-integrate individuals with
substance use problems back into the community. One member of the team was a sociologist who studies social networks,
and one of the important findings was that the best predictor of positive long-term outcomes was having at least one friend
in the recovery houses. Also, part of this team was an economist who found that the economic benefits were greater, and
costs were less for this Oxford House community intervention than an intervention delivered by professionals. Other
important contributions were made by a social worker, a Public Health researcher, Oxford House members, and
undergraduate and graduate students who each contributed unique skills and valuable perspectives to the research team.
You can see how these types of collaborations can emerge by using the idea tree exercise, which different disciplines can
work together to create new ideas and advance knowledge across fields.

Sense of Community

One of the core values of Community Psychology is the key role of psychological sense of community, which describes
our need for a supportive network of people on which we can depend. Promoting a healthy sense of community is one of
the overarching goals of Community Psychology, as a loss of connectedness lies at the root of many of our social
problems. So understanding how to promote a sense of belonging, interdependence, and mutual commitment is integral to
achieving second-order change. If people feel that they exist within a larger interdependent network, they are more willing
to commit to and even make personal sacrifices for that group to bring about long-term social changes. From a
Community Psychology perspective, an intervention would be considered unsuccessful if it increased students’
achievement test scores but fostered competition and rivalry that damaged their sense of community.

Empowerment

Another important feature of Community Psychology is empowerment, defined as the process by which people and
communities who have historically not had control over their lives become masters of their own fate. People and
communities who are empowered have greater autonomy and self-determination, gain more access to resources,
participate in community decision-making, and begin to work toward changing oppressive community and societal
conditions. As shown in Case Study 1.3, individuals such as Russell who have been homeless often feel a lack of control
over their lives. However, once provided stable housing and connections with others, they feel more empowered and able
to gain the needed resources to improve the quality of their lives.

Policy

Community psychologists also enter the policy arena by trying to influence laws and regulations, as illustrated by the
work on reducing minors’ access to tobacco described in Case Study 1.1. Community psychologists have made valuable
contributions at local, state, national, and international levels by collaborating with community-based organizations and
serving as senior policy advisors. It is through policy work that over the last century, the length of the human lifespan has
doubled, poverty has dropped by over 50%, and child and infant mortality rates have been reduced by 90%.

Over the next decades, there is a need for policy-level interventions to help overcome dilemmas such as escalating
population growth (as this will create more demands on our planet’s limited drinking water, energy, and food resources),
growing inequalities between the highest and lowest compensated workers (which will increasingly lead to societal strains
and discontent as automation and artificial intelligence will eliminate many jobs), increasing temperatures due to the
burning of fossil fuels (which will result in higher sea levels and more destructive hurricanes), and the expanding needs of
our growing elderly population. The principles of Community Psychology that have been successfully used to change
policy at the local and community level might also be employed to deal with these more global issues that are impacting
us now, and will increasingly do so in the future. This video link shows what is possible when we reflect upon policy.

Promoting Wellness
Finally, the promotion of wellness is another feature of Community Psychology. Wellness is not simply the stereotypical
lack of illness, but rather the combination of physical, psychological, and social health, including attainment of personal
goals and well-being. Furthermore, Community Psychology applies this concept to also include groups of people, and
communities—in a sense, collective wellness.

FIELDS OF COMMUNITY PSYCHOLOGY

It was the 1960's, and the times they were a-changing'. The 60's were a time to focus on others, solve the world's
problems, and cast away the bonds of the establishment. And for psychologists, the 60's brought about similar changes. In
1965, a group of psychologists held a conference in Swampscott, Mass., to discuss the future of the field of Psychology.
The psychologists discussed the need for the field to expand, shifting from only providing individual psychotherapy
treatment, to psychologists becoming advocates for social and political change.

The group members concluded that focusing on individual psychotherapy was too inefficient to solve multiple
psychological problems in a community. In order to solve mental health problems on a larger scale, they had to focus on
enacting community and social change.

By focusing on social justice, increasing access to social services, and helping to promote change at a community level,
the psychologists aimed to increase the psychological well-being of all members in a community.

Today, professionals in the field of Community Psychology continue the traditions set by the Swampscott group, focusing
on developing broader solutions to multiple problems in a community.

But to truly solve problems at this level, community psychologists first must learn the psychological definition of a
community.

Contemporary Issues in Community Psychology

 Reproductive Rights
 Environmental Issues
 Lesbian, Gay, Bisexual, and Transgender rights
 HIV/AIDS Prevention
 Unemployment
 Violence Prevention
 Substance Abuse Prevention
 New Immigrant Rights
 Homelessness

Defining the Psychological Sense of Community

Human beings are social beings drawn to interacting with each other and forming communities. But what exactly does a
community provide its members?

For community psychologists to effectively analyze a community and its needs, they first learn the psychological
outcomes behind a “psychological sense of community.”

According to “Viewing Community as Responsibility as Well as Resource: Deconstructing the Theoretical Roots of
Psychological Sense of Community,” published in The Journal of Community Psychology, there are two outcomes of
psychological sense of community:

 Psychological well-being
 Community engagement
Because community psychologists work with many members of a community to enact positive changes, encouraging
community engagement is an inherent part of community psychology. But often, those most in need do not feel this sense
of engagement or well-being.

In fact, those most in need might not feel like part of the community at all. For example, a homeless person requires
support but often lacks a voice. Someone working in the field of Community Psychology must act as a voice for this
person, and involve the person in the community to enact changes.

To effectively enact these changes, community psychologists must develop a concrete understanding of the psychological
components of community.

In “Sense of Community: A Definition and Theory” published in The Journal of Community Psychology, researcher
David W. McMillan describes four main components of community that community psychologists still base much of their
research on.

First component: McMillan said community must involve a sense of membership. People who feel they belong in a
community are more likely to positively engage with that community and work with psychologists to improve it.

Second component: This component states that a sense of influence empowers members of a community to take action
and to make a difference. Community members with influence often work directly with a community psychologist to help
enact new projects, helping engage other community members.

Third component: This aspect of community states that members must feel a fulfillment of their needs. This means that
community psychologists must analyze a community to identify those members whose needs are not met. It might be that
handicapped people in the community need more access ramps or parking spots, or could mean that the community
psychologist works with older adults to establish a Meals on Wheels program.

Fourth component: Finally, members of a community must have a shared emotional connection. Working with each other
and forging relationships, members of a community share similar beliefs and have experienced similar events. A
community psychologist working with a community must understand the bond shared by its members to effectively
develop new programs.

Communities must have these characteristics for people to feel accepted and happy in the environment. Community
psychologists must identify those who don't feel this sense of community and find ways to engage and empower these
members. To improve individual wellness on a larger scale, the field of Community Psychology identifies ways to expand
community services through community building.

Building a Stronger Community

One of the main focuses of community psychology is community empowerment. By assessing a community, community
psychologists identify pockets of people who might feel helpless in their present situation. The psychologist’s goal is to
empower these individuals.

For example, consider a coal mining town in West Virginia. When economic downturns hit the town hard, many in the
community have trouble providing enough food for their families.

A community psychologist in this situation might identify the coal miners as the most affected group in the community,
and work with local food agencies and community centers to establish a community-wide initiative to help feed coal
mining families. Working with the agencies and empowering the rest of the community helps provide those most in need
with additional resources. The coal miners and their families might previously have felt helpless and did not think of
themselves as active members of a community. Providing this sense of community empowers the mining families to seek
help, and later, they might even provide similar help to others in need.
Work of Community Psychologist

Community psychology, with its focus on preventing a multitude of mental health problems and providing support in
diverse environments, attracts a certain kind of individual. Globally minded leaders with a knack for organizing,
community psychologists should have a number of outstanding features that set them apart from the rest of the
psychology family.

According to “Qualities For The Community Psychologist,” published in The American Psychologist, there are a number
of qualities a community psychologist must possess to effectively elicit social and community changes. In the article,
author James G. Kelly notes that community psychologists must possess a “clearly identified competence.”

A competence is any skill a community psychologist brings to a community setting to solve a problem. This might be an
expert ability to communicate with multiple agencies, bringing them together under a common cause. The community
psychologist should share this competence with the community, identifying those in the community who have similar
competencies. Kelly also says community psychologists must develop an ecological identity in the community. Kelly
reasons that in order to truly push for changes in a community, the psychologist must become part of it, and care for that
community.

The psychologist cannot see what needs to be fixed in a community without enriching himself or herself in that
community. Because they work with multiple communities in different settings, community psychologists must also have
a large tolerance for diversity. The most diverse members of a community might be in the ones most in need, so the
community psychologist must work with and communicate with those populations.

Working with diverse communities means understanding the unique resources and needs they have. For example, when
working with African American or Native American communities, the psychologist must understand the traditions of
those cultures. Community psychologists must also be prepared to deal with limited resources when working in a
community. Some communities might not have access to services or agencies that are common in other areas. The
community psychologist must understand this, and work to create partnerships and new plans to provide services.

Finally, a community psychologist must be a risk taker. Not every community will have a perfect atmosphere for the
psychologist, so he or she can't be afraid to try something new.

This could involve working with new groups the psychologist didn't previously consider, or might even include partnering
with other communities in the area to provide assistance. Taking risks means not stopping at the first failure, and thinking
outside of the box. According to Kelly, community psychologists with these qualities will effectively meet the needs of a
community, and will be successful in promoting societal change.
HISTORICAL CONTEXT

History divided into 2 parts:

 Mental Health Treatment in United States

 Story of Social Movements leading to formation of Community Psychology Field in US

US also had social problems but it was not voiced out by people who were facing difficulties. Agrarian communities
which existed during that time were finding it difficult even to find houses to live. As cities got upgraded and developed
people who were mentally ill, indigent (poor) or people who are powerless were likely placed in the institution. The
institution was often dank (wet, unpleasant) crowded places where treatment ranged from restrain to cruel punishment.

1700’s France, Philip Pinel initiated reforms in Mental Institutions removing the restraints placed on asylum inmates.

Dorothea Dix (American Nurse & Advocate) taught women in jail – Late (1800’s). Despite her efforts at reform, mental
institutions, especially public ones, continued in a warehouse mentality with respect to their charges. These institutions
grew as the lower class, the powerless, and less privileged members of society were conveniently swept into them.

Waves of early immigrants entering the United States were often mistakenly diagnosed as mentally incompetent and
placed in the overpopulated mental ‘hospitals.’

Late 1800’s Freud developed interest in mental illness and its treatment (Psychoanalysis).

Freud’s basic premise was that emotional disturbance was due to intrapsychic forces within the individual caused by past
experiences. These disturbances could be treated by individual therapy and by attention to the unconscious.

Freud gave us a legacy of intervention aimed at the individual (rather than the societal) level. Likewise, he conferred on
the profession the strong tendency to divest individuals of the power to heal themselves; the physician, or expert, knew
more about psychic healing than did the patient. Freud also oriented professional healers to examine an individual’s past
rather than current circumstances as the cause of disturbance, and to view anxiety and underlying disturbance as endemic
to everyday life. Freud certainly concentrated on an individual’s weaknesses rather than strengths. This perspective
dominated American psychiatry well into the 20th century.
1946 National Mental Health Act passed by Congress, which gave authority to US Public Health Service board to
promote mental health. Psychology proved useful in dealing with mental illness in World War II.

1949 National Institute of Mental Health was established.

Then its either Clinical Psychologists (PhD Research Degree or PsyD Practitioner scholar) or Psychiatrist where
psychologists were battling against psychiatrists. ‘Currently - Integrated Care’

Another aspect of the history of mental health is related to the aftermath of the two world wars. Formerly healthy veterans
returned home as psychiatric casualties (Clipp & Elder, 1996; Rappaport, 1977; Strother, 1987). The experience of war
itself had changed the soldiers and brought on a mental illness.

1945 Veterans Administration took help from APA to expand training in Clinical Psychology.

1949 Conference in Boulder, Colorado approved a model for training Clinical Psychologists (Scientists-practitioner
Model).

1950’s showed significant changes in treatment of mental illness. Notable development is discovery of Pharmacologic
agents to treat psychosis and other form of mental illness. Antipsychotics, tranquilizers, antidepressants, and other
medications were able to change a patient’s display of symptoms. Symptoms were supressed but had major side effects.

With medication patients can move to home community learning coping strategies which is more humane than
institutionalization.

Deinstitutionalization as the costs for hospitalization was high. Unfortunately adequate resources was not considered
during this transition period.

1952 Hans Eysenck published a study critical to Psychotherapy.

Reviewing the literature on psychotherapy, Eysenck found that receiving no treatment worked as well as receiving
treatment. The mere passage of time was as effective in helping people deal with their problems. Other mental health
professionals leveled criticisms at psychological practices, such as psychological testing (Meehl, 1954, 1960) and the
whole concept of mental illness (Elvin, 2000; Szasz, 1961). (A further review of these issues and controversies can be
found.) If intervention was not useful, as Eysenck claimed, what would happen to mentally ill individuals? Would they be
left to suffer because the helping professions could give them little hope? This was the dilemma facing psychology.

1950’s & 1960’s Erich Lindemann’s efforts in Social Psychiatry had brought about a focus on the value of crisis
intervention. His work with survivors of the Cocoanut Grove fire in Boston demonstrated the importance of providing
psychological and social support to people coping with life tragedies. With adequate help provided in a timely manner,
most individuals could learn to deal with their crises. At the same time, the expression of grief was seen as a natural
reaction and not pathological. This emphasis on early intervention and social support proved important to people’s ability
to adapt.

Parallel to these things Kurt Lewin and the National Training Laboratories were studying group processes, leadership
skills for facilitating change and other ways in which social psychology could be applied to everyday life. There was a
growing understanding of the social environment and social interactions and how they contributed to group and individual
abilities to deal with problems and come to healthy solutions.

1960’s deinstitutionalization was done, ill were released into community. Parallel to these developments, social
movements were developing in the larger community.

Social Movements
1930’s around Freud’s death President Franklin D. Roosevelt proclaimed his New Deal. Heeding the lessons of the Great
Depression of the 1920s and 1930s, he experimented with a wide variety of government regulatory reforms, infrastructure
improvements, and employment programs. These efforts eventually included the development of the Social Security
system, unemployment and disability benefits, and a variety of government-sponsored work relief programs, including
ones linked to the building of highways, dams, and other aspects of the nation’s economic infrastructure.

There were other social trends as well. Although women had earlier worked in many capacities, the need for labor during
World War II allowed them to move into less traditional work settings. ‘Rosie the Riveter’ was the iconic woman of the
time, working in a skilled blue-collar position, doing dangerous, heavy work that had previously been reserved for men in
industrial America. After the war, it was difficult to argue that women could not work outside the home, because they had
contributed so much to American war production. This was approximately 20 years after women had gained voting rights
at the national level, with the passage of the 19th Amendment to the Constitution.

Another area of Social Change 1954 US Supreme Court handed down their Brown v. Board of Education of Topeka,
Kansas. This decision overturned an earlier ruling that racial groups could be segregated into ‘separate but equal’
facilities. In reality, the segregated facilities were not equivalent. School systems that had placed Blacks into schools away
from Whites were found to be in violation of the U.S. Constitution. This change in the law was a part of a larger
movement by Blacks to seek justice and their civil rights. Notably, psychologists Kenneth and Mamie Phipps Clark
provided psychological research demonstrating the negative outcomes of segregated schools. (First time Psych Research
was used in Supreme Court)

Black to vote: Rosa Parks did not give up her bus seat to an American, 9 black students seeking entry in a Little Rock
school, students and leaders risking physical abuse and death. Civil rights 1950’sw to 1960’s. Voting rights act of 1965
guaranteed citizens the right to vote.

In the 1960s, the ‘baby boomers’ also came of age. Born in the mid-1940s and into the 1960s, these children of the World
War II veterans entered the adult voting population in the United States in large numbers, shifting the opinions and
politics of that time. Presaging these changing attitudes, in 1960, John F. Kennedy was elected president of the United
States.

Considered by some too young and too inexperienced to be president, Kennedy embodied the optimism and
empowerment of an America that had won a world war and had opened educational and occupational opportunities to the
generation of World War II veterans and their families (Brokaw, 1998). His first inaugural address challenged the nation
to service, saying, ‘Ask not what your country can do for you—ask what you can do for your country.’

One of President Kennedy’s sisters had special needs. This may have fueled his personal interest in mental health issues.
Elected with the promise of social change, he endorsed public policies based on reasoning that social conditions, in
particular poverty, were responsible for negative psychological states.

Findings of those times supported the notion that psychotherapy was reserved for a privileged few, and institutionalization
was the treatment of choice for those outside the upper class. In answer to these findings,

Kennedy proposed mental health services for communities and secured the passage of the Community Mental Health
Centers Act of 1963. The centers were to provide outpatient, emergency, and educational services, recognizing the need
for immediate, local interventions in the form of prevention, crisis services, and community support.

Kennedy was assassinated at the end of 1963, but the funding of community mental health continued into the next
administration. In his 1964 State of the Union address, President Lyndon B. Johnson prescribed a program to move the
country toward a ‘Great Society’ with a plan for a ‘War on Poverty.’ President Johnson wanted to find ways to empower
people who were less fortunate and to help them become productive citizens.
Multiple forces in mental health and in the social movements of the time converged in the mid-1960s. Dissatisfaction with
the effectiveness of traditional individual psychotherapy (Eysenck, 1952), the limitation on the number of people who
could be treated (Hollingshead & Redlich, 1958), and the growing number of mentally ill individuals returning into the
communities combined to raise serious questions regarding the status quo in mental health. In turn, a recognition of
diversity within our population, the appreciation of the strengths within our communities, and a willingness to seek
systemic solutions to problems directed psychologists to focus on new possibilities in interventions.

Swampscott

In May 1965, a conference in Swampscott, Massachusetts (on the outskirts of Boston), was convened to examine how
psychology might best plan for the delivery of psychological services to American communities. Under the leadership of
Don Klein, this training conference was organized and supported by the National Institute of Mental Health (NIMH;
Kelly, 2005). Conference participants, including clinical psychologists concerned with the inadequacies of traditional
psychotherapy and oriented to social and political change, agreed to move beyond therapy to prevention and the inclusion
of an ecological perspective in their work (Bennett et al., 1966). The birth of community psychology in the United States
is attributed to these attendees and their work (Heller et al., 1984; Hersch, 1969; Rappaport, 1977). Appreciating the
influence of social settings on the individual, the framers of the conference proceedings proposed a ‘revolution’ in the
theories of and the interventions for a community’s mental health (Bennett et al., 1966).

2. ENVIRONMENTAL HEALTH ISSUES

Population and environment: a global challenge

The world population is growing by approximately 74 million people per year. Population growth is not evenly distributed
across the globe. Scientists are yet to conclusively determine the human ‘carrying capacity’ of Earth. Population is only
one of many factors influencing the environment. We have consumed more resources in the last 50 years than the whole
of humanity before us. The 20th century saw the biggest increase in the world’s population in human history

Our growing population

We humans are remarkable creatures. From our humble beginnings in small pockets of Africa, we have evolved over
millennia to colonise almost every corner of our planet. We are clever, resilient and adaptable―perhaps a little too
adaptable.

In 2015 the world population is more than 7.3 billion people. That’s more than seven billion three hundred million bodies
that need to be fed, clothed, kept warm and ideally, nurtured and educated. More than 7.3 billion individuals who, while
busy consuming resources, are also producing vast quantities of waste, and our numbers continue to grow. The United
Nations estimates that the world population will reach 9.2 billion by 2050.

For most of our existence the human population has grown very slowly, kept in check by disease, climate fluctuations and
other social factors. It took until 1804 for us to reach 1 billion people. Since then, continuing improvements in nutrition,
medicine and technology have seen our population increase rapidly.

Human population has skyrocketed over the last few hundred years. In 1500 there were 425 million humans; in 2000,
there were 6 billion; and today, in 2015, 7.3 billion.Human population has seen exponential growth over the past few
hundred years. Data source: Our World in Data.

The impact of so many humans on the environment takes two major forms:

 Consumption of resources such as land, food, water, air, fossil fuels and minerals
 Waste products as a result of consumption such as air and water pollutants, toxic materials and greenhouse gases

More than just numbers

Many people worry that unchecked population growth will eventually cause an environmental catastrophe. This is an
understandable fear, and a quick look at the circumstantial evidence certainly shows that as our population has increased,
the health of our environment has decreased. The impact of so many people on the planet has resulted in some scientists
coining a new term to describe our time—the Anthropocene epoch. Unlike previous geological epochs, where various
geological and climate processes defined the time periods, the proposed Anthropecene period is named for the dominant
influence humans and their activities are having on the environment. In essence, humans are a new global geophysical
force.

A group of people watching a fountain beneath skyscrapers in Dubai. We humans have spread across every continent and
created huge changes to landscapes, ecosystems, atmosphere—everything. Image source: Richard Schneider / Flickr.

However, while population size is part of the problem, the issue is bigger and more complex than just counting bodies.

There are many factors at play. Essentially, it is what is happening within those populations—their distribution (density,
migration patterns and urbanisation), their composition (age, sex and income levels) and, most importantly, their
consumption patterns—that are of equal, if not more importance, than just numbers.

Focusing solely on population number obscures the multifaceted relationship between us humans and our environment,
and makes it easier for us to lay the blame at the feet of others, such as those in developing countries, rather than looking
at how our own behaviour may be negatively affecting the planet.

Population size

It's no surprise that as the world population continues to grow, the limits of essential global resources such as potable
water, fertile land, forests and fisheries are becoming more obvious. You don’t have to be a maths whizz to work out that,
on the whole, more people use more resources and create more waste.

Influenced by the work of Thomas Malthus, 'carrying capacity' can be defined as the maximum population size an
environment can sustain indefinitely.

Debate about the actual human carrying capacity of Earth dates back hundreds of years. The range of estimates is
enormous, fluctuating from 500 million people to more than one trillion. Scientists disagree not only on the final number,
but more importantly about the best and most accurate way of determining that number—hence the huge variability.

The majority of studies estimate that the Earth's capacity is at or beneath 8 billion people. Data source: UNEP Global
Environmental Alert Service / One Planet, How Many People? (PDF)

People around the world consume resources differently and unevenly. An average middle-class American consumes 3.3
times the subsistence level of food and almost 250 times the subsistence level of clean water. So if everyone on Earth
lived like a middle class American, then the planet might have a carrying capacity of around 2 billion. However, if people
only consumed what they actually needed, then the Earth could potentially support a much higher figure.

But we need to consider not just quantity but also quality—Earth might be able to theoretically support over one trillion
people, but their quality of life will vary.

Population distribution

The ways in which populations are spread across Earth has an effect on the environment. Developing countries tend to
have higher birth rates due to poverty and lower access to family planning and education, while developed countries have
lower birth rates. In 2015, 80 per cent of the world’s population live in less-developed nations. These faster-growing
populations can add pressure to local environments.

Globally, in almost every country, humans are also becoming more urbanised. In 1960 less than one third of the world’s
population lived in cities. By 2014, that figure was 54 per cent, with a projected rise to 66 per cent by 2050.
While many enthusiasts for centralisation and urbanisation argue this allows for resources to be used more efficiently, in
developing countries this mass movement of people heading towards the cities in search of employment and opportunity
often outstrips the pace of development, leading to slums, poor (if any) environmental regulation, and higher levels of
centralised pollution. Even in developed nations, more people are moving to the cities than ever before. The pressure
placed on growing cities and their resources such as water, energy and food due to continuing growth includes pollution
from additional cars, heaters and other modern luxuries, which can cause a range of localised environmental problems.

Humans have always moved around the world. However, government policies, conflict or environmental crises can
enhance these migrations, often causing short or long-term environmental damage. For example, since 2011 conditions in
the Middle East have seen population transfer (also known as unplanned migration) result in several million refugees
fleeing countries including Syria, Iraq and Afghanistan. The sudden development of often huge refugee camps can affect
water supplies, cause land damage (such as felling of trees for fuel) or pollute environments (lack of sewerage systems).

Population composition

The composition of a population can also affect the surrounding environment. At present, the global population has both
the largest proportion of young people (under 24) and the largest percentage of elderly people in history. As young people
are more likely to migrate, this leads to intensified urban environmental concerns, as listed above.

Life expectancy has increased by approximately 20 years since 1960. While this is a triumph for mankind, and certainly a
good thing for the individual, from the planet's point of view it is just another body that is continuing to consume
resources and produce waste for around 40 per cent longer than in the past.

Ageing populations are another element to the multi-faceted implications of demographic population change, and pose
challenges of their own. For example between 1970 and 2006, Japan's proportion of people over 65 grew from 7 per cent
to more than 20 per cent of its population. This has huge implications on the workforce, as well as government spending
on pensions and health care.

Population income is also an important consideration. The uneven distribution of income results in pressure on the
environment from both the lowest and highest income levels. In order to simply survive, many of the world’s poorest
people partake in unsustainable levels of resource use, for example burning rubbish, tyres or plastics for fuel. They may
also be forced to deplete scarce natural resources, such as forests or animal populations, to feed their families. On the
other end of the spectrum, those with the highest incomes consume disproportionately large levels of resources through
the cars they drive, the homes they live in and the lifestyle choices they make.

On a country-wide level, economic development and environmental damage are also linked. The least developed nations
tend to have lower levels of industrial activity, resulting in lower levels of environmental damage. The most developed
countries have found ways of improving technology and energy efficiency to reduce their environmental impact while
retaining high levels of production. It is the countries in between—those that are developing and experiencing intense
resource consumption (which may be driven by demand from developed countries)—that are often the location of the
most environmental damage.

Population consumption

While poverty and environmental degradation are closely interrelated, it is the unsustainable patterns of consumption and
production, primarily in developed nations, that are of even greater concern.

It’s not often that those in developed countries stop and consider our own levels of consumption. For many, particularly in
industrialized countries, the consumption of goods and resources is just a part of our lives and culture, promoted not only
by advertisers but also by governments wanting to continually grow their economy. Culturally, it is considered a normal
part of life to shop, buy and consume, to continually strive to own a bigger home or a faster car, all frequently promoted
as signs of success. It may be fine to participate in consumer culture and to value material possessions, but in excess it is
harming both the planet and our emotional wellbeing.

The environmental impact of all this consumption is huge. The mass production of goods, many of them unnecessary for a
comfortable life, is using large amounts of energy, creating excess pollution, and generating huge amounts of waste.

To complicate matters, environmental impacts of high levels of consumption are not confined to the local area or even
country. For example, the use of fossil fuels for energy (to drive our bigger cars, heat and cool our bigger houses) has an
impact on global CO2 levels and resulting environmental effects. Similarly, richer countries are also able to rely on
resource and/or waste-intensive imports being produced in poorer countries. This enables them to enjoy the products
without having to deal with the immediate impacts of the factories or pollution that went in to creating them.

On a global scale, not all humans are equally responsible for environmental harm. Consumption patterns and resource use
are very high in some parts of the world, while in others—often in countries with far more people—they are low, and the
basic needs of whole populations are not being met. A study undertaken in 2009 showed that the countries with the fastest
population growth also had the slowest increases in carbon emissions. The reverse was also true—for example the
population of North America grew only 4 per cent between 1980 and 2005, while its carbon emissions grew by 14 per
cent.

Individuals living in developed countries have, in general, a much bigger ecological footprint than those living in the
developing world. The ecological footprint is a standardised measure of how much productive land and water is needed to
produce the resources that are consumed, and to absorb the wastes produced by a person or group of people.

POLLUTION

Environmental pollution is currently the biggest challenge facing the word today.

In the United States 40% of rivers and 46% of lakes are too polluted for fishing, swimming, and aquatic life. Not
surprising though when 1.2 trillion gallons of untreated storm water, industrial waste, and untreated sewage are being
discharge annually into American waters.

One-third of the topsoil in the world is already degraded, and with the current rate of soil degradation caused be improper
agricultural and industrial practices, and deforestation, most of the world’s topsoil could be gone within the next 60 years.

The Great Smog in 1952 killed 8000 people in London. This event was caused by a period of cold weather combined with
windless conditions that formed a dense layer of airborne pollutants, mostly from coal plants, over the city.

There are many sources of pollution and each one has its own effect on the environment and living organisms. This article
will discuss the causes and effects of the different kinds of pollution.

Causes

The causes of pollution are not just limited to fossil fuels and carbons emissions. There are many other types of pollution
including chemical pollution into bodies of water and soil through improper disposal practices and agricultural activities,
and noise and light pollution created by cities and urbanization as a result of population growth.

Air Pollution

There are two types of air pollutants, primary and secondary. Primary pollutants are emitted directly from their source,
while secondary pollutants are formed when primary pollutants react in the atmosphere.
The burning of fossil fuels for transportation and electricity produces both primary and secondary pollutants and is one of
the biggest sources of air pollution.

The fumes from car exhausts contain dangerous gases and particulates including hydrocarbons, nitrogen oxides, and
carbon monoxide. These gases rise into the atmosphere and react with other atmospheric gases creating even more toxic
gases.

According to The Earth Institute, the heavy use of fertilizer for agriculture is a major contributor of fine-particulate air
pollution, with most of Europe, Russia, China, and the United States being affected. The level of pollution caused by
agricultural activities is thought to outweigh all other sources of fine-particulate air pollution in these countries.

Ammonia is the primary air pollutant that comes from agricultural activities. Ammonia enters the air as a gas from
concentrated livestock waste and fields that are over fertilized. This gaseous ammonia then combines with other pollutants
such as nitrogen oxides and sulfates created by vehicles and industrial processes, to create aerosols. Aerosols are tiny
particles that can penetrate deep into the lungs and cause heart and pulmonary disease.Other agricultural air pollutants
include pesticides, herbicides, and fungicides. All of which also contribute to water pollution.

Water Pollution

Nutrient pollution is caused by wastewater, sewage, and fertilizers. The high levels of nutrients in these sources end up in
bodies of water and promote algae and weed growth, which can make the water undrinkable and depleted oxygen causing
aquatic organisms to die.

Pesticides and herbicides applied to crops and residential areas concentrate in the soil and are carried to the groundwater
by rainwater and runoff. For these reasons anytime someone drills a well for water it must be checked for pollutants.

Industrial waste is one of the main causes of water pollution, by creating primary and secondary pollutants including
sulphur, lead and mercury, nitrates and phosphates, and oil spills.

In developing countries around 70% of their solid waste is dumped directly into the ocean or sea. This causes serious
problems including the harming and killing of sea creatures, which ultimately affects humans.

Land & Soil Pollution

Land pollution is the destruction of land as a result of human’s activities and the misuse of land resources. This occurs
when humans apply chemicals such as pesticides and herbicides to the soil, dispose of waste improperly, and irresponsibly
exploit minerals through mining.

Soil is also polluted through leaking underground septic tanks, sewage systems, the leaching of harmful substances from
landfill, and direct discharge of waste water by industrial plants into rivers and oceans.

Rain and flooding can bring pollutants from other already polluted lands to soil at other locations. Over-farming and over-
grazing by agricultural activities causes the soil to lose its nutrient value and structure causing soil degradation, another
type of soil pollution.Landfills can leach harmful substances into the soil and water ways and create very bad smells, and
breeding grounds for rodents that transmit diseases.

Noise & Light Pollution

Noise is considered an environmental pollutant caused by household sources, social events, commercial and industrial
activities, and transportation.
Light pollution is caused by the prolonged and excessive use of artificial lights at night that can cause health problems in
humans and disrupt natural cycles, including wildlife activities. Sources of light pollution include electronic billboards,
night sports grounds, street and car lights, city parks, public places, airports, and residential areas.

Effects

The effects of pollution can be seen every day, all around you. Pollution is destroying ecosystems and drinking water, and
wreaking havoc on human and environmental health.

Effects of Air Pollution

High levels of air pollution can cause an increased risk of heart attack, wheezing, coughing, and breathing problems, and
irritation of the eyes, nose, and throat. Air pollution can also cause worsening of existing heart problems, asthma, and
other lung complications.

Like humans, animals can suffer from a number of health problems due to air pollution, including birth defects,
reproductive failure, and diseases.Air pollution causes a number of environmental effects in addition to the effects on.

Acid rain contains high levels of nitric and sulfuric acids that are created by oxides and sulfur oxides released into the air
by the burning of fossil fuels. Acid rain damages trees and acidifies soils and water bodies, making the water too acidic
for fish and other aquatic life. Nitrogen oxides released into the air by the burning of fossil fuels also contribute to the
nitrogen responsible for toxic algae blooms. The release of man-made compounds including hydrochlorofluorocarbons,
chlorofluorocarbons, and halons formerly used as coolants, foaming agents, pesticides, solvents, aerosol propellants, and
fire-extinguishers are depleting the ozone. The ozone layer in the stratosphere forms a protective layer that reflects
harmful ultraviolet rays back into space that would otherwise destroy animal and plant life.

Effects of Water Pollution

Water pollution is a serious threat to humans, animals, and aquatic life.

The effects of water pollution depend on which chemicals are being dumped where. Bodies of water that are near
urbanized areas tend to be heavily polluted by dumbing of garbage and chemicals, both legally and illegally, by industrial
plants, health centers, and individuals.

By far the biggest consequence of water pollution is the death of aquatic creatures, which can disrupt the entire food
chain. Pollutants such as cadmium, mercury, and lead are eaten by tiny aquatic organisms that are then eaten by fish and
shell fish, becoming more concentrated with each step up the food chain and causing serious problems in humans and
wildlife.

Nutrient pollution can cause toxic algal blooms in drinking water sources that create toxins that kill fish and other aquatic
animals. Direct exposure to this toxic alga causes serious health problems in humans including neurological effects,
respiratory problems, stomach and liver illness, and rashes.

A consequential problem is created when disinfectants used to treat drinking water reach water polluted with toxic algae,
they react creating dioxins. Dioxins are extremely harmful chemical compounds that have been linked with reproductive
and development problems, and even cancer.

Nitrates, caused by fertilizers, also contaminate drinking water and according to the Environmental Protection Agency,
babies who consume water that is high in nitrates can become seriously ill with blue-baby syndrome, which causes
shortness of breath and blue-tinted skin, and can lead to death if not treated early.

Effects of Land & Soil Pollution

Land and soil pollution has substantial consequences for humans, animals, microorganisms and aquatic life. Contaminated
land and soil can cause various problems on the skin, respiratory problems, and even different kinds of cancers.

These toxic substances come into contact with the human body directly through eating fruits and vegetables that have
been grown in polluted soils, being consumed through drinking water that has been contaminated, direct contact with the
skin, and breathing in air polluted with particles and dust.

Deforestation is the biggest concern when it comes to land degradation and soil erosion. Clear cutting of vegetation and
tree cover creates harsh conditions that destroy ecosystems and habitats.

Deforestation also creates an imbalance in atmospheric conditions, reducing the amount of carbon that is naturally taken
out of the atmosphere. This is a serious problem considering that most pollution created by people is carbon based.

Effects of Noise & Light Pollution

Noise pollution can cause stress, anxiety, headaches, irritability, hearing loss, and sleep loss resulting in decreased
productivity. Oil drills, submarines, and other vessels on and in the ocean can cause excessive noise that has resulted in
the injury or death of marine animals, especially whales.

Too much light causes eye strain and stress, harming our eyes and decreasing our quality of life. Light pollution also
causes a decrease in the hormone melatonin that helps us to fall asleep, resulting in restlessness and fatigue. Many
mammals, insects, birds, and reptiles are photoperiodic meaning their movement, mating, growth and development, and
eating cycles are regulated by natural light patterns. Light pollution can interfere with these natural behaviors and cycles,
causing a decrease in wildlife populations.

Conclusion

Pollution needs to be dramatically reduced because it is destroying the environment we live in, contaminating our food
and water, causing diseases and cancers in humans and wildlife, and destroying the air we breathe and the atmosphere that
protects us from harmful ultra-violet radiation. It is the responsibility of every living person to protect the environment,
and with the population ever increasing, pollution problems are only going to get worse unless we do something about it.

Protecting the environment is a long and daunting task, requiring continuous planning, governmental policies, and public
and industrial participation. However the result of ignoring the problem will be catastrophic and life as we know it will
begin to end. By decreasing waste, implementing recycling policies, banning dangerous agricultural chemicals, and
developing safe renewable energy we can significantly reduce the amount of pollution going into the environment
annually and increase our quality of living. Everyone is entitled to clean air to breathe, water to drink, and public lands to
enjoy. If you have any ideas on how to reduce pollution, please drop a comment and share your thoughts.

ALIENATION

Alienation occurs when a person withdraws or becomes isolated from their environment or from other people. People who
show symptoms of alienation will often reject loved ones or society. They may also show feelings of distance and
estrangement, including from their own emotions.

Alienation is a complex, yet common condition. It’s both sociological and psychological, and can affect your health and
aggravate existing medical conditions. Treatment involves diagnosing the cause of alienation, and following through with
treatment.

Symptoms of alienation

Feeling distanced from work, family, and friends is a common symptom of alienation. Other symptoms include:

 feeling helpless
  feeling that the world is empty or meaningless
 feeling left out of conversations or events
 feeling different or separate from everyone else
 having difficulty approaching and speaking with others, especially parents
 feeling unsafe when interacting with others
 refusing to obey rules

There can also be symptoms of depression that include:

 having a poor appetite or overeating,

 sleeping excessively or having insomnia
 being fatigued
 lacking self-worth
 having feelings of hopelessness

Types of alienation

Alienation is a complex condition that affects many people. There are six common types.

 Cultural estrangement: Feeling removed from established values

 Isolation: Having a sense of loneliness or exclusion, such as being a minority in a group
 Meaninglessness: Being unable to see meaning in actions, relationships, or world affairs, or having a sense that
life has no purpose
 Normlessness: Feeling disconnected from social conventions, or engaging in deviant behavior
 Powerlessness: Believing that actions have no effect on outcomes, or that you have no control over your life
 Self-estrangement: Being out of touch with yourself in different ways, mostly being unable to form your own
identity

Causes of alienation

Alienation can have many causes, from psychological disorders to social situations.

Health-related causes

Alienation can be the result of a mental or physical condition. Possible health-related causes of alienation include:

 mental health disorders, such as anxiety, obsessive compulsive disorder, and schizophrenia
 post-traumatic stress disorder (PTSD)
 self-stigma as a result of mental illness
 conditions that cause chronic pain
 any conditions that may cause a person to feel singled out or disconnected

When alienation has health-related causes, there will typically be other symptoms that persist for more than a few days.
Talk to a doctor if you’re concerned about any symptoms.

Social causes

Social causes are typically defined by how you, or someone you know, feels disconnected from other people, their
environment, or themselves. For example, a change in your environment, like changing jobs or schools, can cause
alienation.

Job-related causes
Work alienation occurs when a person feels estranged from what they produce in the workplace. This disconnection may
cause dissatisfaction and a feeling of alienation from:

 the work they do

 their coworkers
 the environment
 themselves

Causes in adolescents

Alienation is common among teenagers. It can also be a side effect of:

 attachment to a parent or caregiver in early childhood

 big changes in their comfort zone
 bullying or peer victimization
 growing up

As children grow, they may begin to distrust adults or the values they were raised with. Teens can often feel isolated from
their parents, teachers, and peers. They may feel anxious about their social skills or physical appearance. Teens can even
feel isolated from their own identity. This can happen as they discover themselves and think about their future.

Adolescent alienation is only considered a symptom if it accompanies other disorders, such as a phobia or a personality
disorder.

Parental causes

Parental alienation is a term that broadly describes negative, alienating behaviors displayed by a parent, like not being
present. Parental alienation syndrome describes a psychiatric disorder in children, particularly in the context of divorce.
Sometimes it can be an explanation for a child’s refusal to visit a parent.

Rejection of a parent has multiple factors. These can include interactions from both parents and feelings of vulnerability
from the child. This is not the same alienation that a child may feel toward a parent who is abusive, particularly if the
child severs ties with that parent as an adult.

Treatment for alienation

To treat alienation, the cause must be identified. People who experience psychological pain because of alienation may
benefit from seeing a mental health professional. Gaining a feeling of empowerment may also help a person battle
alienation.

For adolescents, a sense of purpose is an asset. But searching for that purpose can induce stress. Researchers suggest that
parental support can help teens who experience alienation due to feelings of purposelessness.

URBANISATION

Urbanization: An Environmental Force to Be Reckoned With

Human beings have become an increasingly powerful environmental force over the last 10,000 years. With the advent of
agriculture 8,000 years ago, we began to change the land.And with the industrial revolution, we began to affect our
atmosphere. The recent increase in the world’s population has magnified the effects of our agricultural and economic
activities. But the growth in world population has masked what may be an even more important human-environmental
interaction: While the world’s population is doubling, the world’s urban population is tripling. Within the next few years,
more than half the world’s population will be living in urban areas.
The level and growth of urbanization differ considerably by region (see Figure 1). Among developing countries, Latin
American countries have the highest proportion of their population living in urban areas. But East and South Asia are
likely to have the fastest growth rates in the next 30 years. Almost all of future world population growth will be in towns
and cities. Both the increase in and the redistribution of the earth’s population are likely to affect the natural systems of
the earth and the interactions between the urban environments and populations.

The best data on global urbanization trends come from the United Nations Population Division and the World Bank. The
UN, however, cautions users that the data are often imprecise because the definition of urban varies country by country.
Past projections of urbanization have also often overestimated future rates of growth. Therefore, it is important to be
careful in using urbanization data to draw definitive conclusions.

The Dynamics of Urbanization

In 1800 only about 2 percent of the world’s population lived in urban areas. That was small wonder: Until a century ago,
urban areas were some of the unhealthiest places for people to live. The increased density of populations in urban areas
led to the rapid spread of infectious diseases. Consequently, death rates in urban areas historically were higher than in
rural areas. The only way urban areas maintained their existence until recently was by the continual in-migration of rural
people.

In only 200 years, the world’s urban population has grown from 2 percent to nearly 50 percent of all people. The most
striking examples of the urbanization of the world are the megacities of 10 million or more people. In 1975 only four
megacities existed; in 2000 there were 18. And by 2015 the UN estimates that there will be 22.5 Much of the future
growth, however, will not be in these huge agglomerations, but in the small to medium-size cities around the world.

The growth in urban areas comes from both the increase in migration to the cities and the fertility of urban populations.
Much of urban migration is driven by rural populations’ desire for the advantages that urban areas offer. Urban
advantages include greater opportunities to receive education, health care, and services such as entertainment. The urban
poor have less opportunity for education than the urban nonpoor, but still they have more chance than rural populations.

Urban fertility rates, though lower than rural fertility rates in every region of the world, contribute to the growth of urban
areas. Within urban areas, women who migrated from rural areas have more children than those born in urban areas. Of
course, the rural migrants to urban areas are not a random selection of the rural population; they are more likely to have
wanted fewer children even if they had stayed in the countryside. So the difference between the fertility of urban migrants
and rural women probably exaggerates the impact of urban migration on fertility.

In sub-Saharan Africa, the urban fertility rates are about 1.5 children less than in rural areas; in Latin America the
differences are almost two children. Therefore, the urbanization of the world is likely to slow population growth. It is also
likely to concentrate some environmental effects geographically.

Environmental Effects on Urbanization

Urban populations interact with their environment. Urban people change their environment through their consumption of
food, energy, water, and land. And in turn, the polluted urban environment affects the health and quality of life of the
urban population.

People who live in urban areas have very different consumption patterns than residents in rural areas.10 For example,
urban populations consume much more food, energy, and durable goods than rural populations. In China during the
1970s, the urban populations consumed more than twice as much pork as the rural populations who were raising the pigs.
With economic development, the difference in consumption declined as the rural populations ate better diets. But even a
decade later, urban populations had 60 percent more pork in their diets than rural populations. The increasing
consumption of meat is a sign of growing affluence in Beijing; in India where many urban residents are vegetarians,
greater prosperity is seen in higher consumption of milk.

Urban populations not only consume more food, but they also consume more durable goods. In the early 1990s, Chinese
households in urban areas were two times more likely to have a TV, eight times more likely to have a washing machine,
and 25 times more likely to have a refrigerator than rural households.12 This increased consumption is a function of urban
labor markets, wages, and household structure.

Energy consumption for electricity, transportation, cooking, and heating is much higher in urban areas than in rural
villages. For example, urban populations have many more cars than rural populations per capita. Almost all of the cars in
the world in the 1930s were in the United States. Today we have a car for every two people in the United States. If that
became the norm, in 2050 there would be 5.3 billion cars in the world, all using energy.

In China the per capita consumption of coal in towns and cities is over three times the consumption in rural areas.14
Comparisons of changes in world energy consumption per capita and GNP show that the two are positively correlated but
may not change at the same rate.15 As countries move from using noncommercial forms of energy to commercial forms,
the relative price of energy increases. Economies, therefore, often become more efficient as they develop because of
advances in technology and changes in consumption behavior. The urbanization of the world’s populations, however, will
increase aggregate energy use, despite efficiencies and new technologies. And the increased consumption of energy is
likely to have deleterious environmental effects.

Urban consumption of energy helps create heat islands that can change local weather patterns and weather downwind
from the heat islands. The heat island phenomenon is created because cities radiate heat back into the atmosphere at a rate
15 percent to 30 percent less than rural areas. The combination of the increased energy consumption and difference in
albedo (radiation) means that cities are warmer than rural areas (0.6 to 1.3 C).And these heat islands become traps for
atmospheric pollutants. Cloudiness and fog occur with greater frequency. Precipitation is 5 percent to 10 percent higher in
cities; thunderstorms and hailstorms are much more frequent, but snow days in cities are less common.

Urbanization also affects the broader regional environments. Regions downwind from large industrial complexes also see
increases in the amount of precipitation, air pollution, and the number of days with thunderstorms. Urban areas affect not
only the weather patterns, but also the runoff patterns for water. Urban areas generally generate more rain, but they reduce
the infiltration of water and lower the water tables. This means that runoff occurs more rapidly with greater peak flows.
Flood volumes increase, as do floods and water pollution downstream.

Many of the effects of urban areas on the environment are not necessarily linear. Bigger urban areas do not always create
more environmental problems. And small urban areas can cause large problems. Much of what determines the extent of
the environmental impacts is how the urban populations behave — their consumption and living patterns — not just how
large they are.

Health Effects on Environmental Degradation

The urban environment is an important factor in determining the quality of life in urban areas and the impact of the urban
area on the broader environment. Some urban environmental problems include inadequate water and sanitation, lack of
rubbish disposal, and industrial pollution. Unfortunately, reducing the problems and ameliorating their effects on the
urban population are expensive.

The health implications of these environmental problems include respiratory infections and other infectious and parasitic
diseases. Capital costs for building improved environmental infrastructure — for example, investments in a cleaner public
transportation system such as a subway — and for building more hospitals and clinics are higher in cities, where wages
exceed those paid in rural areas. And urban land prices are much higher because of the competition for space. But not all
urban areas have the same kinds of environmental conditions or health problems. Some research suggests that indicators
of health problems, such as rates of infant mortality, are higher in cities that are growing rapidly than in those where
growth is slower.

Urban Environmental Policy Challenges

Since the 1950s, many cities in developed countries have met urban environmental challenges. Los Angeles has
dramatically reduced air pollution. Many towns that grew up near rivers have succeeded in cleaning up the waters they
befouled with industrial development. But cities at the beginning of their development generally have less wealth to
devote to the mitigation of urban environmental impacts. And if the lack of resources is accompanied by inefficient
government, a growing city may need many years for mitigation. Strong urban governance is critical to making progress.
But it is often the resource in shortest supply. Overlapping jurisdictions for water, air, roads, housing, and industrial
development frustrate efficient governance of these vital environmental resources. The lack of good geographic
information systems means that many public servants are operating with cataracts. The lack of good statistics means that
many urban indicators that would inform careful environmental decision-making

When strong urban governance is lacking, public-private partnerships can become more important.22 These kinds of
partnerships can help set priorities that are shared broadly, and therefore, implemented. Some of these public-private
partnerships have advocated tackling the environmental threats to human health first. “Reducing soot, dust, lead, and
microbial disease presents opportunities to achieve tangible progress at relatively low cost over relatively short periods,”
concluded conferees at a 1994 World Bank gathering on environmentally sustainable development.23 But ultimately there
are many other urban environmental priorities that produce chronic problems for both people and the environment over
the long term that also have to be addressed.

Much of the research that needs to be done on the environmental impacts of urban areas has not been done because of a
lack of data and funding. Most of the data that exist are at a national level. But national research is too coarse for the
environmental improvement of urban areas. Therefore, data and research at the local level need to be developed to provide
the local governments with the information they need to make decisions. Certainly the members of the next generation,
the majority of whom will be living in urban areas, will judge us by whether we were asking the right questions today
about their urban environments. They will want to know whether we funded the right research to address those questions.
And they will also want to know whether we used the research findings wisely.

3. CONCEPT OF PREVENTION

PERSPECTIVES ON PREVENTION

The term "prevention" is typically used to represent activities aimed at stopping or reducing an action or behavior, but can
also be used to represent activities that promote a positive action or behavior while reducing risk.

One of the primary characteristics of the Community Psychology field is its focus on preventing rather than just treating
social and psychological issues, and this can occur by boosting individual skills as well as by engaging in environmental
change. The following provides an example of prevention directed toward saving lives at a beach, as drowning is one of
the leading causes of death.

Imagine a beautiful lake with a long sandy beach surrounded by high cliffs. You notice a person who fell from one of the
cliffs and who is now flailing about in the water. The lifeguard jumps in the water to save him. But then a bit later, another
person wades too far into the water and panics as he does not know how to swim, and the lifeguard again dives into the
water to save him. This pattern continues day after day, and the lifeguard recognizes that she cannot successfully rescue
every person that falls into the water or wades in too deep. The lifeguard thinks that a solution would be to install railings
to prevent people from falling from the cliffs and to teach the others on the beach how to swim. The lifeguard then
attempts to persuade local officials of the need for railings and swimming lessons. During months of meetings with town
officials, several powerful leaders are hesitant about spending the money to fund the needed changes. But the lifeguard is
persistent and finally convinces them that scrambling to save someone only after they start to drown is dangerous, and the
town officials budget the money to install railings on the cliffs and initiate swimming classes.

This example highlights a key prevention theme in the field of Community Psychology, and in this case, the preventive
perspective involved getting to the root of the problem and then securing buy-in from the community in order to secure
resources necessary to implement the changes. As illustrated above, there are two radically different ways of bringing
about change, which are referred to as first- and second-order change.

First-order change attempts to eliminate deficits and problems by focusing exclusively on the individuals. When the
lifeguard on the beach dove into the water to save one person after another, this was an example of a first-order
intervention. There was no attention to identifying the real causes that contributed to people falling into the water and
being at risk for drowning, and this band-aid approach would not provide the structural changes necessary to protect
others on the beach or walking on the cliffs.

A more effective approach involves second-order change, the strategy the lifeguard ultimately adopted, and this involved
installing railings on the cliff and the teaching of swimming skills. Such changes get at the source of the problem and
provide more enduring solutions for the entire community. A real example of this approach involved low-income African
American preschool children who participated in a preventive learning preschool program (called the High/Scope Perry
Preschool)—40 years later, participants in this program were found to have better high school completion, employment,
income, and lower criminal behavior (Belfield et al., 2005).

TYPES OF PREVENTION

The preventive stages are primordial prevention, primary prevention, secondary prevention, and tertiary prevention.
Combined, these strategies not only aim to prevent the onset of disease through risk reduction, but also downstream
complications of a manifested disease.

Primordial Prevention: In 1978, the most recent addition to preventive strategies, primordial prevention, was described.
It consists of risk factor reduction targeted towards an entire population through a focus on social and environmental
conditions. Such measures typically get promoted through laws and national policy. Because primordial prevention is the
earliest prevention modality, it is often aimed at children to decrease as much risk exposure as possible. Primordial
prevention targets the underlying stage of natural disease by targeting the underlying social conditions that promote
disease onset. An example includes improving access to an urban neighborhood to safe sidewalks to promote physical
activity; this, in turn, decreases risk factors for obesity, cardiovascular disease, type 2 diabetes, etc.

Primary Prevention: Primary prevention consists of measures aimed at a susceptible population or individual. The
purpose of primary prevention is to prevent a disease from ever occurring. Thus, its target population is healthy
individuals. It commonly institutes activities that limit risk exposure or increase the immunity of individuals at risk to
prevent a disease from progressing in a susceptible individual to subclinical disease. For example, immunizations are a
form of primary prevention.

Secondary Prevention: Secondary prevention emphasizes early disease detection, and its target is healthy-appearing
individuals with subclinical forms of the disease. The subclinical disease consists of pathologic changes, but no overt
symptoms that are diagnosable in a doctor's visit. Secondary prevention often occurs in the form of screenings. For
example, a Papanicolaou (Pap) smear is a form of secondary prevention aimed to diagnose cervical cancer in its
subclinical state before progression.

Tertiary Prevention: Tertiary prevention targets both the clinical and outcome stages of a disease. It is implemented in
symptomatic patients and aims to reduce the severity of the disease as well as of any associated sequelae. While
secondary prevention seeks to prevent the onset of illness, tertiary prevention aims to reduce the effects of the disease
once established in an individual. Forms of tertiary prevention are commonly rehabilitation efforts.

Quaternary Prevention: According to the Wonca International Dictionary for General/Family Practice, Quaternary
prevention is: "action taken to identify patients at risk of overmedicalization, to protect him from new medical invasion,
and to suggest to him interventions, which are ethically acceptable." Marc Jamoulle initially proposed this concept, and
the targets were mainly patients with illness but without the disease. The definition has undergone recent modification as"
'an action taken to protect individuals (persons/patients) from medical interventions that are likely to cause more harm
than good."

Some examples of commonly used prevention strategies are:

Primordial:

 Government policy: Increasing taxes on cigarettes; Decreasing advertisement of tobacco

 Built Environment: Access to safe walking paths; access to stores with healthy food options

Primary: Immunizations, Tobacco Cessation Programs, Needle Exchange Programs, Micro-Nutrient Supplementation
Programs

Secondary:

 Papanicolaou (Pap) smear for early detection of cervical cancer

 Mammography, for early detection of breast cancer
 Colonoscopies, for early detection of colon cancer
 Blood Pressure Screening

Tertiary: Occupational and physical therapy in burn patients, Cardiac rehab in post-myocardial infarction patients,
Diabetic foot care

Quarternary:

The following conditions are susceptible to over-treatment:

 Radiological incidentalomas
 The use of antiarrhythmic drugs after myocardial infarction that reduced arrhythmias but increased mortality
 The use of hormone replacement therapy led to an increased number of cases of breast cancers, stroke, and
thromboembolic events. It was also a failure in reducing cardiovascular mortality.
 Medically unexplained symptoms
 Functional disorders
 Bodily distress syndrome

COMMUNITY BASED THERAPY PROGRAMS

Counseling is a generic term for any of professional counseling that treats dysfunction occurring within a group of related
people. This term describes a preventive system of counseling that works to combat psychological impairment through the
improvement and development of community support. A community is defined as a group of interacting individuals who
share a commonality. This commonality can be anything from location of residence to career interest, but a community
counselor will use this common characteristic to council groups of people.

Importance
The community that individuals function within can have a significant influence on their identity and connection to others.
A community counselor can work with groups of people experiencing an increased amount of psychological distress to
help determine and address the source of the disturbance. Such interventions are used in communities which are poor and
unsupported to improve mental health resources. Dysfunctional environments can lead individuals to develop social and
psychological impairments. Vulnerable and marginalized populations such as children, minorities, or individuals of a low
socioeconomic status are disproportionately at risk of experiencing psychological impairments. Through the holistic
treatment of a community, counselors can help alleviate mental health issues on a large scale. Community counseling
provides leadership for creating better access to mental health services.

Community Based Therapy Programs

Counseling services generally come in two distinct types: community counseling and medical counseling. The most
common venue for counseling is in an established hospital, where professionals have the added benefit of providing their
services with ready availability of medical services, prescription drug treatments, and diagnoses of disorders that might
require more intensive therapy and other psychological services. Though common, this is not the only way to receive
counseling services for a wide range of diseases, disorders, and other issues.

Community counseling takes the service outside of the hospital and puts it directly into the community, and that’s where
this particular type of counseling gets its name.

Community counseling is often located much closer to where patients actually live. This makes it easy for those with
reduced mobility to attend their appointments without incident or delay.

Community counseling services are often more specialized, allowing professionals to help their patients with a more
particular set of skills.

Community counseling services take a wide variety of forms, and that means they may very well transcend the typical
private practice or “doctor’s office” feeling that many people wrongly associate with the profession. While a large number
of community counseling centers are set up in this way, a large number of community services are offered on location, or
in existing health centers with a slightly different focus than the traditional hospital. Consider some of the most common
venues:

 Correctional facilities
 Mental health centers
 Retirement communities
 Schools and other educational settings
 Business and corporate offices
 Human services agencies

In each of these instances, counselors may simply work from the location several days a week. In between those
appointments, they may still work in a hospital setting or from a community-based private practice. These unique settings
allow those with a strong psychological background to tackle problems where they occur, and stop development of those
problems before they turn into something that is much harder to diagnose, address, and successfully treat.

Role of the counselor

Community counselors can work in a variety of settings such as private practice, mental health centers, rehabilitation
facilities, or prisons. Regardless of the setting, a community counselor's job is to work with individuals to develop
appropriate mental processing and provide preventive services to the community. Preventive efforts can be made by
providing access to community-based organizations or educational programs. Community counselors need to be strong
leaders who can make these direct and indirect services available for their clients.
Models

The Respectful Model

The Respectful Model is a holistic approach of understanding a community and its associated issues. This form of
counseling can be done individually or in groups across all ages and genders. The model is based on a ten-letter acronym
designed to highlights factors that influence community dynamic. Counselors are expected to respect clients regardless of
their religious affiliation, economic status, sexual orientation, psychological health, ethnicity, developmental differences,
trauma, family, physical appearance, or genealogy. This inclusive and holistic approach to community counseling allows
for an appreciation of environmental influence on mental health.

The Marginalized Community Model

Annabel Manzanilla-Manalo and Fermin Manalo developed a community-based counseling approach to help
marginalized groups overcome mental health problems that result from inequality and discrimination. This approach
works to integrate community psychology within the context of a social environment. The model values inclusivity, social
justice, solidarity, and equality. Community counselors work to facilitate healthy development and establish a system that
ensures the delivery of mental health services to the community. This model is focused on empowerment of individuals
with the goal of relieving stigma or shame these individuals might feel because of their marginalized identity. This is
achieved through support of group formation, enhancement of local resources, research, advocacy, and facilitation of
collective action.

Applications

Children

Children can suffer developmental and social delays because of untreated mental health issues. Analysis of archival data
from 364 children who visited a community counseling clinic revealed that treatment could significantly reduce
internalizing and externalizing behavioral problems for children. However, the analysis also found that over half of the
children who began treatment did not complete the full course of the available community counseling services. High
dropout rates are often considered a significant barrier to providing effective community counseling.

Adults

Older individuals who did not receive counseling for early psychological dysfunction or individuals who have
experienced trauma later in life can benefit from community therapy. A study of Vietnam War veterans demonstrated that
community-based readjustment counseling can significantly reduce posttraumatic stress disorder (PTSD) and improve
life-satisfaction. From these results, researchers have hypothesized that community counseling could produce more
effective services for veterans in need of PTSD treatment. Programs and services that work to relieve psychological
impairments such as PTSD can significantly improve the well-being of adults.

Substance abuse

Community counselors can also act as members of the interdisciplinary teams used to holistically treat persons with drug
addiction. Community support and promotion of healthy habits can help improve the well-being of individuals struggling
with addiction. In a study examining recovery from alcoholism, 50 participants were assigned to either a community
counseling-based intervention or a control condition. Results showed a significant reduction in drinking rates for
individuals in the intervention which suggests that community counseling can help aid individuals in the process of
addiction recovery.

4. MODELS

BEHAVIORAL MODEL
The behavioral model in psychology is based on the theory that individuals' actions and behaviors are learned. This model
also states that psychological problems arise, as a result of dysfunctional behavioral patterns that individuals have learned,
and placed into practice. These behavioral patterns are thought to be the result of individuals' life experiences and
environments.

The behavioral model concerns the role of learning in abnormal behavior. Learning is any relatively permanent change in
behavior due to experience and practice which has two main forms –

 Associative learning
 Observational learning

Associative learning is the linking together of information sensed from our environment. This process includes a
phenomenon called Conditioning. Conditioning is a type of associative learning, occurs which two events are linked and
has two forms –

 Classical Conditioning, or linking together two types of stimuli (Ivan Pavlov)

 Operant Conditioning, or linking together a response with its consequence. (B. F. Skinner)

Observational learning occurs when we learn by observing the world around us. Main proponent was Albert Bandura.

Associative learning: Classical conditioning

Classical conditioning (also called response or Pavlovian conditioning) occurs when we link a previously neutral stimulus
with a stimulus that is unlearned or inborn, called an unconditioned stimulus. In respondent conditioning, learning occurs
in three phases: preconditioning, conditioning, and postconditioning.

Pavlov’s classic experiment which includes-

Unconditioned stimulus (UCS): Elicits an unconditioned response (UCR)

Unconditioned Response (UCR): The unlearned response made to an unconditioned stimulus

Conditioned stimulus (CS): Neutral stimulus that acquires some properties of another stimulus with which it is paired

Conditioned response (CR): The learned response made to a previously neutral stimulus that has acquired some properties
of another stimulus with which it was paired

Preconditioning: This stage of learning signifies is that some learning is already present. There is no need to learn it again
as in the case of primary reinforcers and punishers in operant conditioning. In Panel A, food makes a dog salivate. This
does not need to be learned and is the relationship of an unconditioned stimulus (UCS) yielding an unconditioned
response (UCR). Unconditioned means unlearned. In Figure 2.1, we also see that a neutral stimulus (NS) yields nothing.
Dogs do not enter the world knowing to respond to the ringing of a bell (which it hears).

Conditioning. Conditioning is when learning occurs. Through the pairing of a neutral stimulus and unconditioned stimulus
(bell and food, respectively) the dog will learn that the bell ringing (NS) signals food coming (UCS) and salivate (UCR).
The pairing must occur more than once so that needless pairings are not learned such as someone farting right before your
food comes out and now you salivate whenever someone farts (…at least for a while. Eventually the fact that no food
comes will extinguish this reaction but still, it will be weird for a bit).

Postconditioning. Postconditioning, or after learning has occurred, establishes a new and not naturally occurring
relationship of a conditioned stimulus (CS; previously the NS) and conditioned response (CR; the same response). So the
dog now reliably salivates at the sound of the bell because he expects that food will follow, and it does.
John B. Watson:

Demonstrated acquisition of a phobia (exaggerated, seemingly illogical fear) using classical conditioning paradigm.

One of the most famous studies in psychology was conducted by Watson and Rayner (1920). Essentially, they wanted to
explore the possibility of conditioning emotional responses. The researchers ran a 9-month-old child, known as Little
Albert, through a series of trials in which he was exposed to a white rat. At first, he showed no response except curiosity.
Then the researchers began to make a loud sound (UCS) whenever the rat was presented. Little Albert exhibited the
normal fear response to this sound. After several conditioning trials like these, Albert responded with fear to the mere
presence of the white rat.

As fears can be learned, so too they can be unlearned. Considered the follow-up to Watson and Rayner (1920), Jones
(1924) wanted to see if a child (named Peter) who learned to be afraid of white rabbits could be conditioned to become
unafraid of them. Simply, she placed Peter in one end of a room and then brought in the rabbit. The rabbit was far enough
away so as to not cause distress. Then, Jones gave Peter some pleasant food (i.e., something sweet such as cookies;
remember the response to the food is unlearned). She continued this procedure with the rabbit being brought in a bit closer
each time until eventually, Peter did not respond with distress to the rabbit. This process is called counterconditioning or
extinction, or the reversal of previous learning.

Another way to unlearn a fear is called flooding or exposing the person to the maximum level of stimulus and as nothing
aversive occurs, the link between CS and UCS producing the CR of fear should break, leaving the person unafraid. This
type of treatment is rather extreme and is not typically practiced by psychologists.

Classical conditioning helps explain acquisition of phobias, unusual sexual attractions, and other extreme emotional
reactions.

Related to Classical Conditioning:

 Generalization
 Discrimination
 Extinction
 Spontaneous Recovery

Acquisition

There are two important factors which exert strong influence upon the ability of a conditioned stimulus to elicit a
response.
 First is the number of pairings between this stimulus and the unconditioned stimulus. As the number of pairings increases,
the conditioned stimulus comes to evoke a conditioned response with increasing strength. The strength of the response is
measured in terms of magnitude, latency and probability of occurrence of the conditioned response.
 The second factor which exerts an important effect upon the process of classical conditioning is the interval, which
elapses between the presentation of conditioned stimulus and unconditioned stimulus. For many different responses,
conditioning appears to be maximal when this interval is 0.50 seconds. However, further researches suggest that in some
cases, it can be much longer and still produce conditioning.

For example in an experiment of Garcia, McGowan, and Green, (1972), rats were given a sweet tasting liquid to drink,
and were then injected with a drug which makes them sick in stomach. The rats were found to acquire an aversion to the
taste even when the interval between drinking and nausea was more than an hour.

Martin Seligman (1972) noted that humans, too, learn strong aversion to the tastes of foods which makes them sick many
hours after they have eaten. The acquisition of irrational fears or phobias, sexual hang-up (fetish), prejudice and hostile
feelings has successfully been explained through the process of classical conditioning. In both cases, stimuli initially
incapable of eliciting strong reaction acquire this ability through repeated pairing with the unconditional stimuli.

For example a child while playing a new pet suddenly hears the loud sound of a backfiring truck. In all probability the
noise (which may be viewed as an unconditional stimulus) will frighten the child greatly (an unconditioned emotional
response), so that the child burst into tears. If the child happens to live near a busy road and often plays with the pet, this
situation may be repeated – quite by accident – on several other occasions. The child now no longer will play with the pet;
instead he may recoil in terror and seek to escape from its presence.

Similarly sexual hang-up can also be explained through the process of classical conditioning. Assume that a person for
whom an article of clothing (CS) is initially nothing to do with sexual arousal. Now imagine that the man sees the nude
body of his lover (UCS) along with that clothing article, and it happens to take place repeatedly. Now what will happen?
The sexual arousal which is a natural response to the nude body of the lover will be associated with that article of cloth. In
the same way development of prejudice and hostility can also be accounted by the process of classical conditioning.

Generalization and Discrimination

Once the organism is conditioned to one stimulus, it is often found that it will respond to other stimuli, similar in some
dimensions to it. This phenomenon is known as stimulus generalization. Stimulus generalization plays a very important
adaptive role. For example, the sounds made by angry bees, wasps, and hornets are highly similar, but certainly not
identical. Because of stimulus generalization, however an individual who has learned through painful experience to react
with the fear and caution to one of the sound may also respond in a similar manner to others as well.

Opposite to this phenomenon is stimulus discrimination. Within the framework of classical conditioning, the ability to
discriminate between two stimuli is developed when one of the two similar stimuli is consistently followed by an
unconditioned stimulus while the other is not. Under such conditions, tendencies to respond to the first are strengthened,
while the tendencies to respond to the second are weakened. Although the ability of human beings and other organisms to
discriminate between various objects is quite impressive, but it has some limits. The disconcerting effects may result when
these limits are exceeded is suggested by experiments dealing with the phenomenon of experimental neurosis. Let us what
this experimental neurosis is.

In a famous experiment by Shenger-Krestovnika (1921) a circle was used as a conditional stimulus before feeding, and the
dog was also trained to associate an ellipse with not being fed. By small steps the ellipse was then made more and more
like a circle. When the ellipse was almost round, initially the dog could usually distinguish it from a circle. But after a few
weeks the dog became neurotic: it ceased to be able to recognize obvious ellipses and a circle, became very excited, and
was no longer calm during experiments. Pavlov termed the animal’s abnormal condition as experimental neurosis and he
attributed it to a disturbance of the balance between excitatory and inhibitory processes in the nervous system.
This explanation of experimental neurosis is grounded in Pavlov’s theory of personality. He explained personality by
variation in the excitation of the nervous system. He did not, however, attribute neurosis solely to external factors, such as
contradictory stimuli. His experiments on experimental neuroses showed that dogs with different ‘personalities’ were
differentially susceptible to the treatment: the same treatment on different dogs could produce quite different neuroses.
Although the experiment was conducted on an animal, the results of such experiments however, suggest that while the
ability of human beings to discriminate between stimuli is impressive, their ability to discriminate between highly similar
stimuli has definite limits. When the environmental conditions require that these limits be exceeded, extreme stress may
be induced.

Extinction and Spontaneous Recovery

When a conditioned stimulus is repeatedly presented but is never followed by the unconditioned stimulus with which it
was formerly associated, its ability to elicit conditioned response gradually decreases, and may fade completely. This
phenomenon is known as extinction. But if the same extinguished stimulus is then presented again at a later time, its
capacity to evoke the response is found to reappear. This phenomenon is termed spontaneous recovery.

Extinction of conditioned response is also very important for the development of normal personality. If we lack some
mechanism for getting rid of useless reactions to stimuli which no longer serve as reliable cues for the occurrence of such
events, we would become a walking bundle of useless conditioned responses.

Operant Conditioning

Influential on the development of Skinner’s operant conditioning, Thorndike proposed the law of effect (Thorndike,
1905).

Law of effect: the idea that if our behavior produces a favorable consequence, in the future when the same stimulus is
present, we will be more likely to make the response again, expecting the same favorable consequence. Likewise, if our
action leads to dissatisfaction, then we will not repeat the same behavior in the future.

Operant conditioning is a type of associate learning which focuses on consequences that follow a response or behavior
that we make (anything we do, say, or think/feel) and whether it makes a behavior more or less likely to occur.It works on
A-B-C model of behaviour.

A - B - C

(Antecedents) – (Behavior) – (Consequence)

 Operant behavior: A voluntary and controllable behavior that “operates” on an individual’s environment
 Operant conditioning: Voluntary behaviors are controlled by the consequences that follow them
 Differs from classical conditioning- Linked to voluntary, not involuntary, behaviors
 Behaviors are controlled by reinforcer.
 Abnormal behaviors (e.g., head banging) have been linked to environmental reinforcers.

There are two main ways they can present themselves.

Reinforcement: Due to the consequence, a behaviour/response is more likely to occur in the future. It is strengthened.

Punishment: Due to the consequence, a behaviour/response is less likely to occur in the future. It is weakened.

Reinforcement and punishment can occur as two types – positive and negative.

 Positive means that you are giving something – good or bad.

 Negative means that something is being taken away – good or bad.
Observational Learning

There are times when we learn by simply watching others. This is called observational learning. The observational
learning paradigm:

 Behaviors are acquired by watching other people perform those behaviors

 Modeling (vicarious conditioning): Learning by observing models and later imitating them. Exposure to disturbed
models is likely to produce disturbed behaviors

Albert Bandura conducted pivotal research on observational learning and you likely already know all about it from
previous psychology courses. In Bandura’s experiment, children were first brought into a room to watch a video of an
adult model playing nicely or aggressively with a Bobo doll. Next, the children were placed in a room with toys and a
Bobo doll. Children who watched the aggressive model behaved aggressively with the Bobo doll while those who saw the
nice model, played nice. Bandura said if all behaviors are learned by observing others and we model our behaviors on
theirs, then undesirable behaviors can be altered or relearned in the same way. Modeling techniques are used to change
behavior by having clients observe a model in a situation that usually causes them some anxiety. By seeing the model
interact calmly with the fear-evoking stimulus, their fear should subside. This form of behavior therapy is widely used in
clinical and classroom situations. In the classroom, we might use modeling to demonstrate to a student how to do a math
problem. In fact, in many college classrooms, this is exactly what the instructor does.

Evaluating the Behavioral Model

Within the context of abnormal behavior or psychopathology, the behavioral perspective is useful because it suggests that
maladaptive behavior occurs when learning goes awry. The good thing is that what is learned can be unlearned or
relearned using behavior modification which refers to the process of changing behavior. To begin, an applied behavior
analyst will identify a target behavior, or behavior to be changed, define it, work with the client to develop goals, conduct
a functional assessment to understand what the undesirable behavior is, what causes it, and what maintains it. Armed with
this knowledge, a plan is developed and consists of numerous strategies to act on one or all of these elements –
antecedent, behavior, and/or consequence.

 The greatest strength or appeal of the behavioral model is that its tenets are easily tested in the laboratory unlike
those of the psychodynamic model.
 Also, a large number of treatment techniques have been developed and proven to be effective over the years.

Criticisms

Criticisms of behavioral models:

 It oversimplifies behavior and often ignores inner determinants of behaviour

 Behaviorism has also been accused of being mechanistic and seeing people as machines.
 Often neglects importance of inner determinants of behavior
 Overextends animal studies to human behavior

In terms of the latter, cognitive behavior modification procedures arose after the 1960s along with the rise of cognitive
psychology. This lead to a cognitive-behavioral perspective which combines concepts from the behavioral and cognitive
models.

MENTAL HEALTH MODEL

Mental health has been described in a continuum model, where people can measure their mental health in terms of
Thriving, Surviving, Struggling or In Crisis.

Someone who is in the Thriving category will typically feel “normal”, have good sleep habits and energy. For these
folks, it is important to maintain a healthy lifestyle, practice time management, and nurture your support systems.

People in the Surviving category might feel symptoms of irritability and sadness; have trouble sleeping or have low
energy, muscle tension or headaches; and they might start decreasing their amount of social activity. In this category it is
important to get adequate rest, food, and exercise; start engaging in healthy coping strategies; and start identifying
stressors in your life.

Someone in the Struggling category might feel emotional symptoms like anxiety, anger, sadness, or hopelessness. They
might experience restless sleep, fatigue, aches and pains. People in this category might see a performance decline in work
or school and might start withdrawing. For people in this category, it is important to talk with someone about your
difficulties, seek help from a professional, and reach out to your social supports instead of withdrawing.

People in the Crisis category might feel excessive anxiety, extreme emotions, and depressed moods. They might be
unable to fall or stay asleep, but feel exhaustion and are often susceptible to physical illness. They might start avoiding
social events and work or school. For people in this category, it is important to seek professional health as soon as
possible.

The mental health continuum model, developed in collaboration with the United States Marine Corps (USMC) in 2008,
promotes awareness of mental health indicators in self and others, early recognition of distress, management strategies
and prevention. This model goes from healthy adaptive coping (green), through mild and reversible distress or functional
impairment (yellow), to more severe, persistent injury or impairment (orange), to clinical illnesses and disorders requiring
more concentrated medical care (red). The arrows under the four color blocks denote movement in both directions is
possible, thus indicating that there is always the possibility for a return to full health and functioning.

The mental health continuum model is designed to help identify specific changes in health and performance in six
different domains: mood, attitude and performance, sleep, physical health, social well-being, and substance
use/gambling/gaming issues.
ORGANIZATIONAL MODEL

A model can be understood as a medium through which a person looks at the complex realities. It serves as a reference for
the work undertaken and gives a clearer understanding of what could be expected. A model can also be understood as a
strategy or an approach for accomplishing a vision, and the appropriate steps to be followed to get there. Some models
have evolved out of the specific ideologies of change, while some have arisen in response to certain concrete situations or
experiences.

A number of persons have attempted to develop a classification of models of community organization.

Murray. G. Ross (1955) preferred to use the term ‘approach’. He identified three main approaches to community
organization.

These are:

 The General Content Approach

 The Specific Content Approach
 The Process Approach

The General Content Approach: The focus of this approach is on the coordinated and orderly development of services
in the community. This approach incorporates two sub-approaches viz. (a) the strengthening of the existing services and
(b) initiating new services. The general objective is effective planning and organization of a group of services in the
community.

The Specific Content Approach: This approach comes into operation when an individual organization or the community
itself becomes concerned with some specific issue of concern or some requisite reforms, and consciously launches a
programme to achieve the stipulated goal/s or objective/s. Thus, this approach involves specific issue oriented
organization of services.
The Process Approach: This approach does not focus so much on the ‘content’, as on the initiation and sustenance of a
‘process’ in which all the people of the community are involved, either directly or through their representatives. It
involves identification of problem/s and taking purposeful action with regard to the same. The emphasis is more on
building the capacity of the community for self-help initiatives and collaborative enterprise. Four factors are very
important for this approach. These are (i) Self determination of the community; (ii) Indigenous plans; (iii) People’s
willingness to change; and (iv) Community pace.

The Inter-Community Model of Community Work

The scope of this model is wider than the neighborhood model. There are certain problems/needs in the community which
may not be tackled, either within the community or through community resources. For example, the problem of
unemployment or lack of training facilities or health facilities cannot be tackled within a community. Low-income levels
and resource base of the community make it difficult to initiate and sustain a programme which aims to meet some such
needs within the single community context. This calls for an inter-community approach.
The worker locates the programme in a place where people from different communities can come and participate.
The worker visits various communities, to make people aware of the programme and motivates them to participate. A
community nucleus is usually established, comprising of beneficiaries and other influential persons, to dispense
information about the initiative. In such efforts, the representatives of the different communities participate in
deciding the programme, its location and the mode of sharing resources and responsibilities for its management. This
model can lead to the establishment of an organization or council to provide specific services in different
communities.
The inter community work model is different from the neighborhood model, as the scope of its coverage is wider. It
differs from the other two models since its goal is to meet local needs, rather than change the system or structure.

Robert Fisher (1984) presented a much broader perspective of approaches. He identified “three dominant approaches”, to
neighbourhood organizing.

These are as follows:

Social Work Approach: In this approach, the society is viewed as a social organism and all efforts are oriented towards
building a sense of community. The community organizer plays the role of an enabler, an advocate, a planner and a
coordinator, who helps the community to identity a problem in the neighbourhood, attempts to procure the requisite
resources by gathering the existing social services and by lobbying with those in power to meet the needs of the
neighbourhood. This approach is consensual and gradualist in nature. The goals was the Social Settlement Movement in
the US and the War on Poverty Programme of the Johnson administration in the sixties.

The Political Activist Approach: This approach is characterized by militant confrontation and heavy pressure on the
power institutions of society. Power sharing is a major goal. This method is based on advocacy, conflict and negotiation
and is used by mass based organizations such as those initiated by Saul Alinsky, who is also considered to be the founder
of this approach. The organizer is a mobiliser and leadership developer, and the problem condition is social and economic
oppression arising out of powerlessness. The ultimate goal is the elimination of social, economic and political disparities
(a direction with political emphasis).

Neighborhood Maintenance Approach: This approach arose out of both the previous approaches, and is characterized
by middle-class residents and their small business and institutional allies who seek to “defend” their community against
change and perceived threats to property values. The “problem conditions may include decline in municipal services,
deterioration in neighbourhood sanitation, water supply, or increased crime. The organizer might be a volunteer
community leader or a trained specialist in urban planning, community development etc. The method used may be peer
group pressure may be a civic association/neighbourhood association. In the initial phase, peer group pressure may be
used to convince the officials to deliver services to the community, but later it could assume the form of the political
activists approach as they realize that goals can only be achieved through confrontation.
SOCIAL ACTION MODEL

In the year 1968, Jack Rothman introduced three models of community organization.

These were:

 Locality Development
 Social Planning
 Social Action

These three models construct were revised and refined by him in the year 2001 (Rothman, 2001), taking into account the
changes in practices and conditions in communities. Instead of referring to the three approaches as the ‘Models’, he
preferred referring to them as the ‘Core Modes of Community Intervention’. Moreover, these three approaches or modes
are described as ideal-type constructs, which to a very large extent do not exist in pristine, full-blown form in the real
world, but are useful mental tools to describe and analyse reality.

According to Rothman, these three modes of intervention to purposive community change can be discerned in
contemporary American communities and internationally. Community intervention is the general term used to cover the
various forms of community level practice, and has been used instead of the term community organizing, as it has been
found to be a useful overarching term to employ.

The three modes of intervention are:

 Locality Development
 Social Planning/Policy
 Social Action

Mode A: Locality Development This approach presupposes that community change should be pursued through broad
participation by a wide spectrum of people at the local community level in determining goals and taking civic action. It is
a community building endeavor with a strong emphasis on the notions of mutuality, plurality, participation and autonomy.
It fosters community building by promoting process goals: community competency (the ability to solve problems on a
self-help basis) and social integration (harmonious inter-relationships among different ethnic and social class groups). The
approach is humanistic and strongly people-oriented, with the aim of “helping people to help themselves”. Leadership is
drawn from within and direction and control are in the hands of the local people. “Enabling” techniques are emphasized.

Some examples of locality development include neighborhood work programmes conducted by community-based
agencies, and village level work in community development programmes.

While locality development is based on highly respected ideals, it has been criticized by people like Khinduka, who
characterize it as a “soft strategy” for achieving change. Its preoccupation with process can lead to a slow pace of progress
and may divert attention from the important structural issues. Embracing consensus as a basic modus operandi, those who
stand to lose from the proposed reforms may be in a position to veto effective action. Moreover, in contemporary context,
locality is steadily losing its hold over people and powerful national, regional and global forces are influencing the
patterns of life of people.

Mode B: Social Planning/Policy This approach emphasizes a technical process of problem solving regarding substantive
social problems, such as housing, education, health, women’s development etc. This particular orientation to planning is
data-driven and conceives of carefully calibrated change being rooted in social science thinking and empirical objectivity.
The style is technocratic and rationality is a dominant ideal. Community participation is not a core ingredient and may
vary from much to little depending on the problem and the circumstances. The approach presupposes that change in a
complex modern environment requires expert planners who can gather and analyse quantitative data and manoeure large
 bureaucratic organizers in order to improve social conditions. There is heavy reliance on needs assessment, decision
analysis, evaluation research, and other sophisticated statistical tools.

By and large the concern here is with task goals: conceptualizing, selecting, arranging and delivering goods and services
to people who need them. In addition fostering coordination among agencies, avoiding duplication and filling gaps in
services are important concerns here. Planning and policy are grouped together because both involve assembling and
analyzing data for solving social problems.

Two important contemporary constraints impacting this mode, according to Rothman are: (1) Planning has become highly
interactive and diverse interest groups rightfully go into the defining of goals and setting the community agenda. It
involves value choices that go beyond the purview of the expert or bureaucrat; and (2) Impact of reduced governmental
spending on social programmes, due to economic constraints, leading to a lower reliance on the elaborate, data driven
planning approach.

Mode C: Social Action This approach presupposes the existence of an aggrieved or disadvantaged segment of the
population that needs to be organized in order to make demands on the larger community for increased resources or equal
treatment. This approach aims at making fundamental changes in the community, including the redistribution of power
and resources and gaining access to decision making for marginal groups. Practitioners in the social action domain aim to
empower and benefit the poor and the oppressed. The style is primarily one in which social justice is a dominant ideal
(Karp, 1998).

Confrontational tactics like demonstrations, strikes, marches, boycotts and other disruptive or attention gaining moves
have been emphasized, as disadvantaged groups frequently rely heavily on “people power”, which has the potential to
pressure and disrupt’. Practitioners of this approach mobilize low power constituencies and equip them with skills to
impact power. This approach has been used widely by AIDS activists, civil rights power groups, environmental protection
organizations, feminist groups, labour unions and radical political action movements. Human service professionals have
not been prominent in the social action area, but there has been participation on a small-scale basis. Modest salaries,
absence of professional expertise and need for long term commitment are important deterrents in this approach becoming
more widely used.

Three Community Intervention Approached (Rothman, 2001)

Selected Practice Variables Locality Development Social Planning/ Policy Social Action

Goal categories of Community capacity and Problem solving with regard to Shifting of power relationships and
community action integration; Self-help (process substantive community resources; basic institutional
goals) problems (task goals) change (task or process goal)

Assumptions concerning Community lacks viable relationships Substantive social problems Disadvantaged populations, social
community structure and and problem-solving capacity exist like poverty housing, injustice, deprivation, inequality
problem conditions health etc.

Basic change strategy Involving a broad cross section of Gathering data about problems Crystallizing issues and
people in determining and solving their and rational decision making mobilizing people to take action
own problems enabling an effective course of against enemy targets
action.

Characteristic change Consensus; communications among Consensus or conflict Conflict confrontation, direct
tactics and techniques community groups and interests; group action, negotiation
discussion
Practitioner roles Enabled-catalyst co-ordi nator, Fact gatherer and analyst, Activist advocate: agitator,
teacher of problem-solving skills and program implementer, expediter broker, negotiator or, partisan
ethical values

Medium of change Guiding small, task oriented Guiding formal organizations Guiding mass organizations and
groups and treating data political processes

Orientation toward Members of power structure as Power structure as Power structure as external target
power structure collaborators in a common venture employers and sponsors of action: oppressors to be coerced
or overturned
Boundary definition of the Total geographic community Total community or Community segment
beneficiary system community segment
Conception of Citizens Consumers Victims
beneficiaries
Use of empowerment Building the capacity of a community Finding out from consumers Achieving power for the
to make collaborative and informed about their needs for service; beneficiary system-the right and
decisions informing consumers about the means to impact community
their service choices decisions; promoting a feeling of
mastery by participants

The aforementioned table lists a set of practice variables that help describe and compare each of the three
modes of intervention. These include goal categories; assumptions; basic change strategy; change tactics;
practitioner’s roles; orientation towards power structure; definition of beneficiary system; uses of
empowerment etc. The three approaches differ in terms of most of these practice variables.
Rothman further points out that each community intervention mode is not as self-contained and mutually
exclusive as it appears to be. Actually intervention approaches overlap and may be used in mixed form in
practice. (Rothman, 2001).

ECOLOGICAL MODEL: Effects of noise, Crowding, Architectural Factors, Economic Factors, The Study of
Behavior in Natural Social Environment, Kelly’s Studies on Coping in High Stress Environments.

Ecological model is the interaction between, and interdependence of, factors within and across all levels of a health
problem. It highlights people’s interactions with their physical and sociocultural environments.”

Ecological models recognize multiple levels of influence on health behaviors, including:

Intrapersonal/individual factors, which influence behavior such as knowledge, attitudes, beliefs, and personality.

Interpersonal factors, such as interactions with other people, which can provide social support or create barriers to
interpersonal growth that promotes healthy behavior.

Institutional and organizational factors, including the rules, regulations, policies, and informal structures that constrain
or promote healthy behaviors.

Community factors, such as formal or informal social norms that exist among individuals, groups, or organizations, can
limit or enhance healthy behaviors.

Public policy factors, including local, state, and federal policies and laws that regulate or support health actions and
practices for disease prevention including early detection, control, and management.
Considerations for Implementation

The ecological perspective is a useful framework for understanding the range of factors that influence health and well-
being. It is a model that can assist in providing a complete perspective of the factors that affect specific health behaviors,
including the social determinants of health. Because of this, ecological frameworks can be used to integrate components
of other theories and models, thus ensuring the design of a comprehensive health promotion or disease prevention
program or policy approach.

The Healthy People 2020 framework addresses the importance of ecological models in health promotion and disease
prevention. Programs are most likely to be effective when they are designed to address the multiple levels of influence on
health behaviors.

For instance, Kelly’s ecological approach is based on human interactions and adjusting to social settings that are utterly
unusual for them (Jason et al., 2016).

As a result, James G. Kelly proposed four principles that are principal to analyzing human behavior in social
environments, such as “independence, cycling of sources, adaptation, and succession” (Jason et al., 2016, p. 10). To be
more exact, interdependence seems the essential principle of Kelly’s theory which “implies that change in one component
of an ecosystem can change relationships among other components of the system” (Jason et al., 2016, p. 10). In other
words, even a tiny alteration might lead to a considerable enhancement or, on the contrary, diminution of a social
situation. It can be concluded that the notion is presented as a process that occurs in the community and intervention
leading to further change in settings.

According to the co-variation model, three categories of information—consensus, consistency, and distinctiveness of
information—are essential for determining whether attribution is internal or external. The cumulative effect of these three
pieces of information will decide what kind of attribution is formed while viewing someone behaving in a specific social
setting.

Consensus information refers to the degree to which other characters behave similarly to the target individual. The degree
of consensus increases with the percentage of people with the same reaction.

Consistency information refers to how consistently the target individual responds to the stimulus or event on subsequent
occasions.

Distinctiveness information measures how consistently the target person responds to various other stimuli or occurrences.

According to Kelley's theory, when consensus and distinctiveness are low but consistency is strong, we are more likely to
attribute others' behavior to internal factors. In contrast, when consensus, consistency, and distinctiveness are all high, we
are more prone to assume that the other person's behavior results from outside forces. Finally, when consensus is low, but
consistency and distinctiveness are high, we typically ascribe others' conduct to a mix of internal and external variables.
Here’s an example. You’re at a bar on a date and everyone around you is ordering tequila shots. If your date also orders a
tequila shot, consensus is high. If your date decides that they are going to stick to water, consensus is low.

If you notice that your date tends to order tequila shots whenever you’re in a bar on a Friday night, distinctiveness is low.
If the date typically sticks to non-alcoholic beverages at a bar but that night decides to order a tequila shot, distinctiveness
is high.

If you continue to date the person from this example and you notice that they are always the first person to recommend
shots at parties, bars, or weddings, consistency is high. If they tend to stick to non-alcoholic beverages, but decide to take
shots for special occasions, consistency is low.

Low Consensus, Low Distinctiveness, and High Consistency lead us to come to the conclusion that the behavior has a
Dispositional Attribution.

High Consensus, High Distinctiveness, and Low Consistency lead us to come to the conclusion that the behavior has a
Situational Attribution.

SOCIO-CULTURAL MODEL

The socio-cultural psychology examines the influences of social and cultural environments on behavior. Socioculturalists
argue that understanding a person’s behavior requires knowing about the cultural context in which the behavior occurs
(Matsumoto & Juang, 2013). (Culture refers to the shared knowledge, practices, and attitudes of groups of people and can
include language, customs, and beliefs about what behavior is appropriate and inappropriate.)

The sociocultural approach often includes cross-cultural research, meaning research that compares individuals in various
cultures to see how they differ on important psychological attributes. Cross-cultural research is important for testing the
assumption that findings for one culture also generalize to other cultural contexts, and as such it allows psychologists to
test for the possibility that some characteristics are universal (Hofmann & Hinton, 2014).

The sociocultural approach provides researchers and psychologists with a more informed view and understanding of the
motivations which cause a person to behave in a particular way. Instead of relying on biological factors alone, the
approach promises to paint a more vivid picture of the human mind through a wider understanding of how we acquire
cognitive abilities at an early age.

A pioneer of the sociocultural approach was the Soviet psychologist Lev Semyonovich Vygotsky (1896-1934), who
became interested in developmental psychology and helped to change the face of the field.One key element of Vygotsky’s
sociocultural approach is his idea of a Zone of Proximal Development. Image result for Zone of Proximal Development
Commonly abbreviated as ZPD, the Zone of Proximal Development is a way to gauge a child’s ability to learn and grow.
Vygotsky believed that the ZPD was a far better way to gauge. A child’s intelligence than through the standard academic
testing, which can often fail to account for cultural differences with regards to learning. Vygotsky claims that there are
three cultural tools which children use to inform their cognitive abilities.

Politics, cultural ethics, gender, values, beliefs, ethnicity, socioeconomic status influence our behavior in society and
interactions in social groups.

It also includes interpersonal and intrapersonal theory.

 5. EPIDEMIOLOGY

PREVALENCE

Prevalence is a measure of disease that allows us to determine a person's likelihood of having a disease.

Prevalence refers to the total number of individuals in a population who have a disease or health condition at a specific
period of time, usually expressed as a percentage of the population.

Prevalence is especially useful to health system planners and public health professionals. Knowledge of the disease
burden in a population, whether global or local, is essential to securing the resources required to fund special services or
health-promotion programs. For instance, the director of a nursing home must be able to measure the proportion of seniors
with Alzheimer disease in order to plan the appropriate level of services for the residents.

Prevalence = the number of cases of a disease in a specific population at a particular timepoint or over a specified period
of time.

When we talk about prevalence, we can either refer to ‘point prevalence’ or ‘period prevalence’.

Point prevalence is the proportion of people with a particular disease at a particular timepoint and can be calculated as
follows:

Period prevalence is the proportion of people with a particular disease during a given time period.
Prevalence is a useful measure of the burden of disease. Knowing about the prevalence of a specific disease can help us to
understand the demands on health services to manage this disease.

Prevalence changes when people with the condition are cured or die. Bear in mind that increased prevalence doesn’t
necessarily mean a bigger problem. Higher prevalence could mean a prolonged survival without cure or an increase of
new cases, or both. A lower prevalence could mean that more people are dying rather than being cured, a rapid recovery,
and/or a low number of new cases.
INCIDENCE

Incidence is a measure of disease that allows us to determine a person's probability of being diagnosed with a disease
during a given period of time. Therefore, incidence is the number of newly diagnosed cases of a disease. An incidence rate
is the number of new cases of a disease divided by the number of persons at risk for the disease.

Incidence refers to the number of individuals who develop a specific disease or experience a specific health-related event
during a particular time period (such as a month or year).

Incidence = the rate of new cases of a disease occurring in a specific population over a particular period of time.

Two types of incidences are commonly used: ‘incidence proportion’ and ‘incidence rate’.
Incidence proportion, risk or cumulative incidence refers to the number of new cases in your population during a specified
time period. It can be calculated using the following equation:

Incidence rate incorporates time directly into the denominator and can be calculated as follows:

Person years at risk means the total amount of time (in years) that each person of the study population is at risk of the
disease during the period of interest.

MORBIDITY, MORTALITY

Morbidity is another term for illness. A person can have several co-morbidities simultaneously. Morbidities are NOT
deaths.

Morbidity is the state of having an illness or medical condition, either mental or physical. Such issues can progress over
time and gradually affect a person's health and quality of life.

However, the term has absolutely no relationship to your likelihood of death or even how "well" or "unwell" you are. It is
only when a disease or condition progresses that the impact on your health may be felt and the risk of death may increase.

People who have certain morbidities may not live as long as those who do not. It's also possible that morbidity may have
no impact on a person's life expectancy or risk of death, especially if their condition is well-managed.

Morbidity refers to the state of being unhealthy. It applies to all the people affected by a disease in a particular region. The
morbidity rate refers to the number of people affected by a particular disease. This helps health officials to make risk
management and adopt national health systems according to the needs of the population.

Mortality is another term for death. A mortality rate is the number of deaths due to a disease divided by the total
population.

Mortality is another term for death. When used in research, it usually means the number of deaths caused by an event or
illness over a specific period of time.
Insurers and public health experts use these statistics to assess the impact of a disease on healthcare costs or to determine
where healthcare costs are best spent.2

Mortality rates describe the incidence of deaths among a specific population over a specific time. In national studies, it is
typically described as the number of cases per 100,000. (In smaller studies, the mortality rate may be described as deaths.

When an event or a disease causes more deaths than expected, it is called excess mortality. COVID-19 is one such
example. The 2020 pandemic caused 50% more deaths than were expected over that period of time.

HOW EPIDEMIOLOGICAL STUDIES HELP IN IDENTIFYING POSSIBLE CAUSES?

Epidemiology is a discipline which has evolved with the changes taking place in society and the emergence of new
diseases and new discipline related to epidemiology. With these evolutions, it is important to understand epidemiology
and to analyze the evolution of content of definitions of epidemiology.

Types of epidemiology

Epidemiology can cover a wide range of issues, from unintentional injuries to psychosocial stress. Here are a few areas in
which Columbia Mailman faculty and students work:

Infectious Disease Epidemiology for Public Health: This type of epidemiology is at the forefront of today’s world—as
epidemiologists work on the front lines to track and trace the spread of COVID-19. In this concentration, infectious
disease epidemiologists work to detect pathogens or viruses, understand their development and spread, and devise
effective interventions for their prevention and control.

Chronic Disease Epidemiology: Chronic disease epidemiologists battle day-to-day chronic conditions such as cancers,
diabetes, obesity, and more. Epidemiologists in this fieldwork to research the origins, treatment, and health outcomes of
these diseases in the fight towards prevention.

Environmental Epidemiology: Environmental epidemiology focuses on how an individual’s external factors affect health
outcomes. This includes physical factors like pollution or housing, as well as social factors like stress and nutrition.
Environmental epidemiologists work to understand how different environments may result in physical or neurological
outcomes, ranging from psychiatric to cardiovascular disorders.

Violence and Injury Epidemiology: This epidemiological focus aims to address unintentional and intentional injuries
across a lifespan. For example, epidemiologists in this field might focus their research on car accidents and work to
identify the associated risk factors. Armed with extensive research, the goal of violence and injury epidemiology is to
improve a population’s health by reducing the morbidity and mortality rate from unintentional and intentional injuries.

Epidemiologists track diseases

Epidemiology centers around the idea that disease and illness do not exist randomly or in a bubble. Epidemiologists
conduct research to establish the factors that lead to public health issues, the appropriate responses, interventions, and
solutions. By using research—from the field and in the lab—and statistical analysis, epidemiologists can track disease and
predict its future outcomes. In the case of COVID-19, this analysis requires heavy data surveillance, collection, and
interpretation.

Data: Due to the scale and threat of the coronavirus pandemic, testing centers, and healthcare systems are required to
report all related data, providing epidemiologists with a wealth of information upon which to base their studies. With this
information, epidemiologists will track data including:

 Number of Incidences (how many cases over time?)

 Disease Prevalence (how many cases at a specific time?)
  Number of Hospitalizations
 Number of Cases Resulting in Death

Epidemiological Modeling: Using this data and more, epidemiologists create models that help predict the spread of the
disease in the future—including where and when the spread may occur. They may also be able to discern the most
vulnerable populations likely to contract a disease and provide recommendations for intervention. See examples of our
faculty's work modeling COVID data.

Contact Tracing: In an attempt to stop the spread of disease and understand where it might go next, many public health
workers use contact tracing to determine the connections of an infected person.

Epidemiological

A principal aim of epidemiology is to assess the cause of disease. However, since most epidemiological studies are by
nature observational rather than experimental, a number of possible explanations for an observed association need to be
considered before we can infer a cause-effect relationship exists. That is, the observed association may in fact be due to
the effects of one or more of the following:

 Chance (random error)

 Bias (systematic error)
 Confounding

Therefore, an observed statistical association between a risk factor and a disease does not necessarily lead us to infer a
causal relationship. Conversely, the absence of an association does not necessarily imply the absence of a causal
relationship.

The judgement as to whether an observed statistical association represents a cause-effect relationship between exposure
and disease requires inferences far beyond the data from a single study and involves consideration of criteria that include
the magnitude of the association, the consistency of findings from other studies and biologic credibility

6. COMMUNITY CARE OF THE MENTALLY ILL

DRAWBACKS OF LONG-TERM INSTITUTIONAL PSYCHIATRIC CARE

The closure of asylums in the last century has resulted in an increased number of compulsory hospital admissions for
psychiatric patients. Psycho-geriatric patients are highly vulnerable in this respect. Although the traditional buildings
instituted for the care of the mentally afflicted have gone, misconceptions about provision and anecdotes about
incarceration continue to haunt the community. Recent legislative changes have further extended the occurrence of
involuntary hospital admission. Compulsory community care is under constant review. Concurrently the validity of the
concept of mental illness, psychiatric classification and diagnostic dilemmas all continue to be debated. Confinement has
regained respectability in the discourses of present-day British mental health system because of violent offences
committed by psychiatric patients and the public media portraying them as a reflection of failure of community care.

Disadvantages

The Mental Health Acts are open to social abuse and elderly patients can be more defenseless in this respect. Specifically,
they may be: invoked to control behavior; misused for material gain and implicated in subtle expressions of revenge. They
are sometimes invoked to hasten divorce proceedings and to secure the custody of children by a specific parent. They are
also used to control the behavior of children by their parents. Mental Health Acts designed to control psychiatric patients
are being enacted and enforced in some underdeveloped countries that lack an efficient tribunal system to monitor their
effects.
A patient who has been detained is at risk of repeat detention and someone who has been inappropriately assessed
becomes increasingly vulnerable to control on psychiatric grounds. The experience of being detained involuntarily has a
reductive effect on behavior after discharge – it may induce anxiety or post-psychiatric depression. The awareness of
being deemed to require compulsory detention generates such negative attitudes as self-denigration, fear and unhealthy
repression of anger. It may also impede self-direction and the normal sense of internal control and may encourage the
view that in a world perceived as being divided into camps of mutually exclusive ‘normal’ and ‘abnormal’ people, the
patient is in the latter category. Compulsory detention may lead to suicide because the patient loses their sense of
integration within their own society. Furthermore, the fear and anxiety associated with involuntary admission delays the
recovery process. There are other frequently occurring barriers to recovery for those affected such as, loss of capabilities,
whether real or imagined, ineffectual medication due to poor elicitation of symptoms because of patient’s lack of
cooperation and negative drug side effects.

Depressed patients have a higher suicide risk than the population at large and one of the reasons for detention is
suicidality. Some of the subjective symptoms of depression can be ameliorated by denying them, while compulsory
detention may reinforce depressive symptoms. Detention gives carers a false sense of security and this may lead them to
relax their vigilance towards the patient. The Mental Health Acts increase the stigma associated with psychiatric illness
and with the exuberant expression of emotions. Patients who are under section or are frightened of being placed under
section may deliberately mask their symptoms in an attempt to have the section lifted or to avoid sectioning.

No policy exists in a vacuum, and various actors responded at different times to the opportunities they saw in
deinstitutionalization policy. These changes were generally not anticipated, and did not always accrue to the benefit of
individuals with mental illness. Many remain unresolved today.

 Living situations: instead of living in institutions, people with serious mental illness were moved to nursing homes,
single-room occupancy buildings, board-and-care homes or with families who were ill-equipped and poorly supported
to meet their needs.
 Essential services: the array of supports that people with serious mental illness need to live independent and
successful lives in the community were not appreciated and therefore not provided.
 There was insufficient connection between state policy for institutions and federal policy for community care. At the
outset, CMHCs were not even required to provide preadmission screening and follow-up care. Many people fell
through the cracks.
 Mental health systems continued to cling to blunt measures of success, such as bed days, instead of quality of life in
the community.
 Resources were never sufficient for the need:
 State funds that would have been spent on state institutions were not reinvested in community
programs. (State spending on mental health, adjusted for inflation and population growth, was
30 percent less in 1997 than in 1955.)
 Federal funds for the community mental health centers program did not come close to
approaching the early promises or projections of need.
 Third-party health insurance policies and public programs, such as Medicare, provided
limited coverage for the treatment of mental illness, with arbitrary limits and/or high co-
payments that did not meet the needs of people with serious mental disorders.

Multiple funding streams were uncoordinated. Even when needs were eventually recognized it was difficult to braid
together a comprehensive service package.

Reductions in state hospital beds were strongly opposed by unions representing state hospital workers and by
communities where the hospitals were a large and often dominant employer.

While beds were reduced, institutions did not close and so the costs of running the hospitals did not fall very much.
Discrimination in housing—the not in my backyard (NIMBY) syndrome—in employment, and in the community at-large
worked against the goals of community mental health.

DEINSTITUTIONALIZATION IN THE CARE OF THE MENTALLY ILL

Deinstitutionalization can be defined as the replacement of long-stay psychiatric hospitals with smaller, less isolated
community-based alternatives for the care of mentally ill people. According to this definition, deinstitutionalization is not
limited to the reduction of psychiatric hospital censuses, even though this is a common understanding of the term. Rather,
the definition extends beyond hospital depopulation to include the provision of alternative services. Thus, although
downsizing or closing long-stay psychiatric hospitals is a critical part of deinstitutionalization, it is only a part of that
process—it is not all of what deinstitutionalization encompasses.

Accordingly, in theory deinstitutionalization consists of three component processes: the release of persons residing in
psychiatric hospitals to alternative facilities in the community, the diversion of potential new admissions to alternative
facilities, and the development of special services for the care of a noninstitutionalized mentally ill population. The last of
these processes is particularly important, because it assumes that the altered life circumstances of these persons will
inevitably result in new configurations of service needs and a better quality of life.

Deinstitutionalization has left us with a heightened awareness of the humanity and needs of mentally ill persons. It has left
us with a biopsychosocial point of view that implies the interaction of biological, psychological, and sociological events
as they affect the lives of mentally ill persons. Such a biopsychosocial view demands that we consider not only the
biology of mental illness but also the sociological context of care and particularly the special circumstances, needs, and
hopes of individual patients as we plan mental health services with them and for them.

A social process with secondary consequences

Deinstitutionalization involves more than changing the locus of care; it is a social process with secondary consequences.
In addition to its being an important geographical event, deinstitutionalization is an ongoing process that has subtle
implications. More specifically, it is a vital process of ongoing social change—of movement away from one orientation in
treatment and toward another that is radically different—that has had a profound influence on the lives of mentally ill
people. Today, deinstitutionalization affects those individuals who continue to use psychiatric hospitals by shortening
their stays in such facilities and often by making discharge an end in itself that sometimes overrides clinical concerns.
Deinstitutionalization also affects persons who do not use psychiatric hospitals but who might have done so in another
era: the persons whose admissions have been prevented or diverted altogether.

We can no longer measure the success of deinstitutionalization in terms of reduced hospital populations, because when we
do so we can easily lose sight of those mentally ill people who never enter hospitals in the first place (8). We can also lose
sight of the many mentally ill persons who end up back on the streets or in jails and prisons. There are now said to be
more people residing in state prisons and jails than there are in public psychiatric hospitals.

Tailoring service planning to individual needs

Deinstitutionalization has clearly demonstrated the importance of individualized care for mentally ill persons, who
constitute a diverse and heterogeneous group of people. Service planning must be tailored to the needs of specific
individuals.

Mentally ill individuals further vary in the degree to which they are able to tolerate stress and unpredictability. They vary
as well in the kinds of programs that will best serve their needs—for example, whether they can live alone or would be
better suited to congregate residential plans; whether they need intensive psychiatric interventions or would be better
served by less invasive psychiatric care; and whether they are able to work, and, if so, whether they need sheltered or
supported work or competitive employment opportunities.
In the days before deinstitutionalization, service planners had a strong tendency to group all mentally ill persons together
and to ask, in effect, "What ought we to do with the 'mentally ill'?" However, deinstitutionalization has generated a focus
on rehabilitation and individual need, and we are more likely today to rephrase this question as, "What may we do for this
particular person who suffers from mental illness?"—a conceptual shift of major proportions.

Facilitating access to hospital care

It is essential to facilitate access to hospital care for patients who need it, for as long as they need it. In the early years of
deinstitutionalization many believed that if we could only eliminate the countertherapeutic practices that had been
exposed in some of our psychiatric hospitals, we would simultaneously eliminate the need for hospitals altogether.
Unfortunately, much of our early community service planning proceeded on the assumption that we would never again
require extensive resources for inpatient care. However, experience has shown that just as is the case for people who
suffer from somatic illnesses, some mentally ill persons sometimes require hospitalization. Precisely how many must be
hospitalized and under what circumstances depend largely on what alternative services are available in any given
community, because trade-offs are possible. Obviously, fewer people will require hospital care in places that offer a
complete array of excellent and integrated community-based services.

In any case, we know today that the community is not necessarily the most benign treatment site for all mentally ill people
at all times and that access to hospital care for those who need it, for as long as they need it, is absolutely essential to the
success of deinstitutionalization.

Cultural relevance of services

We have often seen that mental health programs that meet with success in one time and place will encounter problems in
another place or time unless specific efforts have been made to adapt the program to local cultural realities. Thus services
must be culturally relevant. For example, it makes good sense to plan services somewhat differently in urban and rural
communities. Not only may there be major variations among these places in the array and quality of facilities, but also
there are often differences in the effectiveness of social support networks. Often there are marked discrepancies in attitude
toward the use of mental health facilities as well.

However, cultural concerns are not defined exclusively by urban or rural residence or ethnicity; additional social factors
must be considered in service planning. For example, people who have spent long periods in psychiatric hospitals may
have learned to relate to caregivers in stereotypical ways—for example, passivity, as we have discussed—that will affect
the manner in which they approach and use the mental health system in the community. This possibility also holds for
individuals who have spent extended periods living in homeless shelters or on the streets.

This lesson thus underscores the fact that one-size-fits-all approaches are not appropriate for people who need mental
health care, not only because each mentally ill person is different from every other as an individual, but also because each
person must be considered within a specific cultural context.

Involving severely mentally ill persons in service planning

Severely mentally ill persons must be involved in service planning to the fullest extent possible. The experiences, values,
and personal goals of individual patients must be acknowledged in the planning process. And this in turn requires that the
person be informed about the nature of his or her illness and about its symptoms, course, and possible consequences. Even
when a person is severely mentally ill, there is always an intact portion of the ego that the clinician should engage in order
for care to be effective; this intact portion must be tapped and rewarded in treatment planning. "Ask the patient" is not an
unreasonable guideline for service planning.

An extension of this lesson involves consulting with families of mentally ill persons as well, whenever that is feasible.
Relatives often have expert knowledge that is otherwise unavailable to service providers. Before deinstitutionalization the
concept that mentally ill persons or their relatives could—or should—participate in service planning was not widely held.
Deinstitutionalization has given us an opportunity to explore the benefits of such involvement, and there is now
widespread acknowledgment of its efficacy.

Flexibility of service systems

Service systems must be flexible, open to change, and not restricted by preconceived ideology. This requirement is
exemplified in the matter of planning housing for mentally ill persons. Ideally all mentally ill persons should be able to
live independently, but in reality no single type of housing equally suits all of these individuals. Some need highly
structured residential settings, whereas others can live quite successfully in independent residences; most fall somewhere
along a continuum between these two extremes. Service systems must respond to clinical needs rather than allow
preconceived ideology to determine the kinds of services they provide. To do otherwise results in many mentally ill
persons' not having their essential needs met and jeopardizes their ability to adjust to life in the community.

Continuity of care in the community

We must achieve continuity of care in the community. The importance of continuity of care tended to be overlooked in the
early years of deinstitutionalization, when many proponents believed that in the absence of the negative effects of
institutional residence, chronicity would disappear. Thus program planning today frequently focuses on patients'
immediate requirements and ignores the future, even though patients' service needs tend to endure. It is crucial that
persons who have severe and long-term mental illness be able to receive services over a long period, perhaps indefinitely,
and preferably from the same agencies and clinicians.

Unfortunately, too little knowledge about the complex and continuing needs of severely mentally ill persons has found its
way into practice. When applied, however, such knowledge has led to a much richer life experience and a higher quality
of life for mentally ill individuals.

ADVANTAGES AND DRAWBACKS OF COMMUNITY CARE OF THE MENTALLY ILL

This complex process entails ensuring access to and developing special alternative community services for the care of the
physical and mental health of the mentally ill, non-institutionalized population, with the aim to improve quality of life,
ensure citizenship and promote social inclusion.

Many countries fail because they close institutions without careful planning and without implementing community.
Failures to establish basic infrastructure, to diversity and to integrate the mental health services are the most common.
This fact can have serious effects such as homelessness, marginalization, and “reinstitutionalization” or
“transinstitutionalization” into prisons or asylums as well as worsening psychiatric conditions and crowding emergency
department.

Informing decision makers about positive strategies and appropriate changes in mental health policies could be a key
factor for mental healthcare development.

The advantages could be divided into those for mental health workers (such as job and practice opportunities together
with the benefits of a rural lifestyle) and those provided by the rural context which facilitate mental health work (personal
resources to tackle mental problems in rural communities, religious resources, and social resources).

Job and Practice Opportunities

In contrast to urban areas, in which health professionals may need to specialize for getting a job, rural areas offer an
opportunity to serve as a generalist, practicing across the life span (Hastings and Cohn 2013). In rural practice, there is a
need to serve as a generalist in order to meet the needs of a heterogeneous group of patients. Because there are fewer
referral options, mental health providers need to work with people presenting with issues across the life span, and this
could be challenging and rewarding for clinicians (Hastings and Cohn 2013). In cities, competition is greater due to a
large number of professionals who opt for the same job which forces people to increase their postgraduate studies if they
want to be competitive.

Another advantage at a professional level is that vacancies in rural areas are not easily filled so opportunities to be hired
are greater. Besides this, sometimes, the economic reward can be higher than in the city and, therefore, more attractive to
staff.

In rural areas, it is common to work with members of the same family at the same time (Hastings and Cohn 2013).
Working with multigenerational families provides a unique opportunity to understand the symptom or problem from
multiple informants and may give a more balanced perspective from which to conceptualize the clinical situation
(Hastings and Cohn 2013). The autonomy offered by rural clinical practice and the opportunity to work with a variety of
diagnosis may be appealing to some mental health workers (Hastings and Cohn 2013).

Rural Lifestyle

Reasons such as a slower life pace, less violence and crimes compared to cities, and variability in client problems have
been reported as factors that keep practitioners in rural settings (Hastings and Cohn 2013). In fact, some individuals find
the values of rural life attractive (Hastings and Cohn 2013).

If mental health workers share the old-style values typically found in rural areas, it will be easier for them to adjust to the
requests of the environment while they enjoy being away from some of the conditions of urban areas (Hastings and Cohn
2013). Rural areas typically feature tight communities with little crime, pollution, and traffic and provide abundant
recreational activities (Hastings and Cohn 2013).

Personal and Religious Resources to Tackle Mental Problems in Rural Communities

A study on perceptions on health care in people with mental health problems in rural areas highlighted strength, self-care,
self-control, willpower, or joy as internal personal resources that are positive health aspects which may serve as
promotional elements in preventive mental health care (Saavedra and Uchofen-Herrera 2016; Salgado-de Snyder et al.
2003).

On the other hand, religion appears to be another important factor. Frequent attendance to religious services has been
significantly associated with lower rates of suicide which suggests that religion and spirituality are resources that
psychiatrists and clinicians may have been undervaluing (Saavedra and Uchofen-Herrera 2016). Instead, these resources
could be used to promote participation in the social context (Saavedra and Uchofen-Herrera 2016). In order to recover
health, rural people, especially in Latin America, often take part in religious rituals as they strongly believe in the healing
power of God (Salgado-de Snyder et al. 2003). Participation in these ceremonies is socially promoted because it has a
great transcendence in both the person and the community (Salgado-de Snyder et al. 2003). Religiosity and faith provide
the individual with spiritual, personal, family, and social resources that can be easily mobilized for the solution of mental
health problems (Salgado-de Snyder et al. 2003).

Social Resources

Usually, when there is not enough self-care to alleviate a mental symptom, help is sought from the social network, whose
members offer their emotional support in the form of advice and guidance and their instrumental support through money,
food, child care, etc. (Salgado-de Snyder et al. 2003). The resources offered by the network remain along the path of
seeking help until healing (Salgado-de Snyder et al. 2003). Social resources and support are important in rural
communities when their members are experiencing various social, economic, or health problems (Selamu et al. 2015). As
a matter of fact, social leaders are highly respected, and their recommendations and advice are taken into account (Selamu
et al. 2015). They have power to exclude a community member or mobilize the community in support of a member
(Selamu et al. 2015).

DISADVANTAGES
Difficulty in Recruiting and Retaining Qualified Staff

Nowadays, one of the most serious issues facing mental health care in rural areas is the difficulty to recruit and retain
qualified personnel who can provide services to individuals in need (Jameson and Blank 2007). This can be explained by
the great demands and efforts that this kind of work requires, not to mention the poor rewards (especially at an economic
level) which produce high levels of job strain and job dissatisfaction.

Rural practice poses many special challenges for the clinician. Mental health workers face excessive workloads, limited
availability of nongovernmental community support services, and limited access to crisis care which forces them to
transfer the management of acute patients to metropolitan services (Buchanan et al. 2006). Inpatient facilities are virtually
nonexistent in rural communities: only 13% of nonmetropolitan places had inpatient facilities, and none of the most rural
settings had such services (Jameson and Blank 2007).

Some degree of professional isolation seems inevitable due to the shortage of mental health professionals in rural areas
(Hastings and Cohn 2013). A shortage of mental health professionals means having fewer peers with whom to consult
difficult cases and fewer referral options. Isolated clinicians may lack the professional and emotional support professional
colleagues provide, and costs can be significant (Hastings and Cohn 2013). Rural clinicians who lack colleagues with
whom to share interests and concerns, and who experience a deficiency of mutually nurturing relationships, were at higher
risk for emotional exhaustion (Hastings and Cohn 2013). One study shows that, “Lack of sufficient guidance, reassurance
of worth, social integration, and attachment were associated with the rural mental health counselors at high risk for
burnout” (Hastings and Cohn 2013).

In addition to the shortage of specialty mental health professionals in rural areas, there is evidence that the workers who
do practice in rural areas experience very high rates of burnout (Jameson and Blank 2007). Burnout was predicted by a
lack of social integration with other professionals, a lack of guidance and advice from authoritative sources, and the
absence of reliable support from others for assistance (Jameson and Blank 2007). This comes as no surprise, given the
overall scarcity of professionals in these areas. The opportunities for support among co-workers in rural areas seem to be
as rare as the providers themselves (Jameson and Blank 2007).

Job dissatisfaction and burnout due to professional isolation and lack of support threaten to prompt rural clinicians to
leave the area, at a time when one of the most critical issues rural mental health care must face is recruiting and retaining
staff to provide much-needed services (Hastings and Cohn 2013). As a matter of fact, one third of the most rural places
totally lack available health professionals to address mental health problems, and a much greater percentage of these
places don’t have specialty mental health services at all (Jameson and Blank 2007).

Besides the issues related to environment, nature of mental health work, and rural location, there are issues related to the
organizations, management, and organizational structure that make recruitment and retaining of qualified staff difficult
(Moore et al. 2010). Mental health care in rural areas is dominated by the public sector which may have difficulties in
compensating professionals at the same competitive rate of urban service providers (Jameson and Blank 2007). Some
studies suggest that in rural areas, recruitment is regarded by managers as a matter of greater urgency than retention or
training and that organizations themselves are of a second order of significance in terms of perceived workforce
difficulties (Moore et al. 2010).

In many countries, the pool of available and potential mental health staff is limited by global, national, and state shortages
of suitable workers, competition with metropolitan and intra-regional organizations, inadequacy of specialist training, and
the choice of qualified people to work in other places (Moore et al. 2010). Rurality means that most services are small,
that workers need generalist skills to travel to clients, and that opportunities for career progression are limited (Moore et
al. 2010). It therefore imposes extra demands on workers and costs per employee and, in turn, greater demand on the
organization’s capacity to recruit and train (Moore et al. 2010).

In addition, education and vocational training are difficult to provide in rural areas where funding for these activities may
not be sufficient. Added to this, there isn’t a multidisciplinary approach, and there are very few specific training programs
for these professionals (Moore et al. 2010). The integration between primary care professionals (such as general practice
physicians and nurses) and specialty mental health-care providers is often seen as low in rural areas (Jameson and Blank
2007).

Other reasons that make recruiting and retaining qualified staff difficult in rural areas are the cultural barriers and lack of
respect for their professional judgment, thereby making it difficult to retain their services (Jameson and Blank 2007).

Individual, Social, and Geographical Factors as Barriers to Treatment

In general, rural residents face barriers to mental health care, including fewer local mental health providers, longer
distance to specialty services, lack of insurance, social stigma, and a tendency to rely on family and other informal support
(Buchanan et al. 2006).

Individuals in rural areas often do cite social stigma and lack of privacy as reasons not to seek help for mental distress
(Jameson and Blank 2007). Some studies have found social stigma associated with mental illness to be higher in rural
areas than in nonrural areas (Jameson and Blank 2007). Several studies have shown that people living in rural areas are
under the influence of stigmatization when it comes to their attitude toward mentally ill patients as they are more likely to
be rejected and stigmatized by society which is an important issue to consider (Gur and Kucuk 2016). Furthermore, the
degree to which stigma was perceived predicted inclination to seek treatment for mental health problems. Individuals in
rural areas also perceive a lack of privacy for primary care treatment of mental illness (Jameson and Blank 2007). Rural
residents recognize each other by their vehicles and tend to know “everything about everybody” (Hastings and Cohn
2013). The stigma associated with seeking mental health treatment is exacerbated by the difficulty to remain discreet in
small communities (Hastings and Cohn 2013). The lack of privacy is also associated with the fact that for mental health
professionals, there is an increased likelihood of being engaged in multiple relationships with patients because of the
reduced population density and the resulting likelihood of encountering one’s patients outside the office (Hastings and
Cohn 2013).

Two factors described as associated with stigma are the authoritarianism, which reflects a condescending view that the
mentally ill is different from normal people, and the social restrictiveness, which is a manifestation of the view that
mentally ill individuals need to be restricted during their hospitalization and later as well so that society can be protected
from their actions and from their posing a threat to the community (Gur and Kucuk 2016). The studies that examined
people’s attitudes toward illnesses reported that, especially in mental diseases such as schizophrenia, negative attitudes
prevail and people with sickness are rejected and social contact with them is avoided (Gur and Kucuk 2016). Particularly
in rural areas, it is reported that attitudes may be even more negative and rejection may be even more evident (Gur and
Kucuk 2016).

The stigma not only affects patients but also mental health professionals. Rural community values may make it difficult
for a psychologist or psychiatrist to be accepted. Stigma regarding mental health practice and suspicion of outsiders are
not uncommon aspects of rural social life (Hastings and Cohn 2013). Rural community values tend to be more
conservative, with religion playing a central role in residents’ lives. Yet mental health providers, as a group, generally
endorse more liberal and less religious ideologies (Hastings and Cohn 2013). These cultural barriers and a lack of
understanding regarding the mental health profession act like an obstacle for helpseeking behavior.

The stigma could be so strong that it also affects general practitioners. Primary care physicians often seem reluctant to
diagnose mental disorders (Jameson and Blank 2007). One study found that approximately half of physicians in primary
care rural settings deliberately misdiagnose depression (Jameson and Blank 2007). These physicians cited uncertainty
about the diagnosis, problems with reimbursement for services if a diagnosis of depression is given, and fear that the
patient may not be able to obtain health insurance in the future as the most common reasons for purposely misdiagnosing
depression (Jameson and Blank 2007). Instead, they often give diagnoses of fatigue/malaise, insomnia, or headache to
depressed patients (Jameson and Blank 2007).

In addition to the social stigma associated with mental illness, rural inhabitants
often do not recognize the need for treatment (Jameson and Blank 2007). The denial

of need for treatment may even be reinforced by social contacts in rural areas

(Jameson and Blank 2007). This is perhaps one of the reasons why the mentally ill may choose to seek alternative
methods of treatment. It is also known that especially

individuals living in rural areas who have lower socioeconomic status do not seek

psychiatric help for either themselves or their relatives. This avoidance seriously affects the ability of people to receive
psychiatric treatment (Gur and Kucuk 2016).

When it comes to alleviating their problems, rural people do not usually consult a doctor. They would only come when the
discomfort persists or when they have been repeatedly referred by a member of the local ethnomedical system or their
social network (Salgado-de Snyder et al. 2003). Individuals residing in rural areas in need of mental health treatment often
turn to informal sources of care like self-help, family, spouses, neighbors, friends, and religious organizations (Jameson
and Blank 2007). For a long time, rural areas have been identified as having poorer access to health services than
metropolitan areas due to a variety of different factors: poor geographical access to services, extended waiting periods for
doctor appointments, and limited access to specialized services (Henderson et al. 2014). Thus, before going to the doctor,
people consider the costs of transportation, consultation, medications, and subsequent consultations (Henderson et al.
2014). The cost of seeking medical care often becomes so high that patients repeatedly postpone the visit which
contributes to their condition worsening (Salgado-de Snyder et al. 2003).

Rural people seeking mental health care face difficulties in accessing psychiatrists and rely upon doctors to provide
primary mental health care (Henderson et al. 2014). Consultation with a mental health specialist, such as a psychiatrist or
psychologist, is highly unlikely among rural people due to three factors: the difficulty of geographical access to these
services, the cost of using them, and the cultural gap between the specialist and the patient which is even bigger than with
the general practitioner (Salgado-de Snyder et al. 2003).

In case a rural inhabitant gets a psychiatric appointment, their commitment to the therapy is uncertain since it involves
several trips for subsequent consultations and assuming the cost of medication (Salgado-de Snyder et al. 2003). Poverty,
marginalization, greater levels of general pathology, and lower involvement in vocational activities in rural zones explain
why it is difficult to access and adhere to mental health services (Jameson and Blank 2007). Although some people find
temporary relief to their symptoms, these do not completely disappear or reappear, so a person can remain on the path of
seeking help for a long time before actually finding a solution to their mental problems (Salgado-de Snyder et al. 2003).
Additionally, significantly larger proportions of rural people lack adequate mental health coverage compared to urban
groups (Hastings and Cohn 2013; Buchanan et al. 2006). Finally, rural inhabitants are more likely to report an inadequate
number of mental health providers in their areas and are dissatisfied with the quality of the mental health care received
(Buchanan et al. 2006).

MENTAL HEALTH MOVEMENT

7. PROMOTING COMMUNITY HEALTH

ISSUES RELATED TO POVERTY, MINORITY STATUS AND HEALTH

EARLY COMMUNITY IDENTIFICATION PROGRAMS

The term community-based often refers to community as the setting for interventions. As setting, the community is
primarily defined geographically and is the location in which interventions are implemented. Such interventions may be
citywide, using mass media or other approaches, or may take place within community institutions, such as neighborhoods,
schools, churches, work sites, voluntary agencies, or other organizations. Various levels of intervention may be employed,
including educational or other strategies that involve individuals, families, social networks, organizations, and public
policy. These community-based interventions may also engage community input through advisory committees or
community coalitions that assist in tailoring interventions to specific target groups or to adapt programs to community
characteristics. However, the focus of these community-based projects is primarily on changing individuals’ behaviors as
a method for reducing the population’s risk of disease. As a result, the target of change may be populations,
but population change is defined as the aggregate of individual changes.

The term community-based may also have a very different meaning, that of the community serving as the target of
change. The community as target refers to the goal of creating healthy community environments through broad systemic
changes in public policy and community-wide institutions and services. In this model, health status characteristics of the
community are the targets of interventions, and community changes, particularly changes thought to be related to health,
are the desired outcomes. Several significant public health initiatives have adopted this model. For example, community
indicators projects use data as a catalytic tool to go beyond using individual behaviors as primary outcomes. Indicators
can range from the number of days exceeding Environmental Protection Agency standards for air quality to the amount of
park and recreation facility space per capita to the proportion of residents living below federal poverty levels. Strategies
are tied to selected indicators, and success is defined as improvement in the indicators over time.

A third model of “community-based” is community as resource. This model is commonly applied in community-based
health promotion because of the widely endorsed belief that a high degree of community ownership and participation is
essential for sustained success in population-level health outcomes. These programs are aimed at marshaling a
community’s internal resources or assets, often across community sectors, to strategically focus their attention on a
selected set of priority health-related strategies. Whether a categorical health issue is predetermined or whether the
community selects, perhaps within certain parameters, its own priorities, these kinds of interventions involve external
resources and some degree of actors external to the community that aim to achieve health outcomes by working through a
wide array of community institutions and resources. Examples of major public health initiatives that have applied this
model include “healthy cities” initiatives within several states, the National Healthy Start program, and the federal Center
for Substance Abuse Prevention Community Partnership program.

Finally, a fourth model of “community-based,” and the one least utilized in public health, is community as agent.
Although closely linked to the model just described, the emphasis in this model is on respecting and reinforcing the
natural adaptive, supportive, and developmental capacities of communities. In the language of Guy Steuart, communities
provide resources for meeting our day-to-day needs. These resources are provided through community institutions
including families, informal social networks, neighborhoods, schools, the workplace, businesses, voluntary agencies, and
political structures. These naturally occurring units of solution meet the needs of many, if not most, community members
without the benefit of direct professional intervention. However, communities are defined as much by whom they exclude
as whom they include, and the network of relationships that defines communities may be under stress.

The goal of community-based programs in this model is to carefully work with these naturally occurring units of solution
as our units of practice, or where and how we choose to intervene. This necessitates a careful assessment of community
structures and processes, in advance, of any intervention. It also requires an insider’s understanding of the community to
identify and work with these naturally occurring units of solution to address community problems. Thus the aim is to
strengthen these units of solution to better meet the needs of community members. This approach may include
strengthening community through neighborhood organizations and network linkages, including informal social networks,
ties between individuals and the organizations that serve them, and connections among community organizations to
strengthen their ability to collaborate. The model also necessitates addressing issues of common concern for the
community, many or most of which are not directly health issues. In other words, this model necessitates starting where
people are.

The importance of these models of community-based interventions is that they reflect different conceptions of the nature
of community, the role of public health in addressing community problems, and the relevance of different outcomes.
When they are presented as pure types, it is understood that no one model is used exclusively with the practice of
community-based health promotion. Although community as setting is obviously limited in its vision, community as agent
can be regarded as romanticized, especially in light of the severe structural economic, social, and political deficits
plaguing some communities. Moreover, Merzel and D’Afflitti illustrate the difficulties in summarizing across program
models with different strategies and expected outcomes. Although many of the earlier projects reviewed by Merzel and
D’Afflitti were based on the idea of community as setting, many of the later projects are based on one of the other 3
models. The latter 3 models—community as target, community as resource, and community as agent—suggest that
appropriate outcomes may not just be changes in individual behaviors but may also include changes in community
capacity.10,11 In fact, it may be argued that contemporary public health has 2 broad goals: strengthening the health of our
communities and building community capacity to address health-related issues.

PROMOTION OF COMMUNITY HEALTH BY

REDUCING ENVIRONMENTAL HAZARDS

Maintain safe food and water

 Support and align local food safety objectives with WA Health’s Foodborne Illness Reduction Strategy 2018-
2021+
 Participate in food product quality and sampling programs (external site)
 Provide food safety education and/or training to local food businesses
 Conduct health promotion activities throughout the year (including Food Safety Week (external site) and Water
Safety Week) to raise awareness about food preparation and hygiene practices in the home, and increase
awareness on water related diseases and water management
 Develop and implement a food compliance and enforcement policy specific to your local district
 Educate food businesses about food allergens
 Educate authorised officers on healthy food principles and advocate local food businesses, including council
owned buildings, to incorporate healthy food options as part of routine inspections
 Advocate for local community events to provide healthy food options as part of events approval processes
 Monitor the bacterial water quality at popular swimming beaches and natural water bodies and communicate
results to the community
 Undertake sanitary surveys of popular swimming beaches to identify any sources of bacterial pollution that may
impact on water quality and initiate strategies to reduce these pollutant sources
 Ensure health warning signs advising the public of health risks of swimming in natural waterways are erected in
popular bathing areas that may require them. Include information about the risks of consuming wild shellfish in
areas that warrant this
 Ensure non-drinking water systems are operated in such a way that the water they supply cannot be mistaken for
drinking water
 Respond to suspected water contamination complaints and provide chemical or microbiological water quality
monitoring services and/or site inspections/investigations and reports
 Provide water safety education to private drinking water providers (those who run a privately run system) to
ensure they are properly maintained
 Provide guidance to owners of onsite water treatment systems to make sure the systems are operated correctly

Maintain healthy built environments and industries

 Develop policies for the application and management of pesticides in areas under the control of local government
 Ensure the local government or contractors comply with the Guideline for the management of pesticide application by
the local government
 Respond to enquiries regarding the management of asbestos products in residential or public buildings
 Ensure conditions are included on Demolition Permits for pre-demolition surveys and asbestos removal and disposal
 Promote the Know Asbestos eLearning course to residents undertaking renovations in areas where asbestos has been
commonly used in buildings, and provide links on your council website
 Improve opportunities and reduce costs of asbestos disposal for local residents (eg. apply for levy exemptions, free
disposal days at LGA waste facilities, organise asbestos/hazardous materials drop off days in a convenient location)
 Increase awareness of the benefits of asbestos roof removal (aging products, difficulties in adequate maintenance,
increased cost of removal for roofs in poor condition, damaged/poorly maintained roofs are a source of soil
contamination)
 Develop or embed regular environmental health communications within your local communication strategies
including:
Fight the Bite campaign messages
National Asbestos Awareness Week (external site)
 Strengthen partnerships with building surveyors to increase knowledge and awareness around building applications
for public buildings to enhance compliance with applicable legislation
 Encourage event organisers to submit details of their events online to the Department of Health to ensure health and
emergency services are aware of high risk or concurrent events
 Assess crowded places in accordance with the Crowded places self-assessment tool, to determine the potential for
terrorist threats and liaise with WA Police and event managers to ensure that the protective security measures put in
place are effective, appropriate and proportionate to the level and type of threat
 Encourage event organisers to consider harm minimisation strategies at their events, such as chill out zones, providing
free potable water that is cool and easily accessible, crowd management plans, Red Frogs, Save a mate etc.
 Appoint Restricted Investigators to assist in enforcing some sections of the Tobacco Products Control Act 2006 and
Regulations
 Ensure environmental health / authorised officers regularly attend training to manage community risks

Manage environmental hazards to protect community health

 Follow up notified cases of mosquito-borne disease (regional WA) and initiate risk management strategies to
eliminate breeding sites
 Advocate for a public health assessments to be integrated into local Development Assessment Panels to ensure health
considerations are addressed in the planning phases of local development projects and facilitate risk management
strategies early. This includes assessing the likelihood of mosquito borne disease breeding occurring near new
residential developments
 Develop and implement a mosquito management program for the local district
 Form a Contiguous Local Authorities Group (CLAG) to access Department of Health funding for mosquito
management
 Participate in community studies and survey’s coordinated by the Department of Health to monitor environmental
hazards that may impact the local community

Improve the environmental health conditions in remote Aboriginal communities

 Assist in the development of a Community Environmental Health Action Plan (CEHAP)

 Assist in the provision of ranger services to support contracted service providers
 Receive environmental health referrals from healthcare providers and follow up by conducting an in-home
environmental health assessment
 Conduct a Safe Bathroom Check as part of an environmental health referral
 Attend your local regional Aboriginal Environmental Health Forum
 Provide technical advice and support as required to contracted Service Providers
 Conduct health promotion activities related to a range of environmental health topics (eg. Fight the Bite)
 Under the Food Act 2008 (external site), conduct inspections of community stores and places where food is prepared
and/or sold
 Assist in the management of domestic animals in communities under the Dog Act 1976

ENCOURAGING PUBLIC PARTICIPATION IN FORMULATION OF PUBLIC HEALTH POLICIES

Selecting the Right Level of Public Participation discusses the different forms that public participation might take
depending on the potential for public influence on a decision. These forms include:

 informing the public by providing information to help them understand the issues, options, and solutions
 consulting with the public to obtain their feedback on alternatives or decisions
 involving the public to ensure their concerns are considered throughout the decision process, particularly in the
development of decision criteria and options
 collaborating with the public to develop decision criteria and alternatives and identify the preferred solution
 empowering the public by placing final decision-making authority in their hands.

Depending of the form of participation sought, public participation makes use of a variety of tools and techniques to
inform the public, generate public input, and, in some cases, build consensus and reach agreement.

Benefits of public participation

Public participation is not simply a nice or necessary thing to do; it actually results in better outcomes and better
governance. When done in a meaningful way, public participation will result in two significant benefits:

 Sponsor agencies will make better and more easily implementable decisions that reflect public interests and
values and are better understood by the public.
 Communities develop long-term capacity to solve and manage challenging social issues, often overcoming
longstanding differences and misunderstandings.

How does public participation result in better decisions?

Public participation contributes to better decisions because decision-makers have more complete information – in the form
of additional facts, values, and perspectives obtained through public input – to bring to bear on the decision process. They
can then incorporate the best information and expertise of all stakeholders. Decisions are more implementable and
sustainable because the decision considers the needs and interests of all stakeholders including vulnerable/marginalized
populations, and stakeholders better understand and are more invested in the outcomes.

As a result, decisions that are informed by public participation processes are seen as more legitimate and are less subject
to challenge. Decision-makers who fully understand stakeholder interests also become better communicators, able to
explain decisions and decision rationale in terms stakeholders understand and in ways that relate to stakeholders’ values
and concerns.

How does public participation develop community capacity?

Another major result of sustained stakeholder participation in decisions and their implementation is the development of
capacity for managing difficult social problems. This capacity includes improved relationships and trust between decision-
makers and the public, and among different stakeholders themselves. Also, when done well, public participation helps to
teach stakeholders meaningful and collaborative ways to approach each other, manage difficult decisions, and resolve
disputes. Stakeholders learn to appreciate each others’ positions by first learning about each others’ values and interests.

Once stakeholders are invited into the decision process, it becomes more difficult for them to merely stand to the side and
say “no.” As participants in good decision-making processes, all stakeholders must understand all sides of an issue, weigh
the pros and cons, and make more thoughtful decisions. Stakeholders and communities do not generally achieve this on
their own. Sponsoring agencies must recognize their responsibility to help communities build their capacity for
collaborative problem solving.

This community model facilitates collaboration to address environmental and/or public health issues in distressed
communities.

Think About Community Capacity Building as Part of Public Participation

Effective public participation depends in part on a sponsor agency’s willingness and ability to involve the public in the
decision process. While it is critical that sponsor agencies develop the skills to think through, plan for, and implement a
public participation process, it is no less important that the public develop the capacity to participate effectively in
decision processes. A well-designed and sincere participation process will not fulfill its potential if the public lacks the
necessary participation skills. Hence, it is important for government agencies to build the public’s participation capacity.

Building participation capacity can be achieved in several ways:

 Modeling the behaviors that you want to see exhibited throughout the process
 Developing and sharing with the public guidance documents that promote the core values of public participation and
delineate best practices
 Providing training to community leaders and stakeholder representatives in foundational public participation and
communication skills
 Giving special consideration and attention to vulnerable populations and marginalized communities.
 Identifying facilitative leaders within sponsor agencies to mentor community groups/leaders by partnering with them
during the planning and implementation of public participation processes. Inviting the public to participate in planning
the process can create a sense of ownership among the public
 Hiring professional third-party facilitators to provide instruction at the project outset to sponsor agency staff and
external stakeholders on participatory behaviors and techniques
 Where appropriate, using deliberative forums that encourage more active forms of participation instead of selecting
forums that are viewed by sponsor agencies as being more “safe” because they control participation
 Providing technical assistance to the public or community groups to help them understand technical information
relevant to the decision.

These strategies can help build the public’s capacity for participation. Ongoing interest in public participation, however,
will depend on the extent to which public participation processes result in the opportunity for meaningful public input and
influence on projects, and the degree to which sponsoring agencies are accountable to these results.

What are the necessary conditions for successful public participation?

Successful public participation requires the following conditions:

 Clear purpose and goals – a well-defined purpose for the public’s role in the project that is real, practical, and shared
among stakeholders. Sponsoring agencies must determine the appropriate level or degree of public participation for
the decision at hand and set the public’s expectations accordingly. No one benefits when agencies promise more in the
way of public participation than they are willing to commit to and deliver. In fact, making promises that cannot be
kept will undermine public confidence in the public participation process
 Clear structure and process – well-defined rules about how public participation will be conducted and how the
decision will be made
 Actual opportunity for influence – the real opportunity for public input to be considered in making the decision
 Commitment to the process – managers and staff alike must be committed to the full range of activities required to
make public participation work and be willing to obtain and consider public input in making the decision
 Inclusive and effective representation – reaching out to representatives of the full range of relevant stakeholder
interests regardless of race, color, national origin, sexual orientation or income.

What are some additional considerations for successful public participation?

In order to establish and maintain effective public participation, sponsoring agencies and decision makers should give
careful consideration to how they are supporting the process. Some important elements to successful public participation
can include the following:

 Sufficient resources to conduct the process – provide the funding and staff to support all aspects of the process,
including a situation assessment, outreach activities, and obtaining and incorporating public input, with resources
dedicated to involving vulnerable populations and overburdened parts of the community
 Participative capacity among staff and participants – conduct training in communication, outreach, and collaborative
problem solving skills
 A climate of integrity – trust and credibility of government are essential for public participation. Public participation
will not flourish where government agencies or decision makers are corrupt or disingenuous about considering public
input
 A belief in the value of public input – the knowledge that public input will result in better decision-making and that
public participation results in better governance
 Capacity to engage - ensuring that agencies know how to design and implement public participation processes, and
that agencies and the public alike have the knowledge and communication skills to participate effectively in the
process
 Complete transparency – the timely sharing of easily understandable and accessible information to educate the public
about the issues and options.

Although the conditions and responsibilities for public participation are significant, you should not feel daunted. Rather,
public participation should be viewed as an opportunity to make a powerful decision – one that resolves issues to the
broadest possible satisfaction and benefit of interested parties. When done well, the time and effort invested in public
participation pay dividends by resulting in a more broadly acceptable, implementable, and sustainable decision.