Public health advocacy and chiropractic: a guide to helping your community reach its health objectives

Abstract

Objective

Doctors of chiropractic (DCs) provide health educational and promotion efforts in the communities they serve by counseling patients at the individual level. This article outlines a method and model in which DCs can effectively serve as public health advocates within their community.

Discussion

The social ecological model of health education and health promotion serves as an excellent template for taking into account every antecedent to disease within a community and how to prevent it through health promotion. A step-by-step guide to getting the DC involved in the community can be centered on this model, with the DC serving as a health advocate for his or her community. Resources are provided to assist in this process.

Conclusion

The DC can and should engage his or her community in areas that are conducive to health through involvement and advocacy roles where these are suitable. A community's health can be enhanced with greater health care provider involvement, and DCs need to consider themselves a part of this process.

Introduction

Among US consumers, the chiropractic profession is the most used group of health care providers sought for complementary and alternative medical care.^1,2 Although doctors of chiropractic (DCs) mainly treat musculoskeletal ailments,³ surveys suggest that most practitioners also consider themselves providers of services aimed at the promotion of health and prevention of disease.^3,4,5 These services typically include some level of nutritional advice and exercise recommendations and often focus on specific strength and flexibility exercises for stabilizing spinal musculature.³ With many of the top 10 causes of death in America seen as preventable, the offering of these health-promoting and disease prevention services by DCs could have a measurable effect on a community's health status. This article will help elucidate how DCs can position themselves as knowledgeable community health advocates and provide an ecological model for them to provide a greater outreach within their communities. This model is further described in this article.

Health promotion can be defined as aiming to increase control over the multilevel and complex determinants of health and illness using social interventions.⁶ Within this article, a theoretical model by which DCs can begin to serve as health advocates in their communities using common, accepted ideas that address health issues will be presented. Ultimately, advocacy on the part of the DCs can help alleviate the notion that health status is simply the result of poor lifestyle choices. This is the premise of the model we will describe. Although personal responsibility for health is always encouraged, often environmental influences play a large role in supporting healthy or unhealthy behaviors. By focusing on those influences that go beyond the individual patient's control, the DCs may be better positioned to serve as resource persons in their community and begin to engage the social, political, and community factors that may represent roadblocks to better health for their patients and their families. Whereas individual levels of promoting health are commonly referred to as micro levels, these community-based efforts are known as macro issues that relate to changing social support and community norms or laws to positively affect health. To best serve the health of citizens, a combination of both micro and macro efforts must be used. For instance, advising a 48-year–old man who is overweight and is borderline diabetic on proper exercise is a micro approach. Advocating for better sidewalks and lighted streets so it is safe to walk in one's community is a macro approach.

Chiropractic and health promotion

Several studies have demonstrated that DCs perform at least some practices that are considered health promotion activities.^3,4,5 In addition, research has called for the adoption of health promotion by DCs to meet the national health outcomes measures set forth by the Healthy People 2010 initiative.^7,8 Stacey et al⁹ state that “The challenge and opportunity facing chiropractors is to consider how they as individual practitioners and a professional group can engage more fully in health promotion.” In 2007, the Council on Chiropractic Education issued curriculum standards and competencies requiring all chiropractic colleges that it regulates to have in place certain educational and competency-based health promotion and wellness features.¹⁰ These standards were established to prepare the new graduate to participate in helping patients prevent disease and to encourage the delivery of health-promoting messages and services to patients. However, they do not specifically address issues beyond those that the patient may control at the micro or individual level. Furthermore, these standards are not likely to teach DCs in the field what to do to promote health at the macro level such as in the case of advocacy roles in policy development or community diagnosis.

The macro view—an ecological model of health promotion

McLeroy et al¹¹ proposed a model of health promotion that takes into account not only individual factors that may influence a person to be healthy or not but also environmental factors as well. This article will cover each of the 5 constructs of this model and will focus on the environmental macro issues as a means of affecting community health in a positive manner through advocacy.

The ecological perspective (EP) is a model that has suggested that the individual, his or her behavior, and the environment in which he or she lives all interplay on the health of the person. The intrapersonal levels by definition are those micro factors that influence the behavior of the person such as his or her attitudes, knowledge, beliefs, or personality traits. Interpersonal issues consider group influences such as family, friends, peers, and other significant influencers. These lend definitions of social identity and support (or lack thereof) to the individual. The environmental concerns that are the focuses of this article are those within the community that involve institutional factors, community factors, and public policy.

Institutional factors include rules, regulations, policies, and other informal processes that may encourage or fail to promote certain recommended health behaviors. Whether a work site has a policy against smoking on the premises is an institutional factor that can affect health. Community factors are social networks and accepted norms of a region including formal and informal standards that may exist among individuals, groups, or communities. Foods and dietary patterns that are long-held traditions are examples of community issues that affect health. They can be positive or negative and regional or national in scope. For instance, the Asian diet has been typically seen as healthier than an American diet. These can be broad and complex and certainly may affect other aspects of the community level constructs in a dynamic manner. The last of the community level constructs is public policy. Public policy includes local, state, and federal polices and laws that can regulate or encourage healthy behaviors, and screen for or prevent disease. Public health laws function at this level. Seatbelt laws, childhood vaccination laws, and even local recycling rules for a community operate at the policy level. It is at the institutional, community, and public policy levels that DCs may best advocate for environmental supports for health promotion.

An ecological framework matrix adapted from the work of McLeroy et al¹¹ (Table 1) essentially states that health choices and behaviors are influenced by multiple factors and indicates where the DC could focus efforts. In recent years, several health promotion initiatives have relied on an EP approach to affect positive health behavior change. Riner and Saywell created the Social Ecology Model of Adolescent Interpersonal Violence Prevention by studying the personal, social, and environmental factors that lead to violence evasion and participation.¹² Peterson et al designed intervention strategies at the micro and macro levels to address obesity and chronic diseases among low-income, postpartum women.¹³ Atzaba-Poria et al examined risk factors for problem behaviors in children and determined that both individual and environmental characteristics may influence behaviors.¹⁴ The EP has also shown promise in the field of substance use prevention and takes into account similar issues in its framework. In addition, several researchers have each advocated for the use of a social ecology framework in preventing and addressing various drug issues.^15,16,17 The EP has been shown to be a useful framework for advancements in public health at both the individual and environmental levels. As health care professionals, DCs have the opportunity to positively affect public health by impacting those institutional, community, and public policies in their state or community. A first step is to choose to be involved and establish the actual needs within a community.

Table 1.

Five levels of social ecological influence on behavior adapted from McLeroy et al¹¹

Levels	Characteristics	Actions by DC
Intrapersonal	Personal knowledge, attitudes, and beliefs concerning particular behaviors; issues of personal skill and self-concept	Educate patient, community leader, and program champions
Interpersonal	Social networks including family, friends, and peer/work groups	Educate public and community leaders; provide resources to groups
Organizational	Social practices with organizational characteristics including the formal and informal rules and regulations for operation within the particular institution; organizational norms and changes of those norms can affect behavior of those individuals involved	Serve as adviser to formal/informal groups, institutions, and organizations
Community	Relationships among organizations, institutions, and informal networks within defined boundaries; includes the social standards or norms that exist within the community	Serve as resource person in the community/committees and in advisory role where possible
Policy	Policies and laws that are designed to protect the health of a community; polices for health protection include regulations for healthy actions, disease prevention, and disease control	Serve as advocate, lobbyist, or activist regarding health policies in the community

Discussion

Needs within the community

The goal of any health care provider should be to help his or her patient enjoy as many years of healthy life as possible. Although most providers operate at the individual level with patients often, it is not enough to promote changes in health behavior. Health care providers should also serve their communities where they can and openly advocate those changes conducive to better health. Serving one's community can include serving as a resource person for health issues including advocating positive changes that may influence better health of a community's citizens. The word advocacy is derived from Latin meaning voice. Both the American Chiropractic Association, the nation's largest trade group for DCs, and the Association of Chiropractic Colleges have adopted position statements that advocate public health involvement and health promotion.^18,19 Doctors of chiropractic can serve as advocates for changes first at the local community level. Christoffel states that advocacy is the application of information and resources (including finances, effort, and votes) to effect systemic changes that shape the way people in a community live.²⁰ The Directors of Health Promotion and Education define advocacy as a step between educating and lobbying whereby one offers support for a change without seeking a specific outcome or decision.²¹ Typically, this will start with some kind of needs assessment identifying either a known need within a community or one previously noted by a group of citizens or even the local government such as the county health department. Each community is different and can clearly have different needs.

Community participation

Checkoway²² outlined the community participation process as planning, social action, needs assessment, and program implementation. He contends that community action can democratize the political process and strengthen leadership in a community. Of course, the type of community may vary. The American Century Dictionary has defined community as “a body of people living in one local.”²³ Generally, they have commonalities; and this may include health risks. An example of a community needs might be a need for a smoking ordinance that would restrict smoking to protect local citizens from second-hand or environmental tobacco smoke. There are other local laws or ordinances that may fall into the same category such as laws to ban cell phone use in cars, teen curfews, or even measures to create passive supports for exercise like a bike or walking path around a city. Promoting the need for physical education in all grade levels and after school sports programs are others that could be defined as needs in many communities but may involve institutional changes in some public schools and most private schools. This is particularly so in areas of the country where obesity is becoming the norm rather than the exception.

Once an actual need in the community is identified, the first step may be to contact a policy maker about the problem.²⁴ Today, this is often done by phone, letter, and even e-mail. Galer-Unti et al²⁴ suggested that the best strategy is meeting with your representative face-to-face. This may help establish an ongoing relationship with them, and it always helps have a face with the name. Keep in mind that most political representatives at the local or even national level are typically not health care providers, so there is usually a learning curve involved. Prepare to educate them about the needs within the community. One should research the topic so that he or she may provide the representative with details that make it easier to support the favored position. However, Checkoway further stated the importance of recognizing that there may be unanswered questions and stressed the need for community participation when doing health promotion.²² There will always be a need for buy-in from the community one serves if one desires a positive outcome.

In addition to public policy, there may be opportunities to work within the community to establish community norms that are more conducive to health. Supporting organizations outside of government that promote healthy activities and health-promoting programs is also worthy of consideration. The Komen Foundation for breast cancer awareness has Pink Ribbon Campaigns, and the American Heart Association holds activities that support healthy behaviors in schools such as Jump-rope for Heart. Some clinicians may want to partner with the Red Cross to offer their building or parking lot as a site for delivery of Red Cross services at certain days of the month. Certainly, there are others worthy of support; but these are popular and available in most communities and provide the DC examples of programs offering a chance to support health-oriented campaigns.

Coalitions

The Prevention Institute listed the “Spectrum of Prevention” when it comes to developing an effective coalition within the community.²⁵ This included influencing policy and legislation, changing organization practices, fostering coalitions and networks, educating providers, promoting community education, and strengthening individual knowledge and skills. Taking this model from the bottom up, one would focus on individual knowledge and skill enhancement. Knowledge is paramount to positive behavior change; but in reality, it is not enough. Promoting education within the community to build community awareness may be essential. Furthermore, although education of various providers of services is also important, the Prevention Institute conceded that ecological/environmental support for healthy behavior typically comes from changing organizational practices or influencing policy and legislation. This often necessitates fostering coalitions and networks within a community.

Community approaches

Loue²⁶ suggested 2 major considerations to advocacy within a community: (1) grassroots or “bottom-up” approaches where the needs are determined by community groups themselves and (2) “top-down” models where needs are identified by outside experts or only the leaders within a community. Although both can be successful, it is also important to know that there can be guidance from outside experts who work to assist the community members in reaching their goals. This is where those with health care or health promotion backgrounds can be of assistance in the process, thereby increasing the chances for success. Regardless of how outside experts are involved, if community partners do not feel a part of the decision-making process, the chance for success decreases.

Once a need is defined for a community and the decision is made to advocate change with a coalition, some important considerations must be taken into account up front. Will the coalition be from members of the community, government groups, or perhaps both? If the community is going to be involved, will the coalition take anyone? In other words, how will the community be represented in an all-inclusive manner? Typically, it is probably a good idea to allow anyone to participate. There must be organization to the efforts, but allowing all interested parties to participate will create more interest and buy-in. Cohen et al,²⁵ in their 8-step guide to effective coalitions (Prevention Institute), listed the following:

• Step 1.

  Analyze the program's objectives and determine whether to form a coalition in the first place.

• Step 2.

  Recruit the right people.

• Step 3.

  Devise a set of preliminary objectives and activities.

• Step 4.

  Convene the coalition.

• Step 5.

  Anticipate the necessary resources.

• Step 6.

  Define elements of a successful coalition structure.

• Step 7.

  Maintain coalition vitality.

• Step 8.

  Make improvements through evaluation.

Included in the above process is recruiting not only the key people in your community who get things done but also local experts whom people will respect. They may not be health experts; but if they are seen as trustworthy in the community, they need to be on board. Know your objectives up front. Will you be open to a compromise if you cannot get exactly what you want? Remember, this is often the reality of a political process. Furthermore, what resources will you need? Do you need money, manpower, and editorial space from the local paper? The process of community change and particularly of changes in local policies or laws takes time. Be prepared to keep your coalition going, and keep your message alive and well in the public eye. And certainly, change it if there are signs things are not working. Nothing says you have to finish exactly as you started. Keep focused on the big picture and how what you will do can improve the health of the community through successful changes in the status quo.

Program champions

With any change in society, whether it be a social movement or law, someone high up in the line of decision-makers has to be involved. The movers and shakers of the world get things done. Find one. Can you determine the member of your county commission, school board, or city council who is most influential and also likely to support your cause? If so, he or she is your champion for your program advocating change. Educate them early in the process. Be clear and concise about what you want to accomplish and why. Frame it for what it is—a health issue. Provide them with support literature to make their decision to support you an easy one. Take members of their constituent base with you when possible. Voters make good advocates.

In some cases, preparing talking points for your program champion may be helpful. Help them educate their fellow committee members. Ask them what they prefer. Again, it is about making their job easier to help you. If you are coming before a political group or policy-making body, let them know up front you are coming and why. It does not hurt to provide information that supports your position. Some city councils and county commissions have a 5-minute agenda where anyone who calls ahead to be heard gets their 5 minutes. Prepare remarks up front; and although anyone can speak at this time, it is best to have your key speakers for your coalition lined up and talking points in hand. Stick to the message! Leave them information that supports what you said behind to review in case they meet in subcommittees to discuss what you are asking for. It is essential to follow-up. This is a process. It will take some time. Prepare to go before the decision-making body more than once, and remind them that you want to be present when your topic is being discussed where this is possible. Keep your local media involved, and appoint a spokesperson to deal with them from your coalition if this is needed. When the local media support your efforts, this may keep your issues front-page news. Fig 1 lists resources that can be used in becoming a better health advocate.

Fig 1.

Community health advocacy resources.

Conclusion

Dr Mary Bassett, Deputy Commissioner of the New York City Department of Health and Mental Hygiene, reminds us, “The challenge to improve public health calls for the involvement of everyone, including those outside the health sector. Learning how to engage more effectively with communities is essential for health professionals who wish to create programs and institute policies that measurably improve health and lives.”²⁷ Doctors of chiropractic can better serve their patients, their families, and their communities when they get involved in the process of change. The EP presents a clear guideline on assessment of community needs that can dictate where and how to focus one's efforts so they are not wasted. Serving as an advocate for community, state, or even national health issues can be a rewarding way to enhance the health of the people we serve. Why not become a leading “voice” in your community when it comes to issues that are conducive to health?