Key theoretical distinctions in community-based health interventions

Abstract

The move to community-based practice is often accompanied by doubts about the veracity of the research or clinical data that might be generated. Critics contend that the introduction of subjectivity that accompanies this maneuver obscures the empirical side of social existence, and thus compromises the discovery of facts. But this erroneous conclusion rests on confusion about several key philosophical distinctions that are discussed in this paper. The clarification that results from addressing these issues enhances the utility of community-based health strategies.

Keywords

Community-based interventions community-based health social philosophy community medicine community-based participatory research

Introduction

Community-based interventions are becoming quite popular. Some clinicians, other practitioners, and many researchers contend that this strategy is necessary for the delivery of health services to be extended and improved throughout the world (Partners in Health, 2011). The basic idea is that community members can be trained to create, implement, monitor, and evaluate health programs. Although professional care providers, such as physicians and other specialists, may be necessary in some cases, ordinary persons can be trained to provide many of the services needed by communities (Kleinman, Eisenberg, & Good, 2006).

Research has shown, additionally, that neighborhood persons do not have to be confined to the periphery of a delivery program (Mutamba, van Ginneken, Paintain, Wandiembe, & Schellenberg, 2013). They can be trained successfully in a wide range of interventions, even medical regimens that are very complex. The guiding principle is that through the dissemination of medical knowledge, including information about some basic drugs and simple practices, many of the problems experienced by communities can be addressed by their members. Through the “train-the-trainers” model, important knowledge can be integrated into communities that enable persons to become responsible for both their health care and their neighbor’s wellbeing (Boutin-Foster, George, Samuel, Fraser-White, & Brown, 2008).

A recurrent theme in this change in orientation is that persons have an intimate knowledge of their communities. And through their increasing involvement in interventions, health projects will be provided in a culturally sensitive manner (Kleinman, 1987). Additionally, and consistent with this intimacy, relevant services will be designed and implemented in an appropriate way. In the end, service delivery will be more efficient and effective, not to mention sustainable in the long term, because of the participation of community members.

This participation has assumed a variety of forms. In Latin America, for example, health promoters, or los promotores de salud, have been viewed as valuable for quite some time. In Haiti, on the other hand, the accompaniment movement has become popular (Behforouz, Farmer, & Mukherjee, 2004). Other examples include the use of community health committees (Wangalwa et al., 2012), cultural brokers (Lefley & Bestman 1991), and indigenous epidemiologists (Brown, 1992) to understand local problems. In all of these cases, persons who are instrumental in their communities take the lead in identifying health issues and appropriate solutions.

The cultural mores of a community, accordingly, guide service programs. The definitions and values of persons are recognized to sustain a valuable pool of knowledge that they use to make decisions about their daily lives, including their views on health and illness. In other words, at the heart of community-based models is the belief that “local knowledge” is vital to designing a successful health plan (Fals Borda, 1988). For this reason, phenomenology has emerged as an appropriate epistemological theory. And through the participation of lay health workers, in addition to other community members, information grounded in experience is brought to the forefront of designing an intervention.

This new approach to knowledge evaluation and use has significant implications for the delivery of health care on at least two levels. For example, the reliance on local knowledge provides significant insight to the path of treatment. Attention is directed to how persons or communities interpret themselves and respond to their surroundings. As a result, services can be improved due to their integration into these personal or collective experiences. Additionally, and equally important, persons can become empowered by this inclusion and begin to exert some control over their health (Gustavsen, 2008). Community-based practitioners have thus begun to encourage local persons to control health projects by allowing them to co-construct, with official planners, data collection instruments, formulate and interpret data, and develop policies. Community-based projects, stated simply, are built from the ground-up (McTaggert, 1991).

New theoretical turn

This community-based orientation is supported by a general shift in philosophy. Due to the emphasis that is placed on participation, knowledge moves from the bottom upward. But in addition to this change in logistics, a shift in epistemology, or theory of knowledge, is also witnessed. Specifically noteworthy is that an intimate connection is understood to exist between the values, beliefs, and commitments of persons and how they view their social situation.

In more philosophical terms, a community-based philosophy is anti-Cartesian (Bordo, 1987). As opposed to Descartes and his followers, dualism is thought to be passé. The standard separation of subjectivity from objectivity, also known as the fact-value distinction, is the principle that is sacrificed by taking this new direction. This distinction, however, is touted to be essential to gathering reliable data about health or any other issue. In typical practice, research or clinical, the point is to overcome the bias that is associated traditionally with subjectivity. In this way, reliable information is in the offing.

With the elevation of participation in importance, dualism is difficult, if not impossible, to maintain. After all, every facet of an intervention is mediated thoroughly by this activity. Searching for data that are untainted by interpretation and perspective is considered to be futile. Rather than objective, data are embedded in language, cultural history, and various institutional modes of discourse and interaction. And at the nexus of this action with others is where meaningful data emerge. In other words, there are no pure facts, but only different interpretations and perspectives.

In view of this role given to interpretation, the work of Peter Berger and Thomas Luckmann has become quite visible in discussing the operation of community-based health interventions (Farmer, Kim, Kleinman, & Basilico et al., 2010; Kleinman, 2010). Their version, like all other renditions of phenomenology, is predicated on “intentionality,” the cornerstone of this philosophy (Husserl, 1964). What phenomenologists mean by this term, while borrowing from Edmund Husserl, is that consciousness is always conscious of something. Although this phrase sounds almost banal, the implications are profound.

With this idea, phenomenologists undercut dualism and the Cartesian tradition. Their intent is to illustrate that consciousness and whatever is known are inextricably linked—all knowledge is thus implicated in interpretation. Hence the social world, including everything therein, such as health and illness, should not be treated as objective. In current parlance, these phenomena are constructed and can have various meanings, based on local dispositions.

Because nothing escapes the influence of interpretation, a community is not simply a place or represented adequately by demographic traits. This collective, instead, is a product of the interaction or joint action of persons that specifies how they view themselves and their relationships. A community, in fact, is not monolithic but comprised of several, often competing, interpretations of normative behaviors and events. Alfred Schutz and Thomas Luckmann, noted phenomenologists, use the term “finite provinces of meaning”, or multiple realities, to characterize this condition (Schutz & Luckmann, 1973: p. 23).

Phenomenologists, including Berger and Luckmann, have popularized a unique term to describe a community, that is, lebenswelt or “life-world (Berger & Luckmann, 1967: p. 16). Rather than captured by “dead” empirical indicators—such as ethnic traits, material properties like poverty, or political boundaries— the identity of a community is an outgrowth of human actions that specify membership, parameters, and norms. In order to comprehend correctly health or care, entrée must be obtained to this interpretive domain. Because persons frame issues through the exercise of their values and commitments, local knowledge is indispensable for the accurate identification of any problems (Berger & Luckmann, 1967: p. 42).

Within this framework, standard indicator analysis would not provide much insight into a social problem (Susser, 2004). Trying to link a disease to empirical properties, such as the quality of housing, income, or educational level, for example, does not provide much information about how persons view illness, define cure, or recognize a proper intervention (Krieger, 2005). But effective community planning requires this sort of insight, so that the needs and aspirations of persons are met. Only entry to the lebenswelt of a community can offer access to this knowledge.

This shift in philosophy should not be too controversial. After all, many practitioners acknowledge that qualitative methods should have a significant role in an epidemiologist’s repertoire of tools (Leung, Yen, & Minkler, 2004). Holistic medicine, additionally, is a product of recognizing that the mind and body interact in many ways. Nonetheless, often the introduction of this subjectivity is thought to impede the discovery of facts; the real physical markers of illness are obscured by the attention given to emotions and other intangibles. Subjectivity thus becomes a threat to objectivity and a liability.

As can be imagined, many epidemiologists and physicians view empirical evidence to be valuable (Thomas, 2006). Knowledge of the number of persons vaccinated against a particular disease, in addition to demographic characteristics, is thought to be invaluable and should not be eclipsed by philosophical squabbles. But this elevation of community participation in importance should not be understood to obscure facts; the prospect for discovering social or cultural health patterns remains. Nonetheless, illnesses and the related behaviors are a local determination that should not be treated as objective (Morris, 2000).

Several distinctions can be made that can help to clarify this issue. In the next sections of this paper, four of these will be addressed. But at this juncture a key point must be made: the rejection of dualism may call into question the standard view of objectivity, but not the ability of persons to corroborate, interpersonally or intersubjectively, any particular interpretation of social existence. In other words, if persons or communities give credence to particular interpretations of behavior, for example, these perspectives can be treated as if they are objective to those individuals or groups involved. Stanley Fish (1980: 14) refers to such communal interpretations as “interpretive communities,” thereby suggesting that all viewpoints are public, and thus verifiable and generalizable, but grounded in participation. The rationale for this change in understanding objectivity will be provided in the following sections.

Evidence-based interventions?

Because of the questions that are raised about objectivity and, by association, empirical evidence, a community-based approach to health care can easily begin to appear esoteric. Several distinctions need to be address that will help to clarify this issue: subjectivity–objectivity, material–materialism, empirical–empiricism, and fact–facticity. While working on community-based projects for at least twenty-five years, these issues have been raised regularly to the authors of this manuscript. But in a much more philosophical manner, these points are at the heart of a rejection of dualism and any attempt to reformulate knowledge in the absence of Cartesianism (Bernstein, 1983).

Subject versus subjectivity

There is no doubt that an active subject is central to a community-based philosophy (Rorty, 2007). Indeed, presupposed by participation is agency. And this action taints everything that is known, including perceptions and accounts of health and illness. As opposed to blank slates, persons are constantly selecting, interpreting, and organizing a body of information—the “recipes,” as Schutz and Luckmann (1973) say—that provides explanations of how a community operates. Rather than constituting a bias, the perspectives that are involved should not be downplayed or ignored. On the other hand, this knowledge cannot be treated as objective, due to the fundamental connection that exists to interpretation. This knowledge is created and elevated in importance through human initiative.

But this information is not subjective in the typical Cartesian or dualistic sense. Such subjectivity implies that knowledge is internal, severed from others, individualized, extremely personal, or singular. Understood in the context of subjectivity, knowledge would be truly esoteric. Health planners, accordingly, should be wary of subjectivity, since such knowledge would never be open to the public, verifiable, or generalizable. In this case, subjective knowledge would have very little utility.

Emphasizing the subject, however, does not imply the acceptance of subjectivity and the related solipsism. In fact, subjects are never separated categorically from others. Although often overlooked, phenomenologists explain that subjects are always intersubjective (Berger & Luckmann, 1967: p. 23). Elevating the subject in importance, therefore, does not automatically restrict the applicability of knowledge. Due to their intersubjective ties, subjects can always exchange and reinterpret information.

But the fact remains that because subjects are involved, knowledge is existential. That is, knowledge has specific meaning and relevance, and thus boundaries—called a “moral context” by Kleinman (2010)—that should not be violated. For example, generalizability rests on how far certain definitions and commitments extend socially and are considered legitimate. Any violation of this idea would result in the imposition of irrelevant and possibly harmful information. The incontrovertible reality is that subjects are basically existential and act, but are fully capable of sharing one perspective or another (Berger & Luckmann, 1967: p. 61; Zaner, 2006). Hence an active subject does not necessarily lead to knowledge becoming subjective and the inability to formulate communal rules about health, illness, or any other factor.

Material versus materialism

By focusing on the subject does not mean that persons live in a perceptual, somewhat ethereal world, divorced from everyday conditions. Often interpretation, and the focus on meaning, is thought to cloud the social position that persons, along with classes, occupy in the world. The assumption of the critics of community-based philosophy is that meaning conceals, or otherwise distracts from, the material conditions that persons face (Murphy, 2014). Obviously, any planning strategy that would engage in such chicanery would overlook an important dimension of personal and collective existence.

But because persons are subjects does not mean that material conditions are irrelevant. Clearly, persons experience deprivation, poverty, and pain (Schutz, 1967). The key factor, however, is experience. Their bodies, bodily functions, and needs, for example, are enacted through experience (Merleau-Ponty, 1968).

Nonetheless, subjects are not confined by matter to view social reality in one way or another. Because the material conditions of existence do not escape the impact of human action, or participation, they are enmeshed in interpretation. Although the material side of life is real, similar conditions may have a very different interpretation and prompt a wide range of reactions. In a community-based project, material surroundings are not ignored but tied to the perspectives held by persons.

What is important to remember is that, according to phenomenology, experience is not passive. Persons do not merely record or reflect the material world. Experience, instead, is intentional and shapes how material conditions are perceived. Even some of the most hardened materialists, for example, recognize a mind-body connection. For this reason, phenomenologists refer to the body as a “lived body” (leib), in order to counter the materialists’ rendition of a machine (Helman, 1984; Kleinman, 2013). How the body is experienced, accordingly, has a lot to do with whether problems are detected, how they are viewed, and if treatment is sought.

At any rate, community-based planners do not deny that persons are material beings and reside in certain conditions. They are not materialists, however, because they do not view these elements to be autonomous and simply imposed on subjects. What is important, and consistent with participation, is how material considerations are reworked by human action (Zaner, 1964). How persons define their housing, for example, is relevant to whether their living conditions are viewed to be problematic. And the bromide that poor housing is a leading indicator of social problems should be modified in light of local definitions.

Although material conditions are important, more significant to community-based health planners is their significance. This meaning, however, does not soften their impact; even in view of interpretation, persons are embodied and have to deal with material elements. The important change, however, is that the consequences of these conditions may vary, based on how they are conceptualized and evaluated in a particular locale.

Empirical versus empiricism

Empirical analysis is often thought to be jeopardized by the introduction of interpretation as a mediating factor of personal or collective life. The general fear is that no stable relationships can be established between variables, such as cause and effect, because of the fickle nature of interpretation. Laws, of course, are out of the question.

Human action is presumed to be too ambivalent for exact and continuous associations between elements to be established. Only empirical links are reliable in this regard. Rather than subjective, and thus fleeting, empirical bonds are substantial and able to be reliably documented. In fact, the term structural is used regularly to describe such connections (Parsons, 1963). Structures are real and lasting. This imagery conveys the message that something concrete is available for assessment or study.

What is rejected by community-based philosophy is empiricism and not empirical assessments. The point is to abandon the assumption that the identity of variables and their relationships is only natural. Gender and race, typical empirical or social determinants, have been shown to be culturally specified (Butler, 1990; Omi & Winant, 1994). And treating either of these phenomena as an independent variable and predictive is fraught with problems related to their social significance and cultural context. Because these contributions to identity are related to historical determinations, personal choices, political ideology, and so forth, their impact is situationally contingent.

Another example relates to stress (Lazarus & Folkman, 1984). Recent research suggests that stressful conditions are neither obvious nor universal. The causes of stress, instead, are a matter of interpretation and personal reactions. Stressful conditions, in other words, do not simply impinge on persons and cause them to act in one way or another, but are mediated by, for example, self-esteem and perceived availability of resources (DeLongis, Folkman, & Lazarus, 1988).

But phenomenologists have never dismissed completely empirical factors. In this regard, Husserl declared that he is the only true empiricist and that researchers should return to focusing on the “things themselves” (Husserl, [1900] 2001). What he has in mind, however, is not the natural objects and their associations extolled by empiricists. Again in line with the importance of intentionality, how the components of everyday existence are intersubjectively negotiated is crucial.

At this moment is when the phenomenological notion of biography becomes relevant (Berger & Luckmann, 1967: pp. 64–65). The idea is that communities tell stories about themselves, and that these storylines supply a logic that helps to explain behavior or events, including health status. Without the aid of empiricism, persons make connections between events, draw conclusions, and make judgments about the future. And due to the fact that subjects are intersubjective, the logic of biographies can be shared and, as Husserl contends, have interpersonal validity until further notice.

As should be noted, phenomenology is thoroughly empirical. The thrust of this philosophy, and community-based applications, is that planners should be aware of how persons understand and deal with events and behavior daily life, as part of organizing and making sense of their usual affairs. Such a focus is truly empirical, to borrow from C. Wright Mills, because communities exist at the juncture of biography and history, interpretation and selective reaction (Mills, 1959). Still, the resulting empirical realm cannot be portrayed adequately by the impersonal data extolled by empiricists.

Fact versus facticity

At the end of the day, the big question is whether a community-based approach deals with facts. Can the behavior of a subject be described in a factual manner? In terms of the discussion thus far the answer is both yes and no.

Clearly the empiricist portrayal of facts is not adopted. Emile Durkheim summarizes this philosophy by saying that facts should be approached as if they are things (Durkheim, [1895] 1982). Some of their most important traits are as follows: facts are independent, constraining, and universal. Durkheim’s conclusion is that, if treated as empirical, data are autonomous, uninfluenced by interpretation, and objective. Obviously this rendition rests on the dualism that is undercut by the ubiquity of participation.

Facts are not envisioned to be brute data in community-based projects, in contrast to the recommendations of empiricists. But clearly facts are important in community-based work. For example, community-based planners are interested in typical empirical indices, such as gender or socio-economic status. In fact, these variables, in addition to other social traits, are the hallmark of most epidemiological analyses, even projects that are community-based.

But as phenomenologists describe, facts represent particular modes of expression that, over time, become “sedimented,” that is, elevated in importance over other, rival interpretations and treated as normative (Berger & Luckmann, 1967: pp. 67–72). Local criteria, accordingly, determine the interpretation of facts that serves as evidence. In this sense, facts are not occluded but highlighted by participation.

These criteria, contrary to empiricists, are not naturally disposed but must be instituted, defended, and constantly reinforced as acceptable. The problem is that competing interpretations may gain credibility and announce a new normative order. For this reason, Melvin Pollner, an ethnomethodologist, announces that facts are “accomplishments” rather than things (Pollner, 1991). Specifically, particular identities, modes of reason, and classificatory practices must be given credence and support in a community, in order to be recognized as supplying evidence.

These phenomena, because of their contingent character, must be constantly legitimized. Through political will and other intersubjective commitments—through what some writers call “dominant signifiers”—the criteria for evidence are created and fortified (Guattari, 1994). Accordingly, facts are very real but locally specified. Once persons adopt a particular perspective, through socialization or other means, specific interpretations and the accompanying explanations are compelling and recognized as evidence. In community-based planning facts are neither dismissed nor treated as objective, but viewed as intersubjective productions that have limited validity. And any expansion of this validity depends on dissemination and acceptance.

Conclusion

Community-based planners have to deal with a fairly knotty philosophical issue. On the one hand, the claim is that this strategy will make interventions more relevant, and thus sustainable, due to the emphasis that is placed on participation. On the other, this same human action is often thought to compromise a project by obscuring empirical realities, including facts. Any evidence would thus be questionable. Such a conclusion, if true, would certainly restrict the appeal of this approach.

But community-based practitioners are not necessarily shy about talking about facts or the material conditions of a community. In point of fact, their interventions are often described as holistic, in addition to culturally sensitive, thereby taking into account environmental, familial, and other relevant conditions (Bronfenbrenner, 1994). Nonetheless, as illustrated throughout this discussion, empirical indices are not understood in the traditional Cartesian sense.

This re-evaluation, however, does not culminate in ambiguity or meaninglessness. Clearly, the dualism that supports empiricism, and the related version of objectivity, is called into question. Although facts are no longer obtrusive, neither are they illusory. In a community-based project facts are local, enmeshed in particular commitments and interpretations, but very real. The members who are attuned to the interpretive reality of a community recognize these norms and hold themselves and others accountable for any violations.

In other words, in communities various modes of expression can become institutionalized, or exempted from re-interpretation, at least momentarily (Schutz, 1962). There is no escape, however, from the interpretation that inundates apparent certainty. But the interpretations that take hold, and become normative, have impact that community-based planners want to assess and sometimes change. Health planning is not undermined in the absence of dualism and a standard rendition of objectivity but enacted in the life-worlds of persons and their associations.

Footnotes

Acknowledgement

We thank Svante Lifvergren for leading the review process of this article. Should there be any comments/reactions you wish to share, please bring them to the interactive portion (Reader Responses column) of the website: .

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

John W Murphy is Professor of Sociology at the University of Miami, Coral Gables, FL. He received his Ph.D. degree from Ohio State University. His areas of interest are social philosophy and community health.

Berkeley A Franz is an Instructor at Ohio University. She received her doctoral degree in 2014 from the University of Miami. Her current research interests are in medical sociology, community development, and the sociology of religion.

Jung Min Choi is Associate Professor of Sociology at San Diego State University. He received his Ph.D. degree from York University, Toronto, Canada. His areas of interest are sociological theory, education, and community health.

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