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Community and health behavior: Who’s pushing people into the river?

Posted By Deepu George, Thursday, July 10, 2014
My dissertation study focused on understanding longitudinal community influences on health behavior, specifically physical activity (PA). As a clinician working in a primary care setting for the past year, I have begun to piece together the different implications of my study variables and the broader theoretical framework. The focus of my study was to understand environmental, social, and personal influences on PA. In order to go beyond individual factors influencing PA, I had to use a broader theoretical framework. The social organizational theory became the central lens through which I operationalized community influences on PA.

In a nutshell, the social organizational theory of community action and change helped me think about social structural and social processes that influence PA. There are real community antecedents that can influence behavior, particularly the physical and social infrastructure. I captured this by looking at neighborhood stability using census tracts contextual data from Add Health national data set. There are also important social organizational processes like informal networks and formal systems. Informal networks are friendship groups and relational settings that foster friendship, involvement, trust, and reciprocity within the community. Formal systems are agencies, organizations, and other structural groups that respond to different needs of the society. For more authoritative papers on the social organizational theory, check out this website.

Overall, results show that neighborhood stability during adolescent years is an important influence on PA over a period of time. Individual social participation through civic engagement and citizenship emerged as a strong influence on PA. Research on PA and its broader influences informs my work as a clinician in primary care setting in two ways.

Physical Activity and Therapy. Philosophers as early as Plato noted that PA is important for human development and growth: “In order for man to succeed in life, God provided him with two means, education and PA. Not separately, one for the soul and the other for the body, but for the two together. With these two means, man can attain perfection.”

Psychotherapy has developed mental and behavioral models to influence emotional and psychological changes. However, biological influences on emotional, psychological, and behavioral changes have largely been ignored in psychotherapy. PA is the ‘royal pathway’ to influence biology in psychotherapy. Including PA in therapy is helpful because of the following evidence:

• PA is intimately connected to workings of the human brain. In fact, regular PA can trigger similar mechanisms of psychiatric medications for anxiety and depression.

• PA has been found to help the following: academic performance, sexual satisfaction, increase concentration, decrease symptoms of depression, anxiety, and improve performance in learning, memory, and recovery from illnesses.

• More curiously, John Ratey and colleagues (results from their work documented in the book Spark), documented mechanisms through which PA improves memory, learning, anxiety and stress response. Their study showed regular PA alters seminal structural aspects of the brain to facilitate growth.

Therapists can find creative ways to incorporate PA as part of their therapy work with patients. Regular PA should be an important element in self-management long after therapy is terminated. Therefore, recommending and prescribing PA as part of therapeutic work is one way of influencing biology to better sustain changes made in therapy.

Physical Activity, Therapy, and Social Organizational Theory. In his essay entitled “A case for refocusing upstream: The political economy of illness”, John B. Mckinlay (2008) wrote an analogy using a river and drowning people to describe clinical medicine:

Sometimes it feels that I am standing by the shore of a swiftly flowing river when I hear the cry of a drowning man. So I jump into the river, pull him to shore, and begin artificial respiration. Just when he begins to breathe, there’s another cry for help. So, I jump into the river, reach him, pull him to shore, apply CPR. And then just as he begins to breathe, there’s another cry for help, and back in the river again and then another yell, and again and again. So, you know, I’m so busy jumping in rescuing them that I have no time to see who the hell is upstream pushing them all in. (p. 578).

Behavior changes like commitment to regular PA and other goals that emerge in therapy have both downstream and upstream factors. While psychological theories help address downstream factors, a lens like the social organization theory can help therapists consider upstream factors. In the present study, social participation and concentrated affluence were strongly associated with PA. Therefore, while behavioral health treatment is analagous to performing CPR (as in providing individual care through therapy), a broader perspective can help therapists and clients consider both upstream and downstream factors that are obstacles to behavioral improvement. In addition, therapists can incorporate individual theories of motivation and planned behavior change to help with PA. Using important reviews like Ratey and Hagerman’s work, therapists can better educate patients about how PA influences biology and brain functioning to help them work with depression and anxiety. To consider upstream or broader aspects of behavior change, therapists can use the social organizational model of community action and change. Understanding community antecedents – the physical and social infrastructure – of a patients’ social, environmental makeup can be instructive in planning various activities.

For example, in one of my recent clinical encounters, to help a patient manage her hypertension, it was important for us to figure out how, when, and where she would walk for exercise. As part of behavioral change work with her (downstream factors), we mapped out a schedule, identified barriers to walking, solutions to overcome present barriers, and made specific behavioral commitments. We further elucidated her motivations and reasons for her commitment to lifestyle changes (walking more regularly and eating a balanced diet). Then, we mapped out her neighborhood (upstream factors), location of the grocery store, took notice of nearby parks, school grounds. We utilized her own knowledge and used Google Maps to track details during her office visit. All of this was entered into her personalized plan for the appointment. As part of her plan, the patient was able to schedule two walks during the week to go to nearby grocery store as part of her walk schedule, especially to increase fruits and vegetables to her diet. Considering both individual level factors (commitment to behavioral change) and community antecedents (parks, school grounds, route to grocery shop) were important clues to change.
Understand the community antecedents – the physical and social infrastructure –  of a patient's environment

Deepu George, PhD, LMFTA, is the current Medical Family Therapy Resident at the Duke/SR-AHEC Family Medicine Residency Program in Fayetteville, NC. He is interested in social determinants of health, medical family therapy, community development and capacity building. With a Master’s Degree in Holistic Psychological Counseling from Bangalore, India, his aim is to continue his passion for applying systems lens in health care, family therapy, conflict resolution & peace-building, and community capacity work. He will soon graduate from the University of Georgia and has recently accepted a teaching position in McAllen, TX.

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