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Community-Based Interventions

Article  in  American Journal of Public Health · May 2003

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that it is imperative that we share
our health personnel and expert-
ise, along with essential pharma-
ceuticals and material goods,
with resource-poor countries—
I have become involved with
HAS to develop a program to
prevent mother-to-infant trans-
mission of HIV infection and to
treat infected individuals. There
is good reason to believe that the
same strong health care infra-
structure that has improved the
survival and well-being of chil-
dren and that allowed Fitzgerald
and colleagues to reduce cases of
congenital syphilis will also pro-
vide the framework for effective
family AIDS prevention and
treatment programs.
The lack of exposure to inter-
national health issues within my
own medical training created ob-
stacles to my providing quality
health care for newly arrived im-
migrant children and their fami-
lies when I first arrived in New
York City decades ago. A rotation
in international pediatrics during
Community-
Based
Interventions
April 2003, Vol 93, No. 4 | American Journal of Public Health
 EDITORIALS 
pediatric residency training
would be an important step to-
ward improving the quality of
community pediatrics in the
United States.
The central philosophy of Al-
bert Schweitzer, as envisioned
and implemented by Larimer
and Gwen Mellon, is alive and
well in Haiti. But it would be an
important, long overdue, and
beneficial evolutionary step in
our own health care system if
we were able to incorporate a
world view into our everyday
practices.
Stephen W. Nicholas, MD
About the Author
Stephen W. Nicholas is with the Depart-
ment of Pediatrics, College of Physicians
and Surgeons, Columbia University, New
York, NY, and with Harlem Hospital Cen-
ter, New York, NY.
Requests for reprints should be sent to
Stephen W. Nicholas, MD, Harlem Hospi-
tal Center, 506 Lenox Ave, Room 17-105,
New York, NY 10037 (e-mail: swn2@
columbia.edu).
The article Reconsidering Com-
munity-Based Health Promotion:
Promise, Performance, and Poten-
tial by Merzel and D’Afflitti1 in
this issue of the Journal makes a
valuable contribution to the
literature on community ap-
proaches to health promotion.
The breadth of studies covered
in this review article, combined
with the prominence the Journal
is giving to the subject in this
issue, suggests how far the field
has come in its understanding
of the links between public
health and communities. The
authors summarize many of the
community-based studies since
1980 and draw useful conclu-
sions for strengthening commu-
nity-based efforts at improving
the health of the US population.
This editorial was accepted December
18, 2002.
References
1. Paris B. Song of Haiti: The Lives of
Dr. Larimer and Gwen Mellon at the Al-
bert Schweitzer Hospital of Deschapelles.
New York, NY: Public Affairs; 2000.
2. Mellon GG. My Road to De-
schapelles. New York, NY: Continuum;
1998.
3. Albert Schweitzer. The Philosophy
of Civilization. CT Campion, trans. New
York, New York: The MacMillan Com-
pany; 1949.
4. Berggren WL, Ewbank DC,
Berggren GG. Reduction of mortality in
rural Haiti through a primary health-
care program. N Engl J Med. 1981;304:
1324–330.
5. Poised for the Future: Annual Report
2001 Hospital Albert Schweitzer. Sara-
sota, Fla: Grant Foundation; 2001.
6. Perry H, Volk D, Philippe F, Dor-
tonne JR, Berggren G, Berggren W.
The long-term impact of a community-
based health care program on infant
and child mortality: the experience of
the Hospital Albert Schweitzer in
Haiti. Paper presented at: Annual
Meeting of the American Public
Health Association; October 24,
2001; Atlanta, Ga.
7. Perry H. Description of Haiti, its
health, health services, and health-related
Moreover, by drawing from the
lessons learned from human
immunodeficiency virus (HIV)-
prevention programs, they pro-
vide significant recommenda-
tions for improving the potential
of community-based strategies.
However, we would like to draw
the readers’ attention to some of
the substantive issues involved
in reviewing such a diverse liter-
ature, including a number raised
by Merzel and D’Afflitti.
The term community-based has
a wide range of meanings. In this
editorial we focus on 4 cate-
gories of community-based proj-
ects based on implicit construc-
tions of community employed by
investigators: community as set-
ting, community as target, com-
munity as agent, and community
behaviors. Background document to the
assessment of HAS programs. Sarasota,
Fla: Grant Foundation; 2000.
8. Fitzgerald DW, Behets F, Preval
J, Schulwolf L, Bommi V, Chaillet P.
Decreased congenital syphilis inci-
dence in Haiti’s rural Artibonite re-
gion following decentralized prenatal
screening. Am J Public Health. 2003;
93:444–446.
9. Patel A, Moodley D, Moodley J. An
evaluation of on-site testing for syphilis.
Trop Doct. 2001;31:79-82.
10. Warner L, Rochat RW, Fichtner
RR, Stoll BJ, Nathan L, Toomey KE.
Missed opportunities for congenital
syphilis prevention in an urban south-
eastern hospital. Sex Transm Dis. 2001;
28:92–98.
11. Downing RG, Otten RA, Marum E,
et al. Optimizing the delivery of HIV
counseling and testing services: the
Uganda experience using rapid HIV an-
tibody test algorithms. J Acquir Immune
Defic Syndr Hum Retrovirol. 1998;18:
384–388.
12. Kassler WJ, Alwano-Edyegu MG,
Marum E, Biryahwaho B, Kataaha P,
Dillon B. Rapid HIV testing with
same-day results: a field trial in
Uganda. Int J STD AIDS. 1998;9:
134–138.
13. Nicholas SW, Abrams EJ. Boarder
babies with AIDS in Harlem: lessons in
applied public health. Am J Public
Health. 2002;92:163–165.
as resource. This typology (many
typologies of community ap-
proaches have been proposed in
the literature, the most fre-
quently used of which is Roth-
man’s Strategies of Community In-
tervention2; we chose not to use
Rothman’s categories explicitly,
although some of his ideas are
included in the discussion) is
used to illustrate the difficulties
in summarizing results across the
array of community-based proj-
ects (of course we recognize that
projects rarely fit our categories
neatly and that any one project
may have characteristics bor-
rowed from each of the cate-
gories). This brief discussion of
“types” of projects is followed by
a discussion of the importance of
community capacity; the use of
Editorials | 529

social ecology as a framework for
community interventions; the use
of a theory of community
change; and the role of public
health values.
A TYPOLOGY OF
COMMUNITY-BASED
INTERVENTIONS
As indicated by some of the
studies reviewed by Merzel and
D’Afflitti, the term community-
based often refers to community
as the setting for interventions.
As setting, the community is pri-
marily defined geographically
and is the location in which in-
terventions are implemented.
Such interventions may be city-
wide, 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 edu-
cational or other strategies that
involve individuals, families, so-
cial networks, organizations, and
public policy. These community-
based interventions may also en-
gage community input through
advisory committees or commu-
nity coalitions that assist in tailor-
ing interventions to specific tar-
get groups or to adapt programs
to community characteristics.
However, the focus of these com-
munity-based projects is prima-
rily on changing individuals’ be-
haviors as a method for reducing
the population’s risk of disease.
As a result, the target of change
may be populations, but popula-
tion change is defined as the ag-
gregate 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
530 | Editorials
 EDITORIALS 
the goal of creating healthy com-
munity environments through
broad systemic changes in public
policy and community-wide insti-
tutions and services. In this
model, health status characteris-
tics of the community are the tar-
gets of interventions, and com-
munity 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.3 Indicators can range
from the number of days exceed-
ing Environmental Protection
Agency standards for air quality
to the amount of park and recre-
ation facility space per capita to
the proportion of residents living
below federal poverty levels.4
Strategies are tied to selected in-
dicators, 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 pro-
motion because of the widely en-
dorsed belief that a high degree
of community ownership and
participation is essential for sus-
tained success in population-level
health outcomes. These pro-
grams 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 strate-
gies. Whether a categorical
health issue is predetermined or
whether the community selects,
perhaps within certain parame-
ters, its own priorities, these
kinds of interventions involve ex-
ternal resources and some de-
gree of actors external to the
community that aim to achieve
health outcomes by working
through a wide array of commu-
nity institutions and resources.
Examples of major public health
initiatives that have applied this
model include “healthy cities” ini-
tiatives within several states,5 the
National Healthy Start program,6
and the federal Center for Sub-
stance Abuse Prevention Com-
munity Partnership program.7
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 rein-
forcing the natural adaptive, sup-
portive, and developmental ca-
pacities of communities. In the
language of Guy Steuart,8 com-
munities 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, busi-
nesses, voluntary agencies, and
political structures. These natu-
rally occurring units of solution
meet the needs of many, if not
most, community members with-
out the benefit of direct profes-
sional intervention. However,
communities are defined as
much by whom they exclude as
whom they include, and the net-
work of relationships that defines
communities may be under
stress.
The goal of community-based
programs in this model is to care-
fully 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 assess-
ment of community structures
and processes, in advance, of any
intervention. It also requires an
American Journal of Public Health | April 2003, Vol 93, No. 4
insider’s understanding of the
community to identify and work
with these naturally occurring
units of solution to address com-
munity problems. Thus the aim
is to strengthen these units of so-
lution to better meet the needs of
community members. This ap-
proach may include strengthen-
ing community through neigh-
borhood organizations and
network linkages, including infor-
mal social networks, ties between
individuals and the organizations
that serve them, and connections
among community organizations
to strengthen their ability to col-
laborate. The model also necessi-
tates addressing issues of com-
mon concern for the community,
many or most of which are not
directly health issues. In other
words, this model necessitates
starting where people are.9
The importance of these mod-
els of community-based interven-
tions 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 pro-
motion. Although community as
setting is obviously limited in its
vision, community as agent can
be regarded as romanticized, es-
pecially in light of the severe
structural economic, social, and
political deficits plaguing some
communities. Moreover, Merzel
and D’Afflitti illustrate the diffi-
culties in summarizing across
program models with different
strategies and expected out-
comes. Although many of the
earlier projects reviewed by
Merzel and D’Afflitti were based
on the idea of community as set-
ting, 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 contempo-
rary public health has 2 broad
goals: strengthening the health of
our communities and building
community capacity to address
health-related issues.
CIVIL SOCIETY,
COMMUNITY CAPACITY,
AND COMMUNITY-BASED
HEALTH PROMOTION
Recent years have seen an ex-
plosion in the literature on civic
renewal, mediating structures
(professional organizations,
churches, block watch organiza-
tions), and social capital starting
in the political science field but
spilling over into other disci-
plines and into the popular liter-
ature as well. This suggests a
broader context within which
community programs take place.
Civil society can be regarded,
for community-based health pro-
motion, as the “setting of set-
tings.”12 Civil society represents
the self-organizing activities of
people within associations,
unions, churches, and communi-
ties. It is neither the state nor
the market. It is not a collection
of individuals pursuing their
own interests, but rather collec-
tivities pursuing common inter-
ests. It encompasses both com-
munity service, formal and
informal, and advocacy, not the
least of which includes voting.
The morality of a civil society
mandates the broadest possible
inclusion in the participation
and institutions that constitute it.
April 2003, Vol 93, No. 4 | American Journal of Public Health
 EDITORIALS 
Thus in calling forth the voices
of even the weakest among a
people, civil society goals are
fully compatible with contempo-
rary public health goals of re-
ducing health disparities.
The vitality of civil society
provides an essential context for
successful community-based
health promotion, especially as
we come to recognize and in-
creasingly utilize the capacity of
communities to mobilize to ad-
dress community issues. Com-
munity capacity may be re-
garded as a crucial variable
mediating between the activities
of health promotion interven-
tions and population-level out-
comes. A number of dimensions
of community capacity have
been identified, among them
skills and knowledge, leadership,
a sense of efficacy, trusting rela-
tionships, and a culture of open-
ness and learning.13 An under-
standing of the community’s
ecology can lead to a better
match with community-based
health promotion interventions
and can provide tools and re-
sources unavailable from outside
agents for making gains against
complex public health problems
like infant mortality, violence,
substance abuse, and many oth-
ers. More profoundly, an appre-
ciation for community capacity
shifts the paradigm underlying
common intervention strategies
to a focus on community build-
ing as a pathway to health. This
may include conscious efforts to
develop new and existing lead-
ership, strengthen community
organizations, and further com-
munity development and in-
terorganizational collaboration.14
These efforts may require ensur-
ing opportunities for community
participation, strengthening rela-
tionships of trust and reciprocity
among community groups and
organizations, and facilitating fo-
rums for community dialogue.
Community capacity represents
both a necessary condition, an
indispensable resource, and a
desired outcome for community
interventions.
ECOLOGICAL
PERSPECTIVES
As indicated in the Merzel
and D’Afflitti article, increasing
attention is being paid to ecolog-
ical perspectives in community-
based interventions. Based on
the work of Urie Bronfenbren-
ner15 and other systems models,
social ecology16–18 places the be-
havior of individuals within a
broad social context, including
the developmental history of the
individual, psychological charac-
teristics (norms, values, atti-
tudes), interpersonal relation-
ships (family, social networks),
neighborhood, organizations,
community, public policy, the
physical environment, and cul-
ture. Behavior is viewed not just
as the result of knowledge, val-
ues, and attitudes of individuals
but as the result of a host of so-
cial influences, including the
people with whom we associate,
the organizations to which we
belong, and the communities in
which we live.
If individuals’ behaviors are
the result of social influences at
different levels of analysis, then
changing behavior may require
using social influences—family,
social networks, organizations,
public policy—as strategies for
change. Our interventions may
include family support (as in
diet and physical-activity inter-
ventions), social network influ-
ences (used in tobacco, physical-
activity, access-to-health-care,
and sexual-activity interventions),
neighborhood characteristics (as
in HIV and violence-prevention
programs), organizational policies
and practices (used in tobacco,
physical-activity, and screening
programs), community factors
(observed in physical-activity,
diet, access-to-health-services,
and violence programs), public
policy (as in tobacco, alcohol,
and access-to-health-care pro-
grams), the physical environment
(used in the prevention-of-
unintentional-injuries and envi-
ronmental-safety programs), and
culture (observed in some coun-
teradvertising interventions).
Thus we can intervene at multi-
ple levels within the social ecol-
ogy as a way of addressing be-
havioral risks.
However, social ecology is
more than the idea that we can
use interventions at multiple lev-
els of the social system. It is also
the idea that each level of analy-
sis is part of an embedded sys-
tem characterized by reciprocal
causality. For example, individu-
als are affected by the families
and informal networks of which
they are members, and individ-
ual characteristics affect the so-
cial networks to which we have
access. Moreover, our social net-
works are largely developed
within the context of organiza-
tions and environments that
bring us into contact with others.
This suggests that ecological in-
terventions may occur at one
level and produce change or
changes at others. We need to
distinguish clearly between levels
of intervention and targets of in-
terventions,19 whether our focus
is on behavioral change,
strengthening units of solution, or
building the civil society.
Models such as social ecology
provide us with not only a sys-
tems framework for thinking
about behavioral change as an
outcome of community-based in-
Editorials | 531

terventions but also a frame-
work for thinking about healthy
communities. What would it be
like if we were to have the pub-
lic’s health as one of our core
values? Perhaps tobacco use can
serve as an example. Since the
1950s, when almost one half of
the US adult population smoked,
we have cut smoking rates in
half. We have seen widespread
shifts in perceptions of smokers
as masculine (Marlboro), sophis-
ticated (Winston), and sexy (Vir-
ginia Slims) adults to widespread
views of smokers as weak willed
and addicted. These changes
have occurred despite the delib-
erate shaping of public opinion
by tobacco producers and the
marketing of tobacco to vulner-
able populations.20 These cul-
tural changes in perceptions of
smoking have not occurred as
the result of any single commu-
nity-based intervention but are
the result of increasing evidence
of the harmful effects of tobacco
use and the cumulative impact
of multiple systemic interven-
tions, including bans on smoking
in airplanes and public build-
ings, rises in the cigarette taxes,
antitobacco advertising, and law-
suits against tobacco companies.
The tobacco example sug-
gests that the goal of commu-
nity-based interventions is not
only to change individual per-
ceptions and behaviors but also
to embed public health values
in our social ecology, including
families, social networks, organi-
zations, public policy, and ulti-
mately our culture—how we
think about things. Although we
lack an effective method for es-
timating effects, perhaps we
should think in terms of com-
munity-based interventions as
part of the social ecology and in
terms of the cumulative effects
of multiple community trials
532 | Editorials
 EDITORIALS 
rather than the effects of a
single project.
THEORIES OF CHANGE
Too rarely do community-
based interventions actually tar-
get organizational, community,
environmental, or policy-level
changes. One compelling reason
is the complexity of fostering
such changes and the field’s lack
of knowledge about the condi-
tions under which social change
occurs. (Even for those most in-
terested in individual behavioral
change, the targeting of higher
ecological levels is essential to
create the social context sup-
porting healthy behavior. The
ways that behavior is institution-
alized (organizational-level
change), normalized (commu-
nity-level change), and legally
bounded (policy-level change)
are essential “social facts,” with-
out which individual behavioral
change is not easily sustained.)
In recent decades, consider-
able progress has been made in
articulating program or imple-
mentation theories,21,22 yet there
are relatively few advances in
developing a theory of commu-
nity change. This inadequacy of
theory seriously hampers the
evaluation of community-based
programs, including estimation
of the magnitude and timing of
outcomes.
Several types of theories are
important for thinking about
community change. Implementa-
tion theory, for example, identi-
fies the activities—the what and
the when—to be undertaken in
any change process and their
links to expected intermediate-
and longer-term outcomes, most
often codified in a program’s
logic model. Typical implementa-
tion theories for community-
based programs include a se-
quenced set of major steps, com-
monly community diagnosis/as-
sessment, planning, intervention,
and evaluation. Such theory is in-
valuable for spelling out the me-
chanics and activities but pro-
vides little understanding of the
how and why—the underlying
process, dynamics and conditions
under which community change
takes place. Moreover, many im-
plementation theories are rela-
tively generic and may not be
linked to community dynamics,
and although they may use infor-
mation on context, it is fre-
quently not clear how commu-
nity context should affect the
implementation process.
Explaining the how and why
of community change is the ex-
press purpose of an underlying
theory of change.23 Theories of
community change are the least
explored and offer the greatest
promise for documenting the
effectiveness of and improve-
ments in community-based
health promotion. To achieve
this, we need to make explicit
our program assumptions about
the causal relationships among
an intervention’s activities and
the mediating factors that lead
to desired outcomes, as well as
the effect of potential con-
founding factors. Logic models
are frequently used for this
purpose.
In addition to more rigorous
designs for outcome studies,
community change theory
would benefit from qualitative
research that explores the vari-
ous factors affecting community
change, linkages among the fac-
tors, and the conditions under
which those linkages occur. Pro-
gram assumptions must be made
explicit so that data collection
and analysis can be undertaken
to track performance. In fact,
building on the excellent review
American Journal of Public Health | April 2003, Vol 93, No. 4
of Merzel and D’Afflitti, one
could fruitfully conduct a cross-
case analysis of theories of
change with a similar inventory
of community-based health pro-
motion. We suspect that one
would find a limited number of
variables being selected for
manipulation—most commonly,
information—and a general lack
of awareness or strategic use of
community factors as levers of
change.
It would be tempting to con-
clude from our brief discussion
of community change and inter-
vention theories that the prob-
lem of strengthening community-
based interventions is largely a
technical or theoretical one.24
However, many of the problems
around which community-based
interventions have been devel-
oped—HIV, adolescent preg-
nancy, diet, tobacco use, other
drug use, alcohol consumption,
physical activity, access to health
services, firearms—have pro-
found personal and cultural
meaning. These problems do not
just result from personal choices;
rather, they say something about
social structure and who we are
as individuals and as a society,
and about our place in society.
Whether we talk about social
class differentials in heart dis-
ease morbidity and mortality or
access to care, public health is
inherently linked to ideas about
how the burden of ill health is—
and should be—distributed in
society.
Public health is more than a
body of theory and intervention
methods. We cannot separate
how we do public health from
why we do public health.
Whether we talk about changing
behavior, changing community
structures, or building community
capacity, these changes cannot be
separated from our ideals about

what constitutes a good commu-
nity or a good society.25
Kenneth R. McLeroy, PhD,
Barbara L. Norton, MBA, MPH,
Michelle C. Kegler, DrPH,
James N. Burdine, DrPH,
Ciro V. Sumaya, MD, MPHTM
About the Authors
Kenneth McLeroy, James Burdine, and Ciro
Sumaya are with the Texas A&M Univer-
sity System School of Rural Public Health,
Bryan. Barbara Norton is a doctoral can-
didate at the University of Oklahoma
School of Public Health, Oklahoma City.
Michelle Kegler is with Emory University
School of Public Health, Atlanta, Ga.
Requests for reprints should be sent to
Kenneth R. McLeroy, PhD, associate dean
for academic affairs, School of Rural Pub-
lic Health, 3000 Briarcrest, Suite 310,
Bryan, TX 77802 (e-mail: kmcleroy@
srph.tamu.edu).
This editorial was accepted November
22, 2002.
References
1. Merzel C, D’Afflitti J. Reconsider-
ing community-based health promotion:
promise, performance, and potential.
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Intervention. Itasca, Ill: FE Peacock Pub-
lishers; 1995.
3. Coulton C. Using community-level
Why Should I
Review a
Paper for the
American
Journal of
Public Health ?
April 2003, Vol 93, No. 4 | American Journal of Public Health
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 EDITORIALS 
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The importance of reviewers to
the American Journal of Public
Health publication process cannot
be underestimated. Without our
reviewers, the Journal would not
only be worse off but would ac-
tually fail to exist as the quality
vehicle for dissemination of pub-
lic health information that it
strives to be. As editors, we are
proud to read submissions and
screen them for validity and con-
tribution, but we rely heavily on
the expertise of reviewers for
their precise comments and criti-
cal responses that maintain the
Journal’s quality and significance.
The past year has brought
many exciting changes for the
Journal, including the hiring of
ity to provide a basis for measurement.
Health Educ Behav. 1998;25:258–278.
11. Norton B, McLeroy K, Burdine J,
Felix R, Dorsey A. Community capacity:
concept, theory, and methods. In: Di-
Clemente R, Crosby R, Kegler M, eds.
Emerging Theories in Health Promotion
Practice and Research. San Francisco,
Calif: Jossey-Bass; 2002:194–227.
12. Walzer M. The idea of a civil soci-
ety: a path to social reconstruction. In:
Dionne EJ, ed. Community Works: The
Revival of Civil Society in America.
Washington, DC: Brookings Institution
Press; 1998: 123–143.
13. Easterling D, Gallagher K, Drisko J,
Johnson T. Promoting Health by Building
Capacity: Evidence and Implications for
Grantmakers. Denver, Colo: The Colo-
rado Trust; 1998:1–24.
14. Chaskin RJ, Brown P, Venkatesh S,
Vidal A. Building Community Capacity.
New York, NY: Aldine de Gruyter;
2001:1-268.
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taining healthy environments: toward a
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tings for Health Promotion: Linking The-
ory and Practice. Thousand Oaks, Calif:
Sage Publications; 2000.
new editorial and production
staff and, most notably, the un-
veiling of a new Web-based
electronic submission system.
These changes have inspired
considerable conversation
among the editorial staff about
the value of our review process
and, of course, the value of our
reviewers.
Because we have the utmost
appreciation for our reviewers,
we have made it a priority to
provide as much support and
guidance as they would like. As
part of our commitment to the
process, we have developed re-
viewer recommendations to
make the job of the reviewer eas-
ier and more efficient. Because
19. Richard L, Potvin L, Kishchuk N,
Prlic H, Green LW. Assessment of the
integration of the ecological approach in
health promotion programs. Am J Health
Promotion. 1996;10:318–328.
20. Warner KE. Selling Smoke: Ciga-
rette Advertising and Public Health.
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evaluation. Res Organizational Change
Dev. 1987;1:1–57.
22. Connell J, Kubisch A. Applying a
theory of change approach to the evalu-
ation of comprehensive community ini-
tiatives: progress, prospects, and prob-
lems. In: Connell J, Kubisch A, Schorr L,
Weiss C, eds. New Approaches to Evalu-
ating Community Initiatives: Concepts,
Methods and Contexts. Washington, DC:
Aspen Institute; 1998:15–44.
23. Weiss CH. Nothing as practical as
good theory: exploring theory-based
evaluation for comprehensive commu-
nity initiatives for children and families.
In: Connell J, Kubisch A, Schorr L,
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24. Buchanan DR. An Ethic for Health
Promotion: Rethinking the Sources of
Human Well-Being. New York: Oxford
University Press; 2000.
25. Bellah RN, Madsen R, Sullivan
WM, Swidler A, Tipton, SM. The Good
Society. New York: Vintage Books; 1991.
one person’s ease and efficiency
is another’s headache, these
guidelines and recommendations
come with an invitation to read
the following once, 10 times, or
not at all—indeed, these are sim-
ply guidelines for those who
want them, not rules carved into
stone.
Of course, no list is complete
without the requisite caveats, and
the reviewer recommendations
are no exception. The following
recommendations represent 2
sets of thoughts about the re-
viewer’s role: the rules we de-
pend on and the exceptions we
make to these rules. Our review-
ers should know that no guide-
lines are inflexible, and the ulti-
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