Policy, system, and environmental (PSE) change is a way of thinking about how to improve health by modifying the policies, systems and environments in a given community. PSE change seeks to make healthy choices more practical, easy and accessible to all members of a community. It may involve creating laws, changing organizational policies or shaping landscapes. A coalition needs to understand how to generate PSE change in order to efficiently and effectively improve the health of its community in a sustainable way. The social-ecological model and the health impact pyramid are two helpful frameworks that can be used to think about PSE change.
The Social-Ecological Model
The social-ecological model is a framework that can be used to identify various factors in one's environment that influence behavior. This model posits that behavior is influenced by factors at the following levels:
- Individual: knowledge, attitudes, beliefs and personality traits
- Interpersonal: friends, family and peers that provide social identity and support
- Organizational: rules, regulations, policies and structures
- Community: social networks, norms and standards
- Public Policy: local, state and federal policies and laws
The social-ecological model asserts that behavioral influences interact across these different levels. Effective community change occurs when the most relevant influences at each level are identified and influences at multiple levels are addressed.
The Health Impact Pyramid
The health impact pyramid is a five-tier pyramid that describes the relative impacts of different types of public health interventions. The five tiers are as follows:
- Interventions designed to address socioeconomic determinants of health
- Interventions that change the context of health-related decisions (such as policies that encourage public transit or building designs that encourage stair use)
- One-time or infrequent protective interventions with long-term benefits (such as immunizations)
- Clinical interventions
- Counseling and education
The base of the health impact pyramid is the broadest, indicating that interventions at the lower levels have a greater potential impact than those at the top of the pyramid. Interventions focusing on the lower levels of the pyramid tend to be most efficient and effective because they reach broader segments of society and require less individual effort (Frieden, 2010). The interventions in the bottom two tiers can be used to reach communities while the top three tiers require individual contact. Although evidence-based clinical interventions can improve health, interventions in the top tiers are limited by individual barriers, such as lack of access to care. Top-tier interventions are also costly, using more resources to reach fewer people. Frieden recommends that interventions be implemented at each tier of the pyramid to achieve maximum, sustainable improvements in community health.
Both the social-ecological model and the health impact pyramid are helpful frameworks that coalitions can use to think about the various factors that affect the health of their communities. When factors are identified, coalition members can brainstorm PSE changes to address the most relevant influences. The process of identifying community health influences and working toward PSE change can benefit a coalition beyond improving the health of their community. This process may result in improved collaboration; improved coordination, growth and development of programs; and leveraging of resources to have a greater impact in the community. Most importantly, this process is more likely to result in sustainable community change than would individual efforts, reinforcing the need for collaborative work. PSE can keep coalition members engaged in the work of the group and pave the way for further collaboration.
Crawford, P.B., Schneider, C.L., Martin, A.C., Spezzano, T., Algert, S., Ganthavorn, C., Nicholson, Y., Neelon, M., Wooten Swanson, P.C. and Donohue, S. (2013). "Communitywide Strategies Key to Preventing Childhood Obesity." California Agriculture, 67(1), 13-20.
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Frieden, T. (2010). "A Framework for Public Health Action: The Health Impact Pyramid." American Journal of Public Health, 100(4), 590-595.
Janosky, J.E., Armoutliev, E.M., Benipal, A., Kingsbury, D., Teller, J.L.S., Snyder, K.L. and Riley, P. (2013). "Coalitions for Impacting the Health of a Community: The Summit County, Ohio, Experience." Population Health Management, 16(4), 246-254.
National Cancer Institute. (2005). Theory at a Glance: A Guide for Health Promotion Practice. Retrieved from cancer.gov/cancertopics/cancerlibrary/theory.pdf. No longer available at this url.
Health Policy Institute of Ohio, Ohio Wellness and Prevention Network. (2012). What is 'Policy, System and Environmental Change?'"
Sallis, J.F., Owen, N. and Fisher, E.B. (2008). "Ecological Models of Health Behavior." Health Behavior and Health Promotion, 4th Edition, 465485. San Francisco, CA: Jossey-Bass.
The Asset-Based Community Development Institute. "Downloadable Resources." Publications on community assessment and community mobilization.
Coalitions Work. "Tools and Resources." Resources for a variety of coalition processes and coalition evaluation.
University of Kansas. "Community Tool Box." Toolkits on a variety of topics related to partnership building and community change.
University of Wisconsin-Extension. "Program Development and Evaluation." Logic Model templates and examples.
Iowa State University, North Central Regional Center for Rural Development. Vision to Action: Take Charge Too. Publication about community assessment, vision development, action planning and evaluation.