Health Promotion International, Vol. 18, No. 4, 279-286, December 2003
© Oxford University Press 2003 All rights reserved
Change in health risk perception following community intervention in Central Havana, Cuba
University of Manitoba, Winnipeg, Canada, 1National Institute of Hygiene Epidemiology and Microbiology (INHEM), Havana, Cuba and 2University of British Columbia, Vancouver, Canada
Address for correspondence: Robert B. Tate, T148–770 Bannatyne Avenue, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, R3E 0W3 Canada, E-mail: tate{at}ms.umanitoba.ca
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONBACKGROUND TO THE INTERVENTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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It is increasingly recognized that individual values, beliefs and behavior operate within a social context. There is growing consensus that local perceptions and indigenous knowledge should be important elements in the evaluation of programs aimed at improving health. Thus, an assessment of changes in health risk perception was included in the evaluation of a multi-component intervention project undertaken between 1996 and 1999 aimed at improving the health and well-being of residents in the inner city community of Cayo Hueso, in Centro Habana, Cuba. The community intervention involved a tremendous mobilization of government and non-governmental organizations, to promote social and cultural activities and address deficiencies in housing, water supply, waste disposal and street illumination. Prior to the interventions, 365 adults were surveyed regarding their perceived health risks regarding 41 health determinants, scored on four-point Likert scales ranging from ‘without risk’ to ‘very risky’. A factor analysis of these data classified perception of risk into five areas: social environment, threats to personal health, lifestyle choices, environmental sanitation and housing conditions. The objective of the current analysis was to determine if there were changes in the level of perceived risk to health over the 5 years pre- versus post-intervention in Cayo Hueso, and if so, whether these changes were significantly different from changes seen during the same 5-year period in Colón, another community in Centro Habana not receiving focused interventions. During the first quarter of 2001, 1703 individuals living in 654 households in Cayo Hueso and Colón were interviewed in their homes using an enhanced version of the 1996 risk perception instrument. Ordinal logistic regression models, adjusted for age, gender and years of education, were fit to assess change in health risk perception between 1996 and 2001. Significant declines in perceived health risk were found in both Cayo Hueso and Colón within all five domains, with significantly greater declines in many areas in Cayo Hueso compared with Colón, particularly with respect to housing-related health risks, indeed the main target of the intervention. Risk perception surveys are useful characterizations of widely held views in a target population. Our findings of decreased perceived health risk following public health, physical and social interventions to improve health suggests that this line of inquiry merits consideration in planning evaluations of multi-sectoral community-based health promotion interventions.
Key words: community interventions; Cuba; risk perception
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONBACKGROUND TO THE INTERVENTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Recent literature on health promotion has focused on the notion that individual values, beliefs and behavior operate within a social context. As reviewed recently in Health Promotion International by Whitelaw and colleagues (Whitelaw et al., 2001
), and discussed at length by Poland et al. (Poland et al., 2000), ‘settings’-based activity has indeed become very popular, as it offers health promotion a conceptual base that allows a much broader multi-sectoral and trans-disciplinary approach to health promotion. Of the various models of settings-based approaches, a preferred approach is one that combines top level commitment and guidance with a high level of community and individual participation (Whitelaw et al., 2001). Douglas, however, noted that settings-based efforts towards health promotion lack rigorous evaluation (Douglas, 1998), hence challenging health promotion researchers to assess evaluative techniques with a more critical eye.
The challenge to develop evaluation strategies for community-based health promotion programs further was taken up by Judd and colleagues (Judd et al., 2001). They, like others (Labonte and Robertson, 1996; Trussler and Marchand, 1998), note that the uniqueness of each community must be recognized in evaluation strategies, and thus, professionals must not dominate in decision-making regarding evaluation. They stress that local perceptions and indigenous knowledge should be important elements in the evaluation of programs, and that evaluation of community-based health promotion programs should embrace a multi-level, multi-strategy vision of individual and environmental change. Furthermore, they caution against an over-emphasis on health status outcomes and individual behavior change. The development of indicators and instruments that measure change on a variety of levels is therefore desirable (Nutbeam, 1998; Judd et al., 2001; Spiegel et al., 2001a), with a balanced approach that accommodates both community realities and decision-makers' concerns for objective evidence.
Accordingly, one of the types of evaluative measures, referred to as ‘experiential standards’ (Judd et al., 2001), is driven by the perceived needs, values and priorities of participants. Thus, changes in health risk perception were included in the evaluation strategy (Yassi et al., 1999) alongside indicators developed collectively by researchers and the community (Spiegel et al., 2001) to evaluate a multi-component, multi-sectoral, settings-based health promotion intervention in a Cuban community.
Perceived health risk is inherently multidimensional, with many characteristics other than the probability of harm affecting human judgement. How ‘risky’ an exposure or behavior is perceived to be by a given individual depends on a long list of factors, including whether the risk is perceived to be voluntary, familiar, amenable to easy change, associated with benefits, and associated with immediate or short-term versus delayed or long-term impacts. While the relationship between changing health risk perceptions and changing health behaviors and health status is still quite unclear, understanding the factors, and in particular the social factors, that impact health risk perception is useful in designing mitigation strategies. ‘Social construction of risk’ refers to the notion that how a society collectively defines and responds to a given hazard is determined by social discourse, not merely by science or technological information (McDaniels, 1998). Cuba has a strong social fabric, and indeed the implementation of a massive intervention in this inner city community in a developing country is itself testimony to community structure (A. Yassi, N. Fernandez, A. Fernandez, J. Spiegel, M. Bonet and R. B. Tate, manuscript submitted). The use of ‘change in health risk perception’ as an indicator of the impact of the intervention implicitly takes into consideration the influence of the social construction of risk. Thus, it is important to understand the very strong influence of social context in evaluating health promotion initiatives in Cuba. In this social context is a component of monitoring changes in health risk perception, which is a particularly useful adjunct to other indicators of effectiveness of the intervention (Spiegel et al., 2001; Spiegel et al., 2003).
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BACKGROUND TO THE INTERVENTION |
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TOPSUMMARYINTRODUCTIONBACKGROUND TO THE INTERVENTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The Cuban context
Over the course of the 1990s, Cuba had to face a severe economic crisis brought on by the collapse of the economies of the Soviet Bloc countries, Cuba's major trading partners, and the intensification of the US embargo. This crisis has had a serious impact on health, the environment and social services. Specifically, effects have been documented on nutrition, transport, water quality, housing and public health services (Garfield and Santana, 1997
). In response to the pressures of this ‘special period’, the Cuban Ministry of Public Health sought interventions to maintain the health achievements of the previous few decades [Garfield, 2000; United Nations Development Programme (UNDP), 2000]. The specific objectives of this government initiative were to increase effectiveness, efficiency, quality of care and population satisfaction (MINSAP, 1996).
In addition, the Cuban Government promoted new initiatives to revise the approach to promoting health. These new initiatives were based on the decentralization of decisions to the level of the newly created Popular Councils, community participation related to the ‘Healthy Cities’ movement, promoting greater involvement in health needs determination, definition of priorities and actions, and inter-sectoral participation of different institutions organized in Popular, Municipal, Provincial and National Councils (MINSAP, 1996; Yassi et al., 1999; Mas et al., 2001).
Centro Habana and the Cayo Hueso community
By 1995, Centro Habana (Central Havana), a municipality of Havana City founded more than 450 years ago, had ~170 000 inhabitants in an area of 3.5 km2. Located in one of the oldest areas of the city, it had the highest population density in the country. More elderly inhabitants resided in this municipality than elsewhere in Cuba, with 13.8% of the population of Centro Habana aged 
65 years, compared with 11.1% in Havana City and 9.1% in Cuba overall. Levels of chronic non-communicable disease (heart disease, cancer and diabetes), as well as injuries, were also higher than in all other municipalities (Municipal Department of Health, 1996).
Investigations conducted over the previous 3 years had documented that this municipality had been experiencing serious housing difficulties. In addition, more than half the population did not have daily access to potable water. The capacity to dispose liquid and solid waste had decreased in Centro Habana, while daily waste collection was carried out in the commercial zone only. In other non-commercial areas, regular waste disposal varied depending on the availability of scarce financial resources. Moreover, the water disposal system was deficient and partially broken. Disease vectors were prevalent, and diarrheal diseases, leptospirosis, tuberculosis and sexually transmitted diseases had increased.
The Popular Council of Cayo Hueso, one of the five Popular Councils in Centro Habana, had 38 193 inhabitants living in an area of 0.83 km2. Housing had become quite problematic, with 70% of houses classified by the Municipal Department of Housing as bad, 38% of which were uninhabitable, and 210 houses were classified as slums, with an index of overcrowd-ing of seven inhabitants per room. The rates of infectious diseases and non-communicable diseases were also documented to be high in this community (Bonet et al., 2001).
‘Plan Cayo Hueso’
Having become aware of the needs of Cayo Hueso through its delegates and non-governmental organizations (NGOs), a set of interventions to improve the quality of life and human health in Cayo Hueso were undertaken between 1996 and 1999. The plan developed saw a tremendous mobilization of governmental organizations and NGOs (Bonet et al., 2001). In addition, the Taller de Transformacion de Cayo Hueso (transformation workshop of Cayo Hueso), an NGO consisting of local artists and community activists, began to build spaces where youth and children could gather, such as the Casa del Niño y la Niña (boys' and girls' house), for which funds were obtained from UNICEF. The Taller also started several programs for seniors, such as self-esteem workshops and exercise programs. Other activities conducted by the Taller during the Plan Cayo Hueso included Tintalla, La Casa del Son, Callejon del Decima o Musica Campesina, Rincon del Feeling, the Quiero a mi Barrio program and the Cooperacion Barrial program—organizations and health promoting programs that promoted various types of dance, music and community pride, and often had themes of improving health and the environment.
In addition, every family was offered a set amount of resources, at below cost price, as a way to stimulate individuals to take on the responsibility of gathering their own resources to complete house repairs. Delegates to the Popular Council encouraged individuals to conduct their home repairs and to assist others that could not do the work on their own. It was, of course, the decision of the families as to whether or not they would spend the time and resources on these identified needs as well as whether or not they would contribute to the interventions in the community as a whole.
Not every household in Cayo Hueso was given the opportunity of housing improvements; only those houses that were considered by the government to be in a repairable state were offered assistance. Houses that were too dilapidated to repair, and housing that was in good condition were left out of the housing improvement intervention. The total amount of government investment in these projects was >13 million pesos (approximately US$60 000), a huge investment for Cuba at that time (Yassi et al., 1999).
A comprehensive set of interventions to address the health determinants was thus initiated in 1996 in the Popular Council of Cayo Hueso, which involved extensive interior and exterior home renovations, repairs to the water supply and waste disposal, improved street illumination, and the promotion of social and cultural activities (Spiegel et al., 2001).
This comprehensive intervention aimed to use a community participatory process to design and implement strategies to improve the quality of life and human health in the community (Israel et al., 1998). Findings regarding the effectiveness of the interventions on improving health indicators and satisfaction (Spiegel et al., 2003) are reported elsewhere, as is an analysis of social capital and its relation to health in Centro Habana (Yassi et al., 2001).
As part of the Plan Cayo Hueso, community surveys were conducted in the five Popular Councils of Centro Habana to determine opinions of residents concerning perception of risk. Part of this survey contained responses to 41 items of risk perception. The English translation of the question preceding the 41 items was ‘During the last 12 months in the place where you have lived, different circumstances or situations may have presented themselves to you in your surroundings: we would like to know how you value these in terms of risk to health’. The level of risk was scored on a four-point Likert scale, ranging from ‘without risk’ to ‘very risky’. The 1996 survey was presented to 365 community adults, and a factor analysis of these data classified perception of risk into five areas: social environment, threats to personal health, lifestyle choices, environmental sanitation and housing conditions (Fernandez et al., 2000).
The objective of the current analysis was to determine if there were changes in the level of perception of risk over the 5 years pre- versus post-intervention in Cayo Hueso, and if so, whether these changes were significantly different from changes seen during the same 5-year period in Colón, another Popular Council of Centro Habana not receiving focused interventions.
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METHODS |
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TOPSUMMARYINTRODUCTIONBACKGROUND TO THE INTERVENTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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During the first quarter of 2001, 1703 individuals living in 654 households in Cayo Hueso and Colón were interviewed in their homes using an enhanced version of the 1996 risk perception instrument. This survey was conducted as a component of the evaluation of the effectiveness of the Cayo Hueso Plan. As was the case in the 1995 survey, there was a dominance of female respondents. Overall in 2001, 364 males and 532 females in Cayo Hueso, and 335 males and 470 females in Colón were interviewed. The mean ages of respondents in 1995 and 2001 were 40 and 45 years, respectively. Thus, in general, an older sample of respondents was obtained for the 2001 survey, and consequently age and gender are adjusted for in all analyses.
The proportion of respondents for the two cross-sectional surveys in the two Popular Councils scoring a risk perception item as ‘very risky’ were tabulated. Ordinal logistic regression models, adjusted for age, gender and years of education, were used to assess change in health risk perception between 1996 and 2000. A regression model, including an indicator variable for year of survey, were fit for each of the 41 risk perception items. Odds ratios with 95% confidence intervals (CI) were estimated from the coefficients of these models. These odds ratios can be interpreted as the odds of an increased perceived risk (if the odds ratio is >1) or a decrease in perceived risk (if the odds ratio is <1) for each specific perception of risk over the 5-year period between surveys. Separate models were fit for residents of Cayo Hueso and residents of Colón. Also, all data from both surveys and both communities were combined, and models were fit including main effects for year and community as well as an interaction term for the year by community interaction. The significance of this interaction was tested by comparing the fit of a model with and without the product term, using the likelihood ratio chi-square test to determine whether the changes in health risk perception in Cayo Hueso and Colón between 1996 and 2001 were of the same magnitude. Results are presented within the five domains described previously (Fernandez et al., 2000).
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RESULTS |
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TOPSUMMARYINTRODUCTIONBACKGROUND TO THE INTERVENTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The proportion of respondents, for each community survey, reporting ‘very risky’ for individual risk perception items is shown in Table 1. There was considerable variability in the level of these percentages, ranging from a low of ~20% to almost 90% for some items.
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Considerable changes in perception of risk to health were found in the area of social environment. Significant declines were found in both Cayo Hueso and Colón between 1996 and 2001 with respect to ‘loud arguing and fighting in homes’, ‘migration to the city from the provinces’ and ‘living in a business area’. Of note is the significantly lower perceived risk to health associated with ‘slum areas’ in Cayo Hueso compared with Colón.
Significant declines in levels of perception of risk in the domain of nine items regarding ‘threats to personal health’ from 1996 to 2001 were more apparent in Cayo Hueso than in Colón. The perception of risk to health for the items ‘frequent diarrhoea’, ‘having lice or scabies’ and ‘oral health’ each declined significantly in both Cayo Hueso and Colón, whereas other items such as ‘combined use of pills and alcohol’, ‘having syphilis or gonorrhoea’ and ‘having parasites’ declined significantly in Cayo Hueso, but not in Colón.
Changes in the perception of risk to health associated with lifestyle items, specifically ‘smoking’, declined significantly in both Cayo Hueso and Colón. ‘Sedentarism’ and ‘anxiety and stress in life’ were both perceived to be lesser risks to health in Colón after 5 years, but remained unchanged in Cayo Hueso.
Lower levels of perceived risk were apparent for general environmental sanitary conditions of streets and public areas in both Cayo Hueso and Colón. In terms of water and air conditions, as measured by ‘quality of drinking water’ and ‘air pollutants due to factories’ and ‘traffic pollution’, appreciable decreases in perceived risk to health were found both in Cayo Hueso and Colón.
A significant decline in risk to health related to housing conditions was found in Cayo Hueso, while no significant changes were found in Colón. Risk to health associated with living in an ‘area of frequent floods’, ‘living in a condemned house’ and the ‘physical building conditions of the house’ were all considerably decreased in Cayo Hueso.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONBACKGROUND TO THE INTERVENTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Perceived risk to health in many items declined between 1996 and 2000 in both the study and comparison communities. However, with adjustment for age, gender and education level, the greatest change was related to housing conditions in Cayo Hueso, consistent with the Plan Cayo Hueso's targeting of this area in the interventions that were undertaken. As discussed by Spiegel and colleagues (J. M. Spiegel, M. Bonet, A. Yassi, P. Mas and R. Tate, manuscript submitted), there was a significant reduction in perceived needs for housing improvement in Cayo Hueso compared with Colón following the intervention. Similarly, other items in which the decline in perceived risk was significant in Cayo Hueso but not in Colón were also specifically targeted by the Plan Cayo Hueso (J. M. Spiegel, M. Bonet, A. Yassi, P. Mas and R. Tate, manuscript submitted).
The differences between the two communities were not as marked as might have been expected. This is undoubtedly attributable to the fact that both communities were subject to the same national and municipal political and economic changes over the period of time examined. In fact, despite the difficult political and economic pressures it has had to bear, Cuba has been remarkably effective in addressing health determinants and concerns. In this sense, the Plan Cayo Hueso should not be regarded as an exception to general policy, but rather as an attempt to target resources in a more concentrated fashion (Ochoa and Pardo 1997; Garfield, 2000). For example Colón, the comparison community, while not targeted for the massive coordinated intervention that occurred in Cayo Hueso, was still the recipient of some aid, and a comparable proportion of individual families did indeed take the initiative to implement repairs in their own homes (J. M. Spiegel, M. Bonet, A. Yassi, P. Mas and R. Tate, manuscript submitted). Moreover, it should be noted that Cayo Hueso was successful at attracting national attention to meet its needs precisely because it had strong civil society organizations, as discussed above. Thus, the existence of the strong social capital in the community (J. M. Spiegel, M. Bonet, A. Yassi, P. Mas and R. Tate, manuscript submitted) may itself explain some of the differences observed.
Experts in risk perception research stress that this type of research is not intended to represent surveys of public technical knowledge or referenda on management alternatives. Furthermore, survey instruments do not provide enough information and do not yield quality input to risk management decisions (McDaniels, 1998). They do, however, provide descriptive insight into issues, and are useful in that they characterize widely held superficial, popular informed views in a target population. Risk perception surveys can be of enormous indirect prescriptive value by clarifying how a society collectively defines and responds to a given hazard, as measured at the individual level (McDaniels et al., 1995). Regardless of this, changes in risk perception following population health interventions have not often been measured. Our findings of significantly decreased perceived health risk following public health, physical and social interventions, specifically in Cayo Hueso, suggest that this type of research is worth considering when selecting indicators to assess the value of interventions to improve health. Given the increasing focus on ‘settings approaches to health promotion’ (Whitelaw et al., 2001) or ‘population health promotion’ (Hamilton and Bhatti, 1996), and given the recognition (Judd et al., 2001) of the desirability of including indicators that reflect community perceptions, this line of inquiry deserves consideration in planning evaluations of multi-sectoral, community-based health promotion interventions such as this.
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ACKNOWLEDGEMENTS |
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This project was supported by the International Development Research Centre of Canada.
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