Community-based prevention and chronic disease self-management programs: problems, praises and pitfalls

There is considerable merit in undertaking to shift disease patterns at the community level. Typical problems reflect difficulties in the application of community-based prevention programmes, rather than inherent deficiencies in the concept itself. Scientific issues bear as much on successful outcomes as project management and practice considerations. Nonetheless, given their limited success, it can be asked whether advocates of community-based programmes have been carried away with the rhetoric of health promotion, pursuing a romanticised vision of community. In this regard, some of the disappointments that have prevailed in recently published community trials may reflect an intentional avoidance of programmes or activities that serve people on a one-to-one level. The equating of ‘community-based’ with ‘community-wide’ approaches to disease prevention overlooks the fact that social norms are institution-bound as much as they are the product of broader social forces. Future work must address the inward involvement of institutions in changing their own norms, not simply seeking outward cooperation in mass media and community-wide efforts for disease prevention.