Journal of Health Care for the Poor and Underserved

337 Brief Communications HEALTH PROMOTION REVISITED To the editor: Osberta Harris's account [Vol. 1, No. 3:265-6] of a series of unsuccessful attempts to provide information and other services to underserved communities raises a number of valid questions. While we may agree with this provider's perception of health care needs in our communities, it is important to note that such a need does not always translate among community residents as a perceived want. To a community that suffers from such pressing problems as hunger, poverty, homelessness, crime, and drug-related violence, the need for health promotion may not be as immediate or important as securing adequate food and shelter. Furthermore, providers must recognize that underserved populations have a history of exploitation that promotes distrust and fear of governmental and quasi-governmental institutions. For most of our health services, the intake procedures alone constitute insurmountable obstacles for people who lack adequate addresses, documentation, or language skills. The callousness and sometimes outright hostility exhibited by health care delivery personnel— amply documented in the case of women, especially women of color—add another barrier to peoples' perception that such services are inaccessible. To these barriers, we must add other issues relating to accessibility: transportation, scheduling, child care, the cultural and linguistic appropriateness of the offerings, and the racial/ethnic composition of provider teams. All need to be assessed if health promotion efforts are to succeed. Many times, the driving force behind health care expeditions into our communities are the research interests of epidemiologists. Though they are publicized as efforts to improve community health, these ventures have often imperceptible results in the eyes of neighborhood residents. Such studies may eventually lead to appropriate interventions, but frequently the immediate reaction in the community is frustration. Many well-meaning efforts flounder because we conduct no collaborative , client-based needs assessment. Instead, we impose on the communities our preconceived notions of what they need. Offerings are planned without community input, and we line up professionals with all of the necessary credentials except the most basic: intimate knowledge of those we are attempting to serve. Because we have an activity designed by professionals, is it any Journal of Health Care for the Poor and Underserved, Vol. 1, No. 4, Spring 1991 338__________________________________________________________ wonder that the community assumes it is for professionals? Our expectations also need to be realistic. When we accept that the process of establishing trust is slow and cumbersome, we should not be discouraged by attendance levels that may be low by other communities' standards. Because there is frequently no baseline against which to measure participation in our communities, we cannot determine on the basis of numbers alone that the community is disinterested or apathetic. Fifty people attending a health fair, or even 25, may indeed reflect a high level of interest in communities that face other consuming concerns. Quantitative evaluation must be tempered with qualitative evaluation if we want to take an unbiased measure of our communities' interest in health promotion. One issue that is central to many ethnic communities' distrust of health promotion efforts, but seldom discussed, is the nature of our technology-based medical system. In many underserved communities, traditional forms of health care constitute the system of choice. Despite resolutions by the World Health Organization advising governments to fund the practice and propagation of traditional and indigenous health care systems, few such efforts are in place in the United States. As a result, ethnic communities are expected to receive all their health care from a system they neither know nor trust. Finally, we must recognize that providers of our own cultural or ethnic backgrounds can be as insensitive to our communities' needs as outsiders, because they have become thoroughly assimilated and share more traits with their new company than with their parentage. Underserved communities trust them no more than they trust other outsiders, and indeed sometimes reserve for them a special animosity. How, then, can we reach the people who so desperately need health care? The obvious answer is to be one of the people we are trying to reach, not separate from them. We cannot be strangers who swoop down on our communities to offer occasional programs, save...