A Review of County Health Councils in Alabama

In 1979, the Alabama Cooperative Extension Service (ACES) along with the University of Alabama at Birmingham (UAB) School of Public Health developed a program to help local people become more involved with community health issues. It was believed these needs extended beyond just medical services and the provision of health care. What many communities needed was a way to mobilize local people for promoting healthy lifestyles and environments where they live and work. This was a goal to which local residents had much to contribute. Thus, a grassroots approach seemed desirable, and the county health council program was developed as the vehicle for accomplishing this goal.

Health councils are organized at the county level to be citizen-based voluntary groups. Their purpose is to increase participation in health planning and programming by developing a social infrastructure to involve a wide spectrum of concerned citizens. Council members represent people who work in or are members of a wide variety of community agencies and organizations. In addition, private citizens with an interest in local health are encouraged to become involved in the councils. These volunteers identify needs and develop activities to address health and quality of life issues in there broadest sense.

Change is accomplished by the councils through promoting lifestyle modifications and by addressing community health needs such as sanitation, water quality, injury prevention, teen pregnancy prevention, and access of medical services. Councils help focus attention on local concerns, as well as promote the allocation of resources to address these concerns. Such efforts can range from the simple documentation of an existing local problem, to implementing activities to meet a local health need. Health councils are dedicated to increasing the degree of control that local people have over both their own health and the health status of the communities in which they live. In Alabama, county health councils represent a way for citizens to have a direct voice in solving health-related issues at the community level.

As of 1992, twelve years after the County Health Council program was introduced and promoted across Alabama, little information was available about its adoption and use. Even the number of active councils in existence across the state was unknown. Information was needed about the status, composition, goals, activities, operation, and structure associated with these community-based health organizations. In response, the Alabama Cooperative Extension Service with assistance from rural sociologists at Auburn University, conducted a program review to increase their knowledge and to determine the extent to which county health councils were functioning as effective mechanisms for promoting and influencing health, particularly in rural counties.

The program review involved two distinct phases of information gathering. First, the current number of existing health councils needed to be documented and their current status established. Second, information needed to be obtained on membership size, goals, activities, etc. of existing councils to determine their organizational and operational structure. This second phase was conducted to address such questions as: "How were these county health councils organized?" "Were the councils promoting and impacting health and wellness in the county?" and if so, "What factors contributed to success in achieving this goal?" To accomplish these objectives, multiple methods were used.

The first step was to conduct telephone interviews with each of the 67 county Cooperative Extension offices and agents with health program responsibilities. The purpose of these interviews was to determine the past and current status of health councils in each county and to determine the role Extension plays in active councils. It was discovered that 48% of the counties currently had an existing health council, 18% had never attempted to organize a health council, 31% had organized a council at some point between 1979 and 1992, but were no longer active, and 3% of the counties were unsure a council ever existed.

The second review phase involved selecting six active county health councils for intensive case studies. The selected health councils were chosen on the basis of their county's population, council's start date, membership size, organizational goals, activities, future plans, and perceived effectiveness. These six councils were selected because of their differences rather than their similarities, except for being considered active councils. For example, one multi-county council consisted of two urban and one rural counties. After selecting these six health councils for study, a variety of methods were employed to obtain information about each council. These methods involved conducting focus group discussions, key leader interviews, mail surveys, and the analysis of available council records and historical information. Data were obtained from the county Cooperative Extension agent, key health council leaders, and health council members.

Composition and Membership

In all six case studies, health council membership was open to all county residents having an interest in local health concerns. Broad-based membership of residents from across the county was a desired goal, but participation tended to involve primarily people representing health and social service agencies.

The relatively few members unaffiliated with such agencies or organizations were often retired people who had joined the council when they were employed and continued to participate after retirement. All six county health councils reported experiencing difficulty maintaining representation from county segments lacking formal health positions such as local businesses, government agencies, and private citizens. One factor that these six councils had in common was a core group of longtime members. In spite of this stable core, all reported frustration over the constant struggle to sustain participation and keep members actively involved. Recruitment of new volunteers was a serious concern.

Participation

The majority of current members first became aware of the County Health Council by means of a personal invitation received from the Cooperative Extension Service and/or the UAB School of Public Health. Most current members who responded to the mail survey indicated being a council participant for five or more years. They also attended meetings on a regular or frequent basis. When asked why they had joined the council and continued to be active, three reasons were often cited: (a) a belief in the need to address health issues and problems in their counties, (b) a desire to play an active role in addressing local health needs, and (c) a request by their employer to represent their agency. One of the most commonly experienced concerns of the six councils was the lack of attendance at council meetings. This problem was usually attributed, in one way or another, to the time of meetings, travel time involved in getting from the work place or home to the meeting, conflicts with other organizational commitments, and lack of interest.

Goals and Objectives

Clearly defined goals were an integral component in the structure of the selected health councils. Each of the six councils had adopted its own goals, consistent with county needs and the interests of council members. Each council was formally organized with a set of by-laws and articulated statements of their goals and/or objectives. They reviewed their purpose periodically. Modification of the goals and objectives occurred when new health or wellness concerns and issues arose within the local community. Flexibility and adaptation to perceived new issues contributed to the sustainability of these councils. The overall or general goal of these councils was viewed as the need to inform and educate local citizens about health and wellness concerns relevant to their county. Council members indicated a strong sense of agreement with the goals of their own council. Moreover, a strong value was placed on the achievement of council goals. Most members believed their council had achieved many of its goals and was continuing to be effective in promoting better health in the county.

Activities

Members of these six County Health Councils perceived their councils to be playing an important and unique role in promoting local awareness, education, and prevention related to a broad range of health concerns. Health activities of these six councils can be classified as one of two types. First, some activities focused on issues affecting a specific population such as youth, elderly, or women. Second, other activities involved an issue that affected the entire county such as rabies, water quality, chronic diseases, injury prevention, and other local health needs. These six health councils had sponsored a variety of active programs over the years. Some example programs include drug education in schools, wellness programs in local industries, water quality projects, and health screening fairs. Such proactive health programs were perceived by members as reaching more county residents than those that merely provided educational information. Overall, members had a more positive attitude toward the council if it sponsored local health and wellness programs.

Not all member assessments of council activities were positive. A few members identified several barriers they saw in conducting an active health council program at the county level. One of the barriers identified was the lack of long-term member participation and commitment to Council activities. This was a commonly expressed problem, as members were prone to getting involved in a specific program or project of interest to them or their organization. When that project was completed, they did not transfer their commitment to the broader range of local health issues and needs. Other barriers mentioned were the lack of funds, internal conflicts within the council, and communication problems. Because none of the councils charged membership dues, there was no readily available source of funds to carry out even small projects. Assistance needed to be obtained from other organizations and agencies.

Performance

Several indicators of council performance were examined in the case studies of these six health councils. Specifically, decision-making, leadership, and productivity were assessed. The majority of members in all six councils perceived that all members had an equal say in group decisions. Moreover, the members saw the council as operating independently from other local and state health groups and organizations with no interference or pressure exerted on them. The leadership structure of all six of these councils was provided by a set of leadership offices including a chairperson, a co-chairperson, and a secretary. Traditionally, an Extension agent acted as secretary and facilitator for the council. The role of the secretary was to provide organizational and educational assistance through his/her contacts with ACES and UAB. All councils relied heavily on the coordination provided by the secretary, who in every case was the Extension agent serving on a permanent basis. Members of all councils perceived the Extension agent and the role that person played as indispensable to a successful council. In addition, a dedicated chairperson was identified as a key factor in council's success and effectiveness. All members agreed that strong leadership from these two officers was required to maintain a viable and functioning council.

County Health Councils were seen as positively influencing the health of local residents. These attitudes were enhanced by successful completion of visible projects contributing to health within the County. Moreover, the councils were perceived as especially productive in networking between agencies and individuals. This was viewed as important because it provided Council members with information about the activities of one agency that were of interest and concern to other agencies, as well as providing insights about available needs and resources within the county. Overall, participants in these six health councils believed the productivity of their Council was the result of the deep commitment by core members to promoting good health in their counties.

County Health Councils have a unique role to play in meeting the health care needs of local areas and citizens. The health council approach empowers county residents to influence the health and wellness issues in their county by employing a grassroots organizational strategy. Based on findings from case studies of six county health councils, the following recommendations are made to aid in the establishment of councils in Alabama and other states and to strengthen existing health councils:

• The Health Council approach needs to be decentralized. The approach needs to be promoted in communities within the county to reach isolated county segments.

• Health councils need to have a broad-based membership comprised of both agency and non-agency participants such as the elderly, poor, and handicapped persons along with individuals from private organizations and health and social service provider agencies.

• The planning and implementation of health projects should be relevant and accomplishable. Projects are more successful if they are not complex and can produce a visible outcome or result.

• County health council meetings need to be at times that encourage health consumer participation such as in the afternoons.

• The health councils need to conduct yearly assessments to determine whether they have achieved objectives and review successes and failures.

• Cooperative Extension Service can play a role in facilitating the organization of these community based organizations. The county agent can utilize their community development skills to mobilize the community to address needed health issues.

Alabama Cooperative Extension Service. (1992). Alabama county health council handbook. Auburn University, AL: Author.

Mecsko, L. A. (1992). Empowering citizens for involvement in health issues: A review of county level health councils in Alabama. Unpublished masters thesis, Auburn University, Auburn, AL.