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that it is imperative that we share our health personnel and expert- ise, along with essential pharma- ceuticals and material goods, with resource-poor countries— I have become involved with HAS to develop a program to prevent mother-to-infant trans- mission of HIV infection and to treat infected individuals. There is good reason to believe that the same strong health care infra- structure that has improved the survival and well-being of chil- dren and that allowed Fitzgerald and colleagues to reduce cases of congenital syphilis will also pro- vide the framework for effective family AIDS prevention and treatment programs.
The lack of exposure to inter- national health issues within my own medical training created ob- stacles to my providing quality health care for newly arrived im- migrant children and their fami- lies when I first arrived in New York City decades ago. A rotation in international pediatrics during
pediatric residency training would be an important step to- ward improving the quality of community pediatrics in the United States.
The central philosophy of Al- bert Schweitzer, as envisioned and implemented by Larimer and Gwen Mellon, is alive and well in Haiti. But it would be an important, long overdue, and beneficial evolutionary step in our own health care system if we were able to incorporate a world view into our everyday practices.
Stephen W. Nicholas, MD
About the Author Stephen W. Nicholas is with the Depart- ment of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, and with Harlem Hospital Cen- ter, New York, NY.
Requests for reprints should be sent to Stephen W. Nicholas, MD, Harlem Hospi- tal Center, 506 Lenox Ave, Room 17-105, New York, NY 10037 (e-mail: swn2@ columbia.edu).
This editorial was accepted December 18, 2002.
References 1. Paris B. Song of Haiti: The Lives of Dr. Larimer and Gwen Mellon at the Al- bert Schweitzer Hospital of Deschapelles. New York, NY: Public Affairs; 2000.
2. Mellon GG. My Road to De- schapelles. New York, NY: Continuum; 1998.
3. Albert Schweitzer. The Philosophy of Civilization. CT Campion, trans. New York, New York: The MacMillan Com- pany; 1949.
4. Berggren WL, Ewbank DC, Berggren GG. Reduction of mortality in rural Haiti through a primary health- care program. N Engl J Med. 1981;304: 1324–330.
5. Poised for the Future: Annual Report 2001 Hospital Albert Schweitzer. Sara- sota, Fla: Grant Foundation; 2001.
6. Perry H, Volk D, Philippe F, Dor- tonne JR, Berggren G, Berggren W. The long-term impact of a community- based health care program on infant and child mortality: the experience of the Hospital Albert Schweitzer in Haiti. Paper presented at: Annual Meeting of the American Public Health Association; October 24, 2001; Atlanta, Ga.
7. Perry H. Description of Haiti, its health, health services, and health-related
behaviors. Background document to the assessment of HAS programs. Sarasota, Fla: Grant Foundation; 2000.
8. Fitzgerald DW, Behets F, Preval J, Schulwolf L, Bommi V, Chaillet P. Decreased congenital syphilis inci- dence in Haiti’s rural Artibonite re- gion following decentralized prenatal screening. Am J Public Health. 2003; 93:444–446.
9. Patel A, Moodley D, Moodley J. An evaluation of on-site testing for syphilis. Trop Doct. 2001;31:79-82.
10. Warner L, Rochat RW, Fichtner RR, Stoll BJ, Nathan L, Toomey KE. Missed opportunities for congenital syphilis prevention in an urban south- eastern hospital. Sex Transm Dis. 2001; 28:92–98.
11. Downing RG, Otten RA, Marum E, et al. Optimizing the delivery of HIV counseling and testing services: the Uganda experience using rapid HIV an- tibody test algorithms. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18: 384–388.
12. Kassler WJ, Alwano-Edyegu MG, Marum E, Biryahwaho B, Kataaha P, Dillon B. Rapid HIV testing with same-day results: a field trial in Uganda. Int J STD AIDS. 1998;9: 134–138.
13. Nicholas SW, Abrams EJ. Boarder babies with AIDS in Harlem: lessons in applied public health. Am J Public Health. 2002;92:163–165.
Community- Based Interventions
The article Reconsidering Com- munity-Based Health Promotion: Promise, Performance, and Poten- tial by Merzel and D’Afflitti1 in this issue of the Journal makes a valuable contribution to the literature on community ap- proaches to health promotion. The breadth of studies covered in this review article, combined with the prominence the Journal is giving to the subject in this issue, suggests how far the field has come in its understanding of the links between public health and communities. The authors summarize many of the community-based studies since 1980 and draw useful conclu- sions for strengthening commu- nity-based efforts at improving the health of the US population.
Moreover, by drawing from the lessons learned from human immunodeficiency virus (HIV)- prevention programs, they pro- vide significant recommenda- tions for improving the potential of community-based strategies. However, we would like to draw the readers’ attention to some of the substantive issues involved in reviewing such a diverse liter- ature, including a number raised by Merzel and D’Afflitti.
The term community-based has a wide range of meanings. In this editorial we focus on 4 cate- gories of community-based proj- ects based on implicit construc- tions of community employed by investigators: community as set- ting, community as target, com- munity as agent, and community
as resource. This typology (many typologies of community ap- proaches have been proposed in the literature, the most fre- quently used of which is Roth- man’s Strategies of Community In- tervention2; we chose not to use Rothman’s categories explicitly, although some of his ideas are included in the discussion) is used to illustrate the difficulties in summarizing results across the array of community-based proj- ects (of course we recognize that projects rarely fit our categories neatly and that any one project may have characteristics bor- rowed from each of the cate- gories). This brief discussion of “types” of projects is followed by a discussion of the importance of community capacity; the use of
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social ecology as a framework for community interventions; the use of a theory of community change; and the role of public health values.
A TYPOLOGY OF COMMUNITY-BASED INTERVENTIONS
As indicated by some of the studies reviewed by Merzel and D’Afflitti, the term community- based often refers to community as the setting for interventions. As setting, the community is pri- marily defined geographically and is the location in which in- terventions are implemented. Such interventions may be city- wide, using mass media or other approaches, or may take place within community institutions, such as neighborhoods, schools, churches, work sites, voluntary agencies, or other organizations. Various levels of intervention may be employed, including edu- cational or other strategies that involve individuals, families, so- cial networks, organizations, and public policy. These community- based interventions may also en- gage community input through advisory committees or commu- nity coalitions that assist in tailor- ing interventions to specific tar- get groups or to adapt programs to community characteristics. However, the focus of these com- munity-based projects is prima- rily on changing individuals’ be- haviors as a method for reducing the population’s risk of disease. As a result, the target of change may be populations, but popula- tion change is defined as the ag- gregate of individual changes.
The term community-based may also have a very different meaning, that of the community serving as the target of change. The community as target refers to
the goal of creating healthy com- munity environments through broad systemic changes in public policy and community-wide insti- tutions and services. In this model, health status characteris- tics of the community are the tar- gets of interventions, and com- munity changes, particularly changes thought to be related to health, are the desired outcomes. Several significant public health initiatives have adopted this model. For example, community indicators projects use data as a catalytic tool to go beyond using individual behaviors as primary outcomes.3 Indicators can range from the number of days exceed- ing Environmental Protection Agency standards for air quality to the amount of park and recre- ation facility space per capita to the proportion of residents living below federal poverty levels.4
Strategies are tied to selected in- dicators, and success is defined as improvement in the indicators over time.
A third model of “community- based” is community as resource. This model is commonly applied in community-based health pro- motion because of the widely en- dorsed belief that a high degree of community ownership and participation is essential for sus- tained success in population-level health outcomes. These pro- grams are aimed at marshaling a community’s internal resources or assets, often across community sectors, to strategically focus their attention on a selected set of priority health-related strate- gies. Whether a categorical health issue is predetermined or whether the community selects, perhaps within certain parame- ters, its own priorities, these kinds of interventions involve ex- ternal resources and some de- gree of actors external to the
community that aim to achieve health outcomes by working through a wide array of commu- nity institutions and resources. Examples of major public health initiatives that have applied this model include “healthy cities” ini- tiatives within several states,5 the National Healthy Start program,6
and the federal Center for Sub- stance Abuse Prevention Com- munity Partnership program.7
Finally, a fourth model of “community-based,” and the one least utilized in public health, is community as agent. Although closely linked to the model just described, the emphasis in this model is on respecting and rein- forcing the natural adaptive, sup- portive, and developmental ca- pacities of communities. In the language of Guy Steuart,8 com- munities provide resources for meeting our day-to-day needs. These resources are provided through community institutions including families, informal social networks, neighborhoods, schools, the workplace, busi- nesses, voluntary agencies, and political structures. These natu- rally occurring units of solution meet the needs of many, if not most, community members with- out the benefit of direct profes- sional intervention. However, communities are defined as much by whom they exclude as whom they include, and the net- work of relationships that defines communities may be under stress.
The goal of community-based programs in this model is to care- fully work with these naturally occurring units of solution as our units of practice, or where and how we choose to intervene. This necessitates a careful assess- ment of community structures and processes, in advance, of any intervention. It also requires an
insider’s understanding of the community to identify and work with these naturally occurring units of solution to address com- munity problems. Thus the aim is to strengthen these units of so- lution to better meet the needs of community members. This ap- proach may include strengthen- ing community through neigh- borhood organizations and network linkages, including infor- mal social networks, ties between individuals and the organizations that serve them, and connections among community organizations to strengthen their ability to col- laborate. The model also necessi- tates addressing issues of com- mon concern for the community, many or most of which are not directly health issues. In other words, this model necessitates starting where people are.9
The importance of these mod- els of community-based interven- tions is that they reflect different conceptions of the nature of community, the role of public health in addressing community problems, and the relevance of different outcomes. When they are presented as pure types, it is understood that no one model is used exclusively with the practice of community-based health pro- motion. Although community as setting is obviously limited in its vision, community as agent can be regarded as romanticized, es- pecially in light of the severe structural economic, social, and political deficits plaguing some communities. Moreover, Merzel and D’Afflitti illustrate the diffi- culties in summarizing across program models with different strategies and expected out- comes. Although many of the earlier projects reviewed by Merzel and D’Afflitti were based on the idea of community as set- ting, many of the later projects
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are based on one of the other 3 models. The latter 3 models— community as target, community as resource, and community as agent—suggest that appropriate outcomes may not just be changes in individual behaviors but may also include changes in community capacity.10,11 In fact, it may be argued that contempo- rary public health has 2 broad goals: strengthening the health of our communities and building community capacity to address health-related issues.
CIVIL SOCIETY, COMMUNITY CAPACITY, AND COMMUNITY-BASED HEALTH PROMOTION
Recent years have seen an ex- plosion in the literature on civic renewal, mediating structures (professional organizations, churches, block watch organiza- tions), and social capital starting in the political science field but spilling over into other disci- plines and into the popular liter- ature as well. This suggests a broader context within which community programs take place. Civil society can be regarded, for community-based health pro- motion, as the “setting of set- tings.”12 Civil society represents the self-organizing activities of people within associations, unions, churches, and communi- ties. It is neither the state nor the market. It is not a collection of individuals pursuing their own interests, but rather collec- tivities pursuing common inter- ests. It encompasses both com- munity service, formal and informal, and advocacy, not the least of which includes voting. The morality of a civil society mandates the broadest possible inclusion in the participation and institutions that constitute it.
Thus in calling forth the voices of even the weakest among a people, civil society goals are fully compatible with contempo- rary public health goals of re- ducing health disparities.
The vitality of civil society provides an essential context for successful community-based health promotion, especially as we come to recognize and in- creasingly utilize the capacity of communities to mobilize to ad- dress community issues. Com- munity capacity may be re- garded as a crucial variable mediating between the activities of health promotion interven- tions and population-level out- comes. A number of dimensions of community capacity have been identified, among them skills and knowledge, leadership, a sense of efficacy, trusting rela- tionships, and a culture of open- ness and learning.13 An under- standing of the community’s ecology can lead to a better match with community-based health promotion interventions and can provide tools and re- sources unavailable from outside agents for making gains against complex public health problems like infant mortality, violence, substance abuse, and many oth- ers. More profoundly, an appre- ciation for community capacity shifts the paradigm underlying common intervention strategies to a focus on community build- ing as a pathway to health. This may include conscious efforts to develop new and existing lead- ership, strengthen community organizations, and further com- munity development and in- terorganizational collaboration.14
These efforts may require ensur- ing opportunities for community participation, strengthening rela- tionships of trust and reciprocity among community groups and
organizations, and facilitating fo- rums for community dialogue. Community capacity represents both a necessary condition, an indispensable resource, and a desired outcome for community interventions.
ECOLOGICAL PERSPECTIVES
As indicated in the Merzel and D’Afflitti article, increasing attention is being paid to ecolog- ical perspectives in community- based interventions. Based on the work of Urie Bronfenbren- ner15 and other systems models, social ecology16–18 places the be- havior of individuals within a broad social context, including the developmental history of the individual, psychological charac- teristics (norms, values, atti- tudes), interpersonal relation- ships (family, social networks), neighborhood, organizations, community, public policy, the physical environment, and cul- ture. Behavior is viewed not just as the result of knowledge, val- ues, and attitudes of individuals but as the result of a host of so- cial influences, including the people with whom we associate, the organizations to which we belong, and the communities in which we live.
If individuals’ behaviors are the result of social influences at different levels of analysis, then changing behavior may require using social influences—family, social networks, organizations, public policy—as strategies for change. Our interventions may include family support (as in diet and physical-activity inter- ventions), social network influ- ences (used in tobacco, physical- activity, access-to-health-care, and sexual-activity interventions), neighborhood characteristics (as
in HIV and violence-prevention programs), organizational policies and practices (used in tobacco, physical-activity, and screening programs), community factors (observed in physical-activity, diet, access-to-health-services, and violence programs), public policy (as in tobacco, alcohol, and access-to-health-care pro- grams), the physical environment (used in the prevention-of- unintentional-injuries and envi- ronmental-safety programs), and culture (observed in some coun- teradvertising interventions). Thus we can intervene at multi- ple levels within the social ecol- ogy as a way of addressing be- havioral risks.
However, social ecology is more than the idea that we can use interventions at multiple lev- els of the social system. It is also the idea that each level of analy- sis is part of an embedded sys- tem characterized by reciprocal causality. For example, individu- als are affected by the families and informal networks of which they are members, and individ- ual characteristics affect the so- cial networks to which we have access. Moreover, our social net- works are largely developed within the context of organiza- tions and environments that bring us into contact with others. This suggests that ecological in- terventions may occur at one level and produce change or changes at others. We need to distinguish clearly between levels of intervention and targets of in- terventions,19 whether our focus is on behavioral change, strengthening units of solution, or building the civil society.
Models such as social ecology provide us with not only a sys- tems framework for thinking about behavioral change as an outcome of community-based in-
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terventions but also a frame- work for thinking about healthy communities. What would it be like if we were to have the pub- lic’s health as one of our core values? Perhaps tobacco use can serve as an example. Since the 1950s, when almost one half of the US adult population smoked, we have cut smoking rates in half. We have seen widespread shifts in perceptions of smokers as masculine (Marlboro), sophis- ticated (Winston), and sexy (Vir- ginia Slims) adults to widespread views of smokers as weak willed and addicted. These changes have occurred despite the delib- erate shaping of public opinion by tobacco producers and the marketing of tobacco to vulner- able populations.20 These cul- tural changes in perceptions of smoking have not occurred as the result of any single commu- nity-based intervention but are the result of increasing evidence of the harmful effects of tobacco use and the cumulative impact of multiple systemic interven- tions, including bans on smoking in airplanes and public build- ings, rises in the cigarette taxes, antitobacco advertising, and law- suits against tobacco companies.
The tobacco example sug- gests that the goal of commu- nity-based interventions is not only to change individual per- ceptions and behaviors but also to embed public health values in our social ecology, including families, social networks, organi- zations, public policy, and ulti- mately our culture—how we think about things. Although we lack an effective method for es- timating effects, perhaps we should think in terms of com- munity-based interventions as part of the social ecology and in terms of the cumulative effects of multiple community trials
rather than the effects of a single project.
THEORIES OF CHANGE
Too rarely do community- based interventions actually tar- get organizational, community, environmental, or policy-level changes. One compelling reason is the complexity of fostering such changes and the field’s lack of knowledge about the condi- tions under which social change occurs. (Even for those most in- terested in individual behavioral change, the targeting of higher ecological levels is essential to create the social context sup- porting healthy behavior. The ways that behavior is institution- alized (organizational-level change), normalized (commu- nity-level change), and legally bounded (policy-level change) are essential “social facts,” with- out which individual behavioral change is not easily sustained.)
In recent decades, consider- able progress has been made in articulating program or imple- mentation theories,21,22 yet there are relatively few advances in developing a theory of commu- nity change. This inadequacy of theory seriously hampers the evaluation of community-based programs, including estimation of the magnitude and timing of outcomes.
Several types of theories are important for thinking about community change. Implementa- tion theory, for example, identi- fies the activities—the what and the when—to be undertaken in any change process and their links to expected intermediate- and longer-term outcomes, most often codified in a program’s logic model. Typical implementa- tion theories for community- based programs include a se-
quenced set of major steps, com- monly community diagnosis/as- sessment, planning, intervention, and evaluation. Such theory is in- valuable for spelling out the me- chanics and activities but pro- vides little understanding of the how and why—the underlying process, dynamics and conditions under which community change takes place. Moreover, many im- plementation theories are rela- tively generic and may not be linked to community dynamics, and although they may use infor- mation on context, it is fre- quently not clear how commu- nity context should affect the implementation process.
Explaining the how and why of community change is the ex- press purpose of an underlying theory of change.23 Theories of community change are the least explored and offer the greatest promise for documenting the effectiveness of and improve- ments in community-based health promotion. To achieve this, we need to make explicit our program assumptions about the causal relationships among an intervention’s activities and the mediating factors that lead to desired outcomes, as well as the effect of potential con- founding factors. Logic models are frequently used for this purpose.
In addition to more rigorous designs for outcome studies, community change theory would benefit from qualitative research that explores the vari- ous factors affecting community change, linkages among the fac- tors, and the conditions under which those linkages occur. Pro- gram assumptions must be made explicit so that data collection and analysis can be undertaken to track performance. In fact, building on the excellent review
of Merzel and D’Afflitti, one could fruitfully conduct a cross- case analysis of theories of change with a similar inventory of community-based health pro- motion. We suspect that one would find a limited number of variables being selected for manipulation—most commonly, information—and a general lack of awareness or strategic use of community factors as levers of change.
It would be tempting to con- clude from our brief discussion of community change and inter- vention theories that the prob- lem of strengthening community- based interventions is largely a technical or theoretical one.24
However, many of the problems around which community-based interventions have been devel- oped—HIV, adolescent preg- nancy, diet, tobacco use, other drug use, alcohol consumption, physical activity, access to health services, firearms—have pro- found personal and cultural meaning. These problems do not just result from personal choices; rather, they say something about social structure and who we are as individuals and as a society, and about our place in society. Whether we talk about social class differentials in heart dis- ease morbidity and mortality or access to care, public health is inherently linked to ideas about how the burden of ill health is— and should be—distributed in society.
Public health is more than a body of theory and intervention methods. We cannot separate how we do public health from why we do public health. Whether we talk about changing behavior, changing community structures, or building community capacity, these changes cannot be separated from our ideals about
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what constitutes a good commu- nity or a good society.25
Kenneth R. McLeroy, PhD, Barbara L. Norton, MBA, MPH,
Michelle C. Kegler, DrPH, James N. Burdine, DrPH,
Ciro V. Sumaya, MD, MPHTM
About the Authors Kenneth McLeroy, James Burdine, and Ciro Sumaya are with the Texas A&M Univer- sity System School of Rural Public Health, Bryan. Barbara Norton is a doctoral can- didate at the University of Oklahoma School of Public Health, Oklahoma City. Michelle Kegler is with Emory University School of Public Health, Atlanta, Ga.
Requests for reprints should be sent to Kenneth R. McLeroy, PhD, associate dean for academic affairs, School of Rural Pub- lic Health, 3000 Briarcrest, Suite 310, Bryan, TX 77802 (e-mail: kmcleroy@ srph.tamu.edu).
This editorial was accepted November 22, 2002.
References 1. Merzel C, D’Afflitti J. Reconsider- ing community-based health promotion: promise, performance, and potential. Am J Public Health. 2003;93:557–574.
2. Rothman J. Strategies of Community Intervention. Itasca, Ill: FE Peacock Pub- lishers; 1995.
3. Coulton C. Using community-level
indicators of children’s well-being in comprehensive community initiatives. In: Connell J, Kubisch A, Schorr L, Weiss C, eds. New Approaches to Evalu- ating Community Initiatives. Washington DC: The Aspen Institute; 1995: 173–200.
4. The Community Indicators Hand- book. San Francisco: Redefining Prog- ress; 1997.
5. Duhl LJ, Lee PR. Focus on healthy communities [theme issue]. Public Health Rep. 2000;115:107–295.
6. Minkler M, Thompson M, Bell J, Rose K. Contributions to community in- volvement to organizational-level em- powerment: the federal Healthy Start experience. Health Educ Behav. 2001; 28:783–807.
7. Yin RK, Kaftarian SJ, Jacobs NJ. Empowerment evaluation at federal and local levels. In: Fetterman D, Kaftarian S, Wandersman A, eds. Empowerment Evaluation: Knowledge and Tools for Self- Assessment and Accountability. Thou- sand Oaks, Calif: Sage Publications; 1996:188–207.
8. Steckler A, Israel B, Dawson L, Eng E. Theme issue: community health development: an anthology of the works of Guy Steuart. Health Educ Q. 1993; suppl 1:S1–S153.
9. Nyswander D. Education for health: some principles and their appli- cations. Health Educ Monogr. 1956;14: 65–70.
10. Goodman RM, Speers MA, McLeroy K, et al. Identifying and defin- ing the dimensions of community capac-
ity to provide a basis for measurement. Health Educ Behav. 1998;25:258–278.
11. Norton B, McLeroy K, Burdine J, Felix R, Dorsey A. Community capacity: concept, theory, and methods. In: Di- Clemente R, Crosby R, Kegler M, eds. Emerging Theories in Health Promotion Practice and Research. San Francisco, Calif: Jossey-Bass; 2002:194–227.
12. Walzer M. The idea of a civil soci- ety: a path to social reconstruction. In: Dionne EJ, ed. Community Works: The Revival of Civil Society in America. Washington, DC: Brookings Institution Press; 1998: 123–143.
13. Easterling D, Gallagher K, Drisko J, Johnson T. Promoting Health by Building Capacity: Evidence and Implications for Grantmakers. Denver, Colo: The Colo- rado Trust; 1998:1–24.
14. Chaskin RJ, Brown P, Venkatesh S, Vidal A. Building Community Capacity. New York, NY: Aldine de Gruyter; 2001:1-268.
15. Bronfenbrenner U. The Ecology of Human Development. Cambridge, Mass: Harvard University Press; 1979.
16. McLeroy K, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15:351–377.
17. Stokols D. Establishing and main- taining healthy environments: toward a social ecology of health promotion. Am Psychol. 1992;47:6–22.
18. Poland B, Green L, Rootman I. Set- tings for Health Promotion: Linking The- ory and Practice. Thousand Oaks, Calif: Sage Publications; 2000.
19. Richard L, Potvin L, Kishchuk N, Prlic H, Green LW. Assessment of the integration of the ecological approach in health promotion programs. Am J Health Promotion. 1996;10:318–328.
20. Warner KE. Selling Smoke: Ciga- rette Advertising and Public Health. Washington, DC: American Public Health Association; 1986.
21. Porras J, Robertson P. Organization development theory: a typology and evaluation. Res Organizational Change Dev. 1987;1:1–57.
22. Connell J, Kubisch A. Applying a theory of change approach to the evalu- ation of comprehensive community ini- tiatives: progress, prospects, and prob- lems. In: Connell J, Kubisch A, Schorr L, Weiss C, eds. New Approaches to Evalu- ating Community Initiatives: Concepts, Methods and Contexts. Washington, DC: Aspen Institute; 1998:15–44.
23. Weiss CH. Nothing as practical as good theory: exploring theory-based evaluation for comprehensive commu- nity initiatives for children and families. In: Connell J, Kubisch A, Schorr L, Weiss C, eds. New Approaches to Evalu- ating Community Initiatives: Concepts, Methods and Contexts. Washington, DC: Aspen Institute; 1995:65-92.
24. Buchanan DR. An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being. New York: Oxford University Press; 2000.
25. Bellah RN, Madsen R, Sullivan WM, Swidler A, Tipton, SM. The Good Society. New York: Vintage Books; 1991.
Why Should I Review a Paper for the American Journal of Public Health ?
The importance of reviewers to the American Journal of Public Health publication process cannot be underestimated. Without our reviewers, the Journal would not only be worse off but would ac- tually fail to exist as the quality vehicle for dissemination of pub- lic health information that it strives to be. As editors, we are proud to read submissions and screen them for validity and con- tribution, but we rely heavily on the expertise of reviewers for their precise comments and criti- cal responses that maintain the Journal’s quality and significance.
The past year has brought many exciting changes for the Journal, including the hiring of
new editorial and production staff and, most notably, the un- veiling of a new Web-based electronic submission system. These changes have inspired considerable conversation among the editorial staff about the value of our review process and, of course, the value of our reviewers.
Because we have the utmost appreciation for our reviewers, we have made it a priority to provide as much support and guidance as they would like. As part of our commitment to the process, we have developed re- viewer recommendations to make the job of the reviewer eas- ier and more efficient. Because
one person’s ease and efficiency is another’s headache, these guidelines and recommendations come with an invitation to read the following once, 10 times, or not at all—indeed, these are sim- ply guidelines for those who want them, not rules carved into stone.
Of course, no list is complete without the requisite caveats, and the reviewer recommendations are no exception. The following recommendations represent 2 sets of thoughts about the re- viewer’s role: the rules we de- pend on and the exceptions we make to these rules. Our review- ers should know that no guide- lines are inflexible, and the ulti-
