Efforts to change policies and the environments in which people live, work, and play have gained increasing attention over the past several decades. Yet health promotion frameworks that illustrate the complex processes that produce health-enhancing structural changes are limited. Building on the experiences of health educators, community activists, and community-based researchers described in this supplement and elsewhere, as well as several political, social, and behavioral science theories, we propose a new framework to organize our thinking about producing policy, environmental, and other structural changes. We build on the social ecological model, a framework widely employed in public health research and practice, by turning it inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthy policy and environmental development. We conclude by describing how health promotion practitioners and researchers can foster structural change by (1) conveying the health and social relevance of policy and environmental change initiatives, (2) building partnerships to support them, and (3) promoting more equitable distributions of the resources necessary for people to meet their daily needs, control their lives, and freely participate in the public sphere.

OBJECTIVES: This study examines the impact of the condom availability program in New York City public high schools by comparing rates of sexual activity and condom use for New York students and similar students in Chicago. METHODS: A total of 7119 students from 12 randomly selected New York schools and 5738 students from 10 Chicago schools participated in a cross-sectional survey. RESULTS: New York students, compared with Chicago students, reported equal rates of sexual activity but higher rates of condom use at last intercourse (odds ratio [OR] = 1.36). For higher-risk students (those with three or more sexual partners in the past 6 months), condom use was greater in New York (OR = 1.85) than in Chicago. CONCLUSIONS: Condom availability has a modest but significant effect on condom use and does not increase rates of sexual activity. These findings suggest that school-based condom availability can lower the risk of HIV and other sexually transmitted diseases for urban teenagers in the United States.

Although the public health literature has increasingly called on practitioners to implement changes to social, environmental, and political structures as a means of improving population health, recent research suggests that articles evaluating organization, community, or policy changes are more limited than those focused on programs with individuals or their social networks. Even when these approaches appear promising, we do not fully understand whether they will benefit all population groups or can be successful in the absence of accompanying individually oriented programs. The role of this broad category of approaches, including both policy and environmental changes, in decreasing health disparities is also unclear, often benefiting some communities more than others. Finally, the political nature of policy and environmental change, including the impact on personal autonomy, raises questions about the appropriate role for public health professionals in advancing specific policies and practices that alter the conditions in which people live. This article addresses these issues and ends with a series of questions about the effectiveness and ethical implementation of what we have termed “structural initiatives.”

Seventy-four first- and second-year students, participating in focus groups at a northeastern U.S. university, discussed recollections of messages received at home, prior to sexual debut, about sex and sexuality. Responses were categorized as Characteristics of Communication (nature of interactions participants had at home about sexuality) and Major Message Content (actual themes of those conversations). Commonly reported characteristics were trouble talking with parents; most conversations happened with mothers; participants feared parents’ reactions; and among lesbian, gay, bisexual groups, feared parents’ discovering their nonheterosexual orientation. Commonly reported message content included use protection and, among women, wait. Women reported messages that were at best, mixed, and at worst, threatening or moralistic. Men reported fewer conversations, and those recalled were more neutral or encouraging, especially from fathers. Parental messages to males and females differed qualitatively, reflected stereotypical assumptions about gender roles, desire, and appropriate conditions under which to have sex, and lacked support for nonheterosexual orientations.

This case discusses how we used scoping review methodology to map the literature in an emergent area of research, “structural change” public heal