|Learn about access, barriers and opportunities and how they relate to community health and development.|
What do we mean by modifying access, barriers, and opportunities?
What constitutes access to community services?
What are the barriers to access to community services?
What do we mean by opportunities for access to services... and for access to or use of unsafe or unhealthy behaviors or circumstances?
What tactics might be useful in modifying access, barriers, and opportunities?
When you begin an initiative or intervention, you have participants in mind. They may be members of a specific group – defined by geographic or language characteristics, by social or economic factors, or by needs – or participants may include all members of the community. In either case, your initiative or intervention is unlikely to be successful if your intended participants don’t get involved in it.
In other words, your effort will be fruitless unless participants have access to it. That doesn’t mean only physical access – being able to reach or get into a building, for instance – but informational, social, and psychological access as well. People have to know that what you’re offering exists, to see it as important to them, and to be willing to use it. In addition, the physical, social, and psychological barriers to their using it have to be reduced or eliminated, and their opportunities to use it have to be maximized. Otherwise, many of them will be shut out, a situation both unfair and contrary to your goals.
Chapter 23 is about ways to improve access – for specific groups or for everyone – to the services that enhance life in the community. Those services extend to products (medication, for instance), practices (daily exercise, voting), amenities (libraries, parks, etc.), information, and institutions (government, higher education). In this section, we’ll discuss what that means in general; the following sections will examine in detail a number of ways to reach the goal of improving access to service.
The following video on the obesity epidemic beautifully illustrates the importance of modifying access, barriers, and opportunities:
What do we mean by modifying access, barriers, and opportunities?
Access to what? Barriers to what? Opportunities for what? What exactly are we talking about here?
In general terms, this chapter is about making sure that people who need them have the ability to take advantage of the full range of community services – health services, education, human services, recreation, the arts, etc. That’s what access to community services is. It includes the need for universal access to those things that contribute to a high quality of life in a community – decent employment, a healthy and enjoyable environment, participation in public issues, and responsive and honest government, to name a few. It encompasses access to healthy practices and products. And it also implies access to the information that will make much of this possible – information about nutrition, for example, about the positions of candidates, about the environmental effects of various courses of action.
The barriers here are the conditions, policies, or attitudes that prevent or make difficult the use and enjoyment of these services, amenities, practices, products, and information, as well as those personal and social hurdles that many people have to surmount in day-to-day life.
“Opportunities” is not simply another word for “access,” but refers to something slightly different. By making access easier, and by removing barriers, you can create more opportunities for people to use community services. Remember, however, that an opportunity is only the ability to take advantage of something: it’s up to the individual to decide whether to do it or not. You can create opportunities for people to further their education, to quit smoking, to train for jobs, or to become home owners; but you can’t guarantee that people will seize those opportunities, even with your encouragement.
Modifying access, barriers, and opportunities
To modify something is to change some aspect of it – here, we mean changing it for the better. That may mean increasing, decreasing, replacing, or removing it, depending upon what the goal is. In most of the cases here, we’ll be talking about increasing access and opportunities, and decreasing barriers, but there are large exceptions. Most communities, for instance, would want to limit access – especially for young people – to alcohol, tobacco, drugs, and handguns. A community health organization might want to find ways to decrease access to unhealthy foods and practices, in order to promote healthy lifestyles.
That community health organization might try to cut down on opportunities for people to eat junk food by convincing local stores to replace some of their chip and candy displays with healthier snacks – nuts and fruit, perhaps. By the same token, a group working on the reduction and prevention of youth violence could try to decrease opportunities for violence by installing more streetlights, encouraging people to be out on the streets in the evening, and organizing neighborhood patrols.
In all of these cases, barriers are being created, rather than being lifted, in order to make it more difficult for people to engage in unhealthy or dangerous practices. The ultimate goal, whether increasing or decreasing access, barriers, or opportunities, is change that leads to healthier communities and an enhanced quality of life for everyone.
In this section, we’ll look at access, barriers, and opportunities, and then discuss how they can be modified to help assure that enhanced quality of life.
What constitutes access to community services?
There are several different ways to look at access, all of them relevant here.
- Availability of services, amenities, or products. If a necessary service doesn’t exist, then those who need it have no access to that service. If a service can only accommodate a small number of those who need it, then most have no access to that service. If a service can only be used by those who speak a particular language, then those who don’t speak that language have no access to it. If a service exists, but those who need it don’t know about it, then they don’t have access to that service. If a service exists, but is not available at a time when those who need it can use it (no evening or weekend hours for those who work full-time day jobs, for example), then they have no access to that service. If a service is limited to a particular small group by funding or organizational policy, it isn’t accessible to many who need it. These conditions also hold for such amenities as sports facilities, cultural programs, and libraries, and for information. They hold as well for healthy products – whole grain bread, fresh fruit and vegetables, clean water, etc.
- Literal, physical access to a service or amenity. This may mean the ability to enter or use a site – wheelchair ramping or elevators, for instance, automatic doors, or bathrooms and seating designed for people with disabilities. It may also refer to the ability to get to a site, as exemplified by a central location, convenience to public transportation, the response to a far-flung rural population, etc. Finally, folks who have no phones or computers, who have difficulty reading or speaking English, or who are hearing- or sight-impaired could have difficulty finding or using services, especially those such as teleconferences or distance-learning courses.
- Access to information. In many ways, this is similar to physical access. Information must be in a form accessible to those who need it – the right language, the right medium (a radio ad or a picture for those who can’t read, for instance), etc. It has to be placed where those who need it can find it – local newspapers or newsletters, for example, the Spanish-language radio station, or the laundromat bulletin board. Most important, those who have the information have to be willing to share it. Many a community initiative has centered around simply getting information on important issues to the public, because officials, corporations, or others who had it didn’t want it to get out.
- Effectiveness. If a service exists, but doesn’t accomplish its purpose – a drug rehabilitation program a high percentage of whose graduates start abusing drugs again, for instance – then those who need it have no access to a service that can help them.
What are the barriers to access to services, amenities, practices, products, and information?
Barriers to access come in all shapes and sizes. The essential differences among them depend on who creates them – the society, particular institutions or organizations (including government), or those who need access themselves.
These are barriers that exist because of “the way things are,” and because of the assumptions that a majority of people in a community or a country make about the nature of the world. They include:
- Education. Inequalities in public education – in the countries where public education exists – often place enormous barriers in the way of low-income or minority populations. Even where education is readily available, those who don’t do well as children often find themselves at a permanent disadvantage for the rest of their lives.
- Employment. There are societal forces that strongly influence who gains employment and who doesn’t. Some of these have to do with stereotyping and prejudice (see directly below), but others are related to where employers are located, and the messages they and the media send to certain groups about employment. Forces may also exist within the groups themselves that make employment difficult. All of these forces probably combine, for instance, to make it more than just coincidence that unemployment for young black men in the U.S. is considerably higher than the overall unemployment rate.
- Stereotyping and prejudice. Even in places where unequal treatment is illegal, members of certain groups are often treated differently, simply because of the way they are viewed by the society at large.
- Lack of understanding of the need for services. Often, the lack of services stems from a general lack of understanding about the need for those services. Most people may assume that services are readily available (everyone can easily get health care) or are not needed (illiteracy isn’t a problem in America). Inadequate funding for services can stem from the same lack of understanding.
- The choices the society makes. The society often chooses tax cuts over improved services, or decides to fund military initiatives rather than fighting hunger or poverty. In a democratic nation, these are choices that the people make, with their ballots and their approval or disapproval of government policy.
A related issue here is that of the choices the society makes for people, rather than with them. Professionals and politicians often assume they know what particular groups should need and want, and set out to give it to them. Although they usually do this with the best of intentions, it is generally a bad idea to create programs or interventions without at least consulting with those for whom they are intended. People are unlikely to flock to a program that they see as irrelevant to their lives
Institutions – schools and colleges, government bodies, hospitals, organizations, workplaces, businesses, etc. – often intentionally or unintentionally make it difficult for particular individuals or groups (or sometimes for anyone) to take advantage of what they have to offer. While institutions usually reflect the attitudes and practices of the society, many may react to those of their particular constituents, board members, or other internal powers. Some of the ways in which they may deny access:
- Location. Institutions may assume that everyone can reach them, not realizing that for many people, transportation can be difficult or too expensive. In rural areas, in cities where there is inadequate public transportation, or for people for whom even a dollar or two a day is a major cost, transportation may present an all-but-insurmountable obstacle.
- Physical access. Individuals with permanent or temporary disabilities, seniors, and small children and their parents are among those who may need elevators, ramps, wide corridors, special bathroom facilities, or other accommodations. If institutions are not equipped with these, and are not willing or able to make adjustments, these folks can be denied access to them.
- Administrative barriers. Some institutions and organizations seem to make rules just to make it harder for people to use their services or facilities. Long, complicated forms – difficult for everyone, but especially for those with less education – long waits for service, hard-to-use or frustrating phone systems, and complex or intimidating procedures, for example, all get in the way of easy access. The same is true for blindness to the needs of the population in question (e.g., scheduling).
- Poor or no communication. Institutions are sometimes staffed by bureaucrats who use “insider” language that average people find hard to understand, or by people who don’t speak the language of many of the people they deal with. They may also communicate disapproval of those they speak with, or make little effort to communicate with members of some groups.
- Lack of cultural sensitivity. Institutions that don’t understand, or don’t realize they don’t understand, the cultures of groups other than the majority can easily adopt procedures or communication styles that drive members of those groups away. Such institutions may also expect individuals of all backgrounds to behave according to a limited set of (generally middle class) standards, or to have skills they may not have.
Some of the barriers to access are personal to those who are trying to gain it.
- Psychological barriers. Shame or embarrassment about what they need (basic skills, treatment for STD’s) or fear of failure keep many people from seeking services, from using such public amenities as libraries, or even from registering to vote.
- The uncertainty of poverty. Disadvantaged individuals have a higher incidence of chaos in their lives than middle class people. Health care crises are more frequent (and health care often more difficult to obtain), transportation more of an issue (cars that break down frequently, or no car at all), communication more difficult (no phone or e-mail), housing less secure (low-income people typically spend a much larger portion of their income on housing), and financial disaster always looming.
- Cultural or religious issues. Some cultures object to the education or employment of women. Some cultures or religions have restrictions against or ethical concerns about some or all medical care, borrowing money, allowing children to participate in after-school or recreational activities, eating particular foods, etc. These cultural standards may conflict with various services in the community.
- Family concerns. In addition to the ever-present need for child care, many potential users of community services and amenities hesitate or refuse because of other family issues. Spouses or other family members – or the individual himself – may object to the time an individual spends in receiving services, or to the resulting changes in the family routine. Sometimes new independence or skills, or a change in roles as a result of an intervention (a previously dependent wife becoming employed, for instance) can lead to conflict.
- Lack of basic skills or education. The inability to read and write the majority language, or to do at least basic math, is likely to keep people from accessing needed services.
- Lack of job and personal skills. In addition to educational gaps, some people find themselves with few skills required to get and keep a job –– and thus reduce their chances of gaining income or forming personal networks.
What do we mean by opportunities for access to services…and for access to unsafe or unhealthy behaviors or circumstances?
Communities, organizations, and individuals can modify services, amenities, products, and information to provide more opportunities for access for everyone, or for specific groups. They can also, often unintentionally, encourage unhealthy or otherwise harmful behavior by providing opportunities to engage in it. And, by the same token, they can discourage unhealthy or otherwise harmful behavior by cutting down on the opportunities to engage in it.
Increasing opportunities for access may involve addressing such issues as availability or affordability or effectiveness, but it may also rest on simpler changes. Providing basic information, persuading a merchant to stock new items, or posting new signs might go a long way toward your goal. It’s important to analyze the situation, and determine what’s blocking access. It could be something major, or a complex combination of factors, but it could also be a smaller matter that can be more easily addressed.
Decreasing opportunities for access to unhealthy or dangerous practices and products calls for analysis. You should try to understand which practices and products can be affected by actions you can take, and also how those practices and products get to the people you want to reach.
What tactics might be useful in modifying access, barriers, and opportunities?
This chapter examines five tactics – action plans – for modifying access, barriers, and opportunities:
- Reducing access to unhealthy products and practices
- Enhancing access to services, healthy practices and products, and information
- Extending opportunities for people of lower income
- Increasing access for people with physical disabilities
- Using outreach to increase access
Each of these tactics will be treated in detail in its own section in this chapter. We’ll introduce them briefly here, and discuss how each can be part of a larger strategy for long-term change.
1. Reducing access to unhealthy products and practices
Limiting the opportunities for behavior unhealthy or harmful to either the individual or the society as a whole is a way to increase opportunities to engage in healthy behavior, just as eliminating barriers increases the opportunities to gain access to services. Some examples of limiting access to unhealthy or dangerous behavior or products:
- Increasing street lighting, to make undetected violence and other crime harder to commit.
- Banning smoking in public buildings and restaurants.
- Regulating the sale of weapons.
- Enforcing age regulations for alcohol sales in restaurants and stores.
- Encouraging food vendors to eliminate some unhealthy products and to replace them with equally tasty, more nutritious ones.
- Turning abandoned buildings – often a source of crime – into affordable housing.
- Using taxes to discourage the use of particular products. Common examples are levying high taxes on gasoline (to encourage conservation), cigarettes, or alcohol.
A campaign to change behavior – to promote healthy nutrition and exercise, for instance – might use a combination of this and other tactics in an overall strategy to increase the use of healthy products, and cut down on the use of less desirable ones.
2. Enhancing access to services, amenities, healthy practices and products, and information.
This usually means addressing one or more of the issues described earlier as elements of access, and may also involve limiting access to some activities or products.
Some ways to increase access:
- Adjusting the schedules, locations, and structures of services, activities, etc. to best meet the needs of those they’re meant to reach.
- Developing new forms of transportation
- Providing physical and communication access for people with disabilities and speakers of other languages.
- Using cultural sensitivity and knowledge to make services and amenities more attractive to members of non-majority cultures.
- Forming support groups and other supportive services for those trying to change unhealthy behavior.
- Working with the community to replace unhealthy products with healthy alternatives. We’ve already mentioned changing snack food displays in stores. You might also convince restaurants to offer healthy selections.
These types of actions are perhaps among the most commonly used in a strategy to enhance access. They can stand alone, or be used in combination with others to fill out a larger strategic plan.
3. Extending opportunities for the poor.
Many of the specific actions here might be the same as those for enhancing access, but there are some that aim more closely at this target. Some examples:
- Programs and services with means-tested admission requirements. Entry to such programs is dependent on a participant’s income being below a certain level. A variation is programs designed for and/or limited to welfare recipients or other closely-defined low-income populations. Examples in the U.S. are many basic education and job-training programs (often including job-readiness), Pell grants for higher education, and Medicaid (federal medical insurance for people of low-income).
- “Development zones” and similar programs, whereby industries and businesses receive tax breaks and/or subsidies for locating in low-income communities and employing residents.
- Affirmative action. This policy takes factors including "race, color, religion, sex or national origin” into consideration in order to benefit an underrepresented group, usually as a means to counter the effects of a history of discrimination.
- Social entrepreneurship. This can take the form of small business loans to impoverished people, or sponsorship of creative new or already-existing entrepreneurial programs for the poor by such international organizations as Ashoka or Oxfam. In a developing country, a loan as small as $25.00 can allow a family to go from desperately poor to healthily self-sufficient. In some cases, such loans can transform a whole village, in both economics and attitude.
These tactics, coupled with those aimed at enhancing access in general, can be particularly useful in an anti-poverty initiative.
4. Increasing access for people with physical disabilities.
It may seem that this kind of access is merely a matter of making some specific changes in physical facilities. The Americans with Disabilities Act (ADA) provides guidelines for those physical changes. In fact, there’s more to it than that. The physical changes are really all-encompassing, if they’re to be done right, and there are other changes involved as well. Some of those changes include:
- Acceptance. An organization, business, or institution needs to work on viewing people with disabilities as normal human beings, rather than defining them by their disabilities. Creating an accessible environment involves developing attitudes that recognize disabilities and the needs of those who have them, but also recognizing those folks as human beings with the same makeup as everyone else, and treat them that way.
- Communication. People who have sight, speech, or hearing impairments may need accommodations in order to understand or be understood. These can include TDD devices that translate speech into print over the telephone and sign language interpretation at meetings or events for people with hearing impairments; raised letters on signs, and recorded materials and minutes for those with impaired vision; and sensitivity to communication needs, so that everyone gets necessary information.
- Physical access. To be truly physically accessible, a site needs more than a ramp or elevator so that people in wheelchairs can get in. Doors have to be openable, bathrooms have to be large enough for a wheelchair and have appropriate fixtures and handrails, corridors and doorways have to be wide enough, there has to be an alternate exit and escape plan in case of fire or other emergency, meeting rooms and offices have to be set up to make it easy for people with disabilities to use them, etc. Physical accessibility takes a lot of thought and effort, and sometimes a fair amount of money as well. (More information on complying with the Americans with Disabilities Act can be found here.)
The Americans with Disabilities Act requires any facility or organization that receives public money to either make itself physically and otherwise accessible, or to make “reasonable accommodations.” This phrase is open to interpretation, but generally means that such facilities and organizations have to make a good-faith effort, within the limits of financial reality, to ensure that people with disabilities receive the same level of service or the same opportunities as those without disabilities. ADA can be used to bring suit in cases where negotiation fails.
The U.S. Supreme Court has recently ruled (2004) that people with disabilities can sue a state when no effort at accommodation is made, and the lack of accessibility is obvious. The case in question was one in which a man in a wheelchair had to leave his chair and crawl up two flights of steps to reach a courtroom where a case in which he was involved was being heard. When he refused to perform this feat a second time later in the same day, he was cited for contempt of court, and successfully sued the state for violation of his rights under ADA.
5. Using outreach to increase access
The term “outreach” covers a lot of ground. It can mean anything from putting information where you hope people will see it to delivering services directly to them in their homes or on the street. The key here is that, in order to use a service, people have to first know it exists, be willing to use it, and be able to use it (i.e., have access to it). Outreach can be used to address any or all of these necessities. An outreach plan is therefore crucial to the use of the other tactics discussed here.
- Outreach to increase awareness. If people don’t know about a service, they’re obviously not likely to use it. Outreach – through the media, public meetings and presentations, home visits, postering, working with community opinion leaders, etc. – can help them find out about what’s available. Such awareness outreach often includes training people from the population you’re trying to reach to act as community educators. Because they have an understanding of the population’s needs and attitudes, and because they are trusted as community members, they can often be more effective than outsiders.
- Outreach to increase willingness. You might reframe a service to make it more acceptable (e.g., more convenient or less embarrassing) to potential users. You might, for example, adjust the way the service is presented or provided to eliminate aspects of it that are objectionable to the culture of potential users.
- Outreach to reduce barriers. Here is where you might bring the service directly to users, either by setting up satellite offices or sites, or by going into homes or the streets with personnel and equipment. Outreach workers who serve the homeless or gang members, for instance, are engaging in this type of outreach.
These outreach workers often demonstrate as well how a combination of all three types of outreach may be needed to serve a particular population. The homeless, for instance, may need information to understand both that they may have a need for, say, TB screening, and that such screening and treatment, if necessary, are available. Outreach workers in this case may be equipped to provide both information and the service itself.
For an intervention or initiative to have an impact, people have to participate in it. The same is true for community amenities – libraries, cultural facilities, hiking trails, etc. – information, and institutions. Healthy products and practices have to be used if they’re to have a positive impact on the lives of individuals or the community.
In all these instances, the important issue is access: the ease with which people can gain it, the barriers that keep them from it, and the opportunities provided for them to take advantage of it. By addressing each of these – and understanding also the factors that lead people toward unhealthy or negative products, practices, and situations – you can enhance access and increase the likelihood of positive social change in your community.
The full ADA accessibility guidelines.
Access to health care for women with disabilities. From 4Woman.gov, the National Women’s Health Information Center.
The Access Project “works to strengthen community action, promote social change, and improve health, especially for those who are most vulnerable. By supporting local initiatives and community leaders, The Access Project is dedicated to strengthening the voice of underserved communities in the public and private policy discussions that directly affect them.”
CDC Video on the obesity epidemic; this video highlights access, barriers, and opportunities related to healthy nutrition and physical activity.
Center for Health Care Access of the League for the Hard of Hearing. Access to health care for the deaf, deaf-blind, and hard-of-hearing.
Closing the Gap. Information sheet on improving access to and outcomes from health and human services for Queensland, Australia, native people.
The Curb-Cut Effect by Angela Glover Blackwell. Laws and programs designed to benefit vulnerable groups, such as the disabled or people of color, often end up benefiting all of society.
The Department of Human Services of the state of Victoria, Australia, reports on efforts to ensure access to human services for individuals with cultural and language differences.
Full text of the Freedom of Information Act (FOIA).
Health Care Access. News releases, commentary, and articles on health care access issues from the Rand Corporation.
The Health Care Action Campaign of the Universal Health Care Action Network.
New York Daily News story on Mayor Bloomberg’s signing of a bill to provide translation to improve access to New York City human services for non-English speakers.
United Way 211. Information on the possibility of a national human service access phone number (211). People in need of human services could dial 211 and be connected to a local information center that would help them find and contact the appropriate service.
The Uninsured and Their Access to Health Care. A fact sheet outlining the uninsured problem from the Kaiser Commission on Medicaid and the Uninsured.
This helpful Worksite CSA Toolkit, developed by the Lawrence-Douglas County Health Department, shares practical guidance on how to start a Community Supported Agriculture program to make subscriptions to fresh, locally-grown produce available at your workplace. Read more about workplace CSA programs, or view related appendices.
McKnight, John. (1995). The Careless Society. New York, NY: Basic Books.