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Community interventions are complex social processes that need to move beyond single interventions and outcomes at individual levels of short-term change. A scientific paradigm is emerging that supports collaborative, multilevel, culturally situated community interventions aimed at creating sustainable community-level impact. This paradigm is rooted in a deep history of ecological and collaborative thinking across public health, psychology, anthropology, and other fields of social science. The new paradigm makes a number of primary assertions that affect conceptualization of health issues, intervention design, and intervention evaluation. To elaborate the paradigm and advance the science of community intervention, we offer suggestions for promoting a scientific agenda, developing collaborations among professionals and communities, and examining the culture of science.

Letters to the editor referring to a recent Journal article are encouragedup to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www.editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at men6@nyu.edu. [ABSTRACT FROM AUTHOR]

Methods for translating the findings of controlled trials, such as the Diabetes Prevention Program, into real-world community application have not been clearly defined. A standardized research methodology for making and evaluating such a transition is needed. We introduce the multisite translational community trial (mTCT) as the research analog to the multisite randomized controlled trial. The mTCT is adapted to incorporate the principles and practices of community-based participatory research and the increased relevance and generalizability gained from diverse community settings. The mTCT is a tool designed to bridge the gap between what a clinical trial demonstrates can work in principle and what is needed to make it workable and effective in real-world settings. Its utility could be put to the test, in particular with practice-based research networks such as the Prevention Research Centers.

A 5-tier pyramid best describes the impact of different types of public health interventions and provides a framework to improve health. At the base of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socioeconomic determinants of health. In ascending order are interventions that change the context to make individuals' default decisions healthy, clinical interventions that require limited contact but confer long-term protection, ongoing direct clinical care, and health education and counseling. Interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and require less individual effort. Implementing interventions at each of the levels can achieve the maximum possible sustained public health benefit.

According to data reported by Leibowitz et al., lack of Medicaid coverage (and, presumably, private insurance) results in lowered circumcision rates.1 We disagree with the authors’ interpretation of these findings and with their concern that poor babies could be deprived of benefits from circumcision. On the contrary, neonatal circumcision places boys at immediate risk for complications,2 methicillin-resistant Staphylococcus aureus,3 and even death.4 Leibowitz et al. should have concluded that poor children are now at lower risk of neonatal circumcision harm. Further, as their data show, it is clearly not just poor children who are not being circumcised. In some US regions, a majority of male babies from all income brackets do not undergo circumcision. Although there is no evidence that boys not circumcised at birth are any less healthy than those who are circumcised, there is evidence of the opposite. For example, the HIV rate in America is far higher than in Europe, where males are rarely circumcised.5 The penile cancer rate is no lower in America than it is in Europe.6 A recent study showed that urinary tract infections occurred in 6 of 24 infants circumcised by a physician (25%) and in 42 of 87 infants circumcised by a religious circumciser; the calculated odds ratio for contracting a urinary tract infection were 2.8 (95% confidence interval = 1, 9.4).7 A comprehensive cost–utility study found that neonatal circumcision's complications and consequences increased health-care costs 742% beyond the cost of the circumcision itself and therefore is not a justifiable public health measure.8 It concludes that if neonatal circumcision were “cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising.”8(p584) Leibowitz et al. reinforce the overly confident notion, created by the extensive media coverage of 3 randomized clinical trials in Africa, that circumcision is partially effective against HIV. In doing so, they ignore both contradictory evidence and the fact that the trial circumstances are not generalizable to Africa, let alone America.9 Even if male circumcision were somewhat effective in reducing HIV infection among heterosexual adults in certain areas of high HIV prevalence, the leap to recommending population-wide neonatal circumcision in the United States is still unjustifiable.10 With nearly 50 million Americans lacking health insurance, and poor children going without many basic services, it is ethically, morally, and perhaps legally inappropriate that any Medicaid program continues to fund an elective and harmful procedure. We applaud the 16 states that have recognized that taxpayers should not be spending money on this unnecessary procedure and the other states that are considering dropping Medicaid coverage. No state should be wasting money on infant circumcision.

Seven dilemmas of evaluation and measurement posed by the nature of health education are presented, together with suggestions for their resolution. These include the dilemmas of : 1) rigor of experimental design vs significance or program adaptability; 2) internal validity or "true" effectiveness vs external validity or feasibility; 3) experimental vs placebo effectsl 4) effectiveness vs economy of scale; 5) risk vs payoff; 6) measurement of long-term vs short-term out-comon. Emphasis is placed on the need to develop a more cumulative data base through standardization of measures, replication of experiments in different settings, and better documentation, reporting, and diffusion of experiences in practice.