Although community health is a popular concept, it lacks a clear working definition in research and practice. One reason is that the concept of community health belongs to multiple disciplines, including public health, medicine, and psychology. An inherently interdisciplinary concept, community health has no one home; however, common elements can be found across disciplines in terms of how it is discussed. Throughout these discussions, community health has been presented as a conceptual framework that can be applied to understand health, a process by which health interventions can be designed and implemented, and an outcome with implications for measurement.
As a conceptual framework, community health offers a view of health as the product of individual and extra-individual factors. This framework moves beyond a traditional focus on person-level factors and reframes both causes of disease and sources of health as interactions between individuals and their social and physical environments. Community health as a perspective is a relatively new concept. The time since 1980 has been cited as seeing enormous growth in the awareness of the need to attend to environmental causes of health. Rather than focusing only on modifying individual behavior, a community health perspective prescribes both behavior- and environmental-based strategies. The rise of this perspective has been credited to the acknowledgment that most public health problems are too complex to be understood simply as a product of individual behavior.
Possibly because of its interdisciplinary nature and lack of one core disciplinary home, the concept of community health is still in its formative stage. In discussing community health as a conceptual framework, researchers have referred to two similar, more established frameworks, including the socioecological model and empowerment theory. Both of these perspectives are based on the assumption that individual and environmental factors come together to influence health and illness, and both offer a set of principles guiding the approach to understanding health and disease, preventing disease, and promoting health.
The socioecological model specifies the following three assumptions: (1) environmental settings have multiple physical, social, and cultural dimensions that affect a variety of individual physical, emotional, mental, and social health outcomes; (2) individual characteristics such as genetics, psychological characteristics, and behavior affect health and, moreover, interact with the environment to affect individual outcomes; and (3) the variety of diverse settings within an individual's life interact to affect health. Community health has ecological roots and similarly views individuals as being nested within a series of embedded systems that are interrelated and interdependent. These systems range from social dynamics to physical organizations and can include families, neighborhood groups, schools, places of worship, government policies, and both explicit and unspoken prejudices. A community health perspective acknowledges the dynamic interaction between the systems in which individuals exist and acknowledges the importance of both systems being able to effectively meet the needs of individuals, and individuals effectively accessing systems of support. A community health perspective sees the effective functioning of these systems as vital to the health of individuals.
Empowerment theory views health as the product of an individual's social, economic, and environmental condition. Using an approach slightly different from the socioecological model, empowerment theory has at its core the need for authentic involvement of community members throughout the process of understanding the contributors to health and disease, and ultimately promoting health. Empowerment theory states that different groups in a society hold different levels of power and that this power affects the control that individuals have over their own health. Under this framework, community health stems directly from the ability of individuals to be involved in decision making in their communities. Empowerment advocates for the creation of more comprehensive networks of support and views healthy relationships between a community and other effective organizations as critical—organizations such as criminal justice systems, school systems, and healthcare providers. Participation is essential to this process as community members are vital to building and maintaining relationships across healthy settings.
Though differing in their approaches to promoting health, these models demonstrate the key assumptions of a community health framework: the recognition of individual and environmental causes of health, a focus on the interaction between individual and environmental factors, and an acknowledgment of the importance of including community members in the process.
Researchers and theorists have also discussed community health as a process, specifically focusing on approaches to intervention. The presumption of health as being defined by both individual and environmental factors necessitates changing not only individual behavior but also those social factors causing disease or preventing optimum health. A community health framework positions community-level intervention as a distinct approach to keeping individuals healthy: The environment can be a protective factor for individual health. Opportunities afforded (or not afforded) by the environment are essential to the health and well-being of an individual. In the reframing of health and disease as interactions between individuals and environments, strategies such as self-help, community development, and social action have been discussed as being key to community health practice. Central to this process is the concept of collaborative practice.
A community health framework advocates collaboration both among individual members of the community and among various community systems. The process of community health involves the mobilization of community members to work collectively on their own behalf; there is an explicit focus on capacity building, which involves the sharing of information, skills, and resources to organize community members into leadership roles. Community members are involved in the process of understanding the contributors to health and disease, as well as the delivery of health interventions. Community health acknowledges that no one knows the community better than its members; as a result, these individuals can play an important part in recognizing barriers to health in their communities as well as making decisions about how to address these barriers. These collaborations can lead to more authentic, effective, and sustainable interventions.
Collaboration among community organizations provides an overall environment of care for individuals. Because this step can appear more daunting than the task of involving individual community members in the health promotion process, efforts have often fallen short of coordinating various needed systems to create healthy systems of care. Calls have been made for better integration among community organizations as essential to facilitating the health of community members, and research has begun to demonstrate that organizational and environmental infrastructure and support are essential to the effectiveness of health-related programming. However, more needs to be done. A community health approach advocates for a series of systems that provide what is needed for a diverse group of individuals to stay healthy: healthcare systems that reach out to multiple groups of people in culturally appropriate ways, educational systems that meet the needs of a diverse group of learners, employment and recreational opportunities for those with varying ability levels, opportunities for the building of social connections and exchange of social support, and neighborhood environments that promote physical safety and protection from environmental pollutants. To be effective, a key requirement is that these systems should work in concert with each other, offering multiple opportunities for personenvironment fit, in that individual needs and resources are complemented by the multiple environments in which a person lives.
A number of efforts have been made to lay the groundwork for community health practice. For example, in the early 1990s, the Minnesota Heart Health Program developed an intervention to foster heart health in three communities. It began with a survey intended to identify community leaders who would then be asked to become members of an advisory board with government officials and health professionals to provide guidance on programs, health education campaigns, and related policy. This effort resulted in a public education media campaign and a number of programs involving multiple organizations in the community, including school curricula on smoking, exercise, and nutrition; and an annual communitywide quit smoking contest and work site smoking policy planning assistance. An evaluation of the program demonstrated greater participation in heart disease health promotion and a greater sense of “social connectedness,” although more so among stable organizations whose current needs and interests were in line with the goals of the intervention.
A number of guidelines for community health promotion programs have been developed. Many emphasize the importance of understanding the relevant aspect of the social and physical environment, which can influence a variety of health outcomes, as well as the interactions between these environmental characteristics and pertinent individual factors. Once these factors and interactions are better understood, interventions can be developed to enhance the person-environment fit, which can occur when individuals enjoy a high degree of control over their environment and are able to modify it according to their needs. Interventions can therefore work to facilitate the flexibility and responsiveness of social and physical environments. An important part of health promotion programs not mentioned is the need to teach individuals to be aware of and advocate for the types of settings and setting characteristics that they need.
Community health can also be discussed as an outcome. What does a healthy community look like? Following from the above, a healthy community is free from physical violence, environmental pollutants, disease, and discrimination. Furthermore, it is one in which community members are active and involved in decision-making processes, systems of care are coordinated and accessible to all community members, and multiple opportunities are available for person-environment fit. A healthy community focuses on keeping its members healthy through disease prevention and health promotion as well as providing effective treatment for those who are sick. These are but some of the characteristics that operationalize the theory and process presented above.
In addition to discussing how to achieve these outcomes, it is also important to discuss how such outcomes can be monitored and measured. The measurement of community health presents a challenge because of the complexity of the concept. The fact that community health views health as an interaction between individual, social, and physical environmental factors necessitates the measurement of at least three constructs: (1) individuals, (2) the environment, and (3) the interaction between them. Currently, the most sophisticated measures are available for individual-level constructs. For measurements of individual outcomes, morbidity and mortality rates can be computed, which permit a picture of the health of a group of people to be obtained. For example, mortality rates from heart disease, cancer, and stroke can be used to assess the physical health of a community. Examining these rates can be helpful in understanding trends in health and disease, particularly in understanding health disparities between subgroups of the population.
Techniques related to both environmental assessment and the measurement of individual-environment interactions need further development; however, strides have been made regarding extraindividual assessment. Environmental assessments developed to date can be divided into two broad categories: (1) those that assess the environment subjectively (i.e., from the perspective of individuals assessing that environment) and (2) those that assess the environment more objectively. Examples of the former include the variety of environmental scales developed that allow individuals to rate their satisfaction with different aspects of their environment. Such measures have been adapted to classrooms, family environments, and work settings. Examples of the latter involve counting up the number of businesses in a community with handicap-accessible entrances or the number of available health clinics in a community. Each of these broad classes of measurement provides important information about the environment, with the subjective measures actually providing some information about the interaction between an individual and his or her environment and the objective measures providing information about the environment that perhaps individual community members cannot observe or will not report. Ideally, these measurement strategies should be used to complement each other in describing the environment.
Finally, efforts must be made at assessing the interaction between individuals and the environment to understand how it affects health. In addition to the subjective environmental measures discussed above, measures of the individual and environmental components of community competence can also assist in approximating this interaction. Community competence involves two components: (1) the competence of community resources in meeting the needs of individual community members and (2) the competence of individuals in accessing these resources. Assessing the first component involves measuring the effectiveness of various social systems, for example, the healthcare, education, employment training, housing, and criminal justice systems. Evaluation research has made strides in developing methodologies for assessing the process and outcomes of such service delivery systems. Assessing the second component involves measuring an individual's ability to effectively use resources in the community. Viewing results of both types of assessments can begin to uncover the level of fit between individuals and their communities.
The task of measuring these multiple components can become overwhelming, particularly as multiple methods (e.g., surveys, observations, and health records) are necessary for capturing the multiple components and levels of analyses involved in the health equation. How then can variables be identified for study? How can health professionals and researchers decide on a course of action in intervention? One approach is to use strategies based on “middle-range” theories of the variety of factors that contribute to and are likely to alleviate a particular health problem. Assessing and attempting to either eliminate or bolster a set of variables thought to affect the condition in question provides a productive start to understanding health.
The concept of community health advocates for health as the product of the individual and his or her environment. A community health approach involves enhancing the environment to become more health promoting as a way to facilitate individual health. One vehicle for action includes public health policy. Each of the different levels of community health—framework, process, and outcome—includes a number of overlapping implications for public health policy.
Working within a community health framework, public health policymakers must acknowledge and address individual and environmental factors, and the interaction between them, as the determinants of health. The community health perspective broadens what is considered “public health” policy because every aspect of society potentially affects health. Public health policy should therefore focus not only on topics that are clearly related to health but also those whose linkages may not be as explicit. Examples include promoting community development, creating safe communities with functioning resources, and allocating resources in such a way to build a solid infrastructure both with and between communities for health-promoting initiatives to thrive. Policy around the implementation of services and programs should mandate a thorough assessment of the local community resources and needs, building on the former to address the latter. Furthermore, policies across the board should promote citizen participation: Authentic opportunities for community members to be involved in making decisions about their communities should be built in as an essential part of the process. An understanding of the relevant individual and environmental characteristics affecting health is critical to beginning any type of policy initiative.
Community health provides a conceptual framework, a set of intervention guidelines, and outcomes to target by understanding health as a product of individual and environmental factors. Because community health is a relatively new concept, the specific mechanisms by which environments interact with individual factors in affecting individual health have not been understood well. Further work must continue to identify the process by which these interactions occur and foster health promoting communities to positively affect the health of individual community members.
Disease, Epidemiology, Health, Health Disparities, Health Planning, Medical Sociology, Preventive Care, Public Health
American Public Health Association (APHA): http://www.apha.org
Association for Community Health Improvement (ACHI): http://www.communityhlth.org
National Association of Community Health Centers (NACHE): http://www.nache.com
National Rural Health Association (NRHA): http://www.nrharural.org
World Health Organization (WHO): http://www.who.int
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