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Anne McMurray and Jill Clendon advance the discussion of health as a product of the interaction between people and their environment. The social, cultural and political determinants that affect …

Anne McMurray and Jill Clendon advance the discussion of health as a product of the interaction between people and their environment. The social, cultural and political determinants that affect individual and community health are explored from a multidisciplinary perspective and based on extensive research. Gender and cultural inclusiveness provide an essential backdrop to evidence-based policy, research and the provision of equitable health care for all.

Written in an engaging style, this new edition features a common case study running throughout the text. ‘The Miller Family’ case study evolves so that the issues examined in each chapter are played out by each of the family members. The extended family crosses Australia and New Zealand and provides examples of Primary Health Care issues in both countries including accessing care, child health services, adolescent health, contemporary family issues, ageing, cultural support and inclusive healthcare.

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  • 1. Anne McMurray Jill Clendon
  • 2. Community Health and Wellness 4Primary Health Care in Practice
  • 3. Anne McMurray Jill ClendonSydney Edinburgh London New York Philadelphia St Louis Toronto
  • 4. Contents Foreword About the authors Preface Acknowledgements Reviewers Section 1 Healthy people, healthy places 1 Introduction to the section 1 Chapter 1 Health as a socio-ecological concept 5 Introduction 5 What is health? 7 Health and wellness 7 Defining ‘community’ and ‘community health’ 9 Community health and wellness 9 Social determinants of health 11 The role of communities in intergenerational health 13 Social capital 14 Sustainable community health 15 Community development: helping communities change 16 Health literacy 17 Research to practice 20 Case study: meet the Millers 22 Reflecting on the big issues 22 Reflecting questions: how would I use this knowledge in practice? 23 Researching practice: intergenerational health 24 Chapter 2 Primary health care: principles and practices 28 Introduction 28 Clarification of terms 29 Primary health care (PHC) 29 Primary, secondary and tertiary prevention 30 Primary care 30 Public health, population health and primary health care: a brief history 32 Population health 32 Primary health care and the Declaration of Alma Ata 33 Problems with the ‘old public health’ era 33 PHC and the social gradient 34 PHC and the health promotion charters 34 PHC principles 36 Accessibility: a case of equity and social justice 36 Appropriate technology 37 The ethics of appropriate technologies 38 Increased emphasis on health promotion 39 Health education 39 Cultural sensitivity, cultural safety 41 v
  • 5. CONTENTS Intersectoral collaboration 42 Public participation 43 Community health promotion: the Ottawa Charter for Health Promotion 44 Implications for community health promotion 45 Leadership, professionalism and citizenship 46 Case study 48 Reflecting on the big issues 48 Reflective questions: how would I use this knowledge in practice? 48 Research-informed practice 49 Chapter 3 Promoting health in an era of globalisation 53 Introduction 53 Globalisation 53 The pros and cons of globalisation 55 Globalisation as a health promotion variable 56 Health promotion strategies for global health 57 Health as security 58 Health as development 58 Health as a global public good 60 Health as a human right 61 Building the evidence base: the population approach 61 The global burden of disease project 62 The epidemiology of health and public health 62 Social epidemiology 64 Health and place 65 Healthy cities 66 The healthy cities movement 67 Health promotion planning: diarrhoea and dirt to community activism 67 Community-wide health promotion and the ‘new health education’ 68 Community assessment: health planning for the enabling community 70 Phase one: the lay of the land 71 Phase two: mapping resource 72 Phase three: who will help? 73 Phase four: people, place, health and gatekeepers 73 Phase five: strengths, weaknesses, threats, opportunities 73 Case study 74 Reflecting on the big issues 74 Reflective questions: how would I use this knowledge in practice? 75 Research-informed practice 75 Chapter 4 Enabling health and wellness: practice roles and models of care 79 Introduction 79 The role of nurses and midwives in promoting social justice 79 Nurse practitioners and advanced practice: models of practice 80 Experiences in the UK: public health, population health and role development 83 Primary health care roles: specialist or generalist? 84 Practice nursing: Australia 85 Practice nursing: New Zealand 86 Managing chronic conditions in the community 87 Child health nursing practice 89 School health nursing 90 Rural and remote area nursing practice 94vi
  • 6. Contents Paramedic practice in the community 96 Community mental health nursing practice 97 Occupational health nursing 99 Collaborative models of nursing and midwifery in the community 102 Helping people change 103 Case study 105 Reflecting on the big issues 105 Reflective questions: how would I use this knowledge in practice? 106 Research-informed practice 106Section 2 Sustainable health for the family and the individual 116Chapter 5 Healthy families 119 Introduction 119 The family, community and society 119 Defining the family 121 Family functions 121 Family developmental pathways 122 Changing families, changing partners, changing roles 123 Fertility, child bearing and population trends 126 Families and work 127 Casualisation, part time work and parental leave 128 Work and stress 128 Gender issues and work 129 Fly-in-fly-out families 130 Couple relationships 132 Social influences on couple relationships 133 Relationship satisfaction 133 Healthy couples, healthy families: communication and resilience 134 Communication and power 135 Communication and change 135 Adaptation and resilience 136 Marriage, separation, divorce and parenting 136 Divorce and parenting 137 Divorce and the blended family 138 The impact of divorce on parents 138 Non-resident parenting 138 Parenting and child support 139 Divorce and the rights of the child 139 Violence in the family 140 Intimate partner violence 141 IPV and the children 142 Migrant families and health 143 Migration and family life 143 Migrants, refugees, stress and coping 143 Families dealing with illness 144 Family caregiving issues 145 Caring for children with disabilities 146 Caregiver stress 146 Rural families 147 Social determinants of the health of rural families 148 Family life in the 21st century 148 Goals for healthy families 149 vii
  • 7. CONTENTS Building healthy public policy 149 Marriage policies 149 Parental and children’s rights policies 150 Policies protecting human rights and non-violence 150 Inclusive policies 151 Policies for vulnerable families 151 Policies protecting the community 152 Creating supportive environments 152 Parent groups 152 Culturally inclusive support 153 Strengthening community action 153 Supporting family decision-making 154 Family support in the workplace 154 Family advocacy 154 Developing personal skills 155 Supporting civic participation 155 Supporting family relationship skills 155 Reorienting health services 156 Assessment and screening 156 Family-centred care 156 Health professionals 157 Evidence-based practice 157 Case study 158 Reflecting on the big issues 158 Reflective questions: how would I use this knowledge in practice? 159 Research-informed practice 159 Chapter 6 Healthy children 166 Introduction 166 The healthy child 167 Biological embedding and childhood stress 168 Socio-economic factors and childhood stress 168 Global child health, disadvantage and poverty 169 Children and homelessness 171 Indicators of child health in Australia and New Zealand 171 Health indicators for Indigenous children 172 Chronic illnesses in childhood 172 Nutrition, physical activity and the social determinants of child health 173 Breastfeeding 174 Healthy pregnancy 175 Antenatal care 176 Childbirth 176 Postnatal depression 177 Children’s psychosocial wellbeing 178 Mental ill health 179 Learning readiness and social development 179 Resilience 180 Parenting patterns and children’s health outcomes 181 Family lifestyle practices 182 Obesogenic environments 183 Keeping children safe 184 Critical pathways to child health 185 Goals for child health 186viii
  • 8. Contents Building healthy public policy 187 Collaborative policy development 188 Creating supportive environments 190 Strengthening community action 192 Developing personal skills 193 Reorienting health services 193 Case study 195 Reflecting on the big issues 195 Reflective questions: how would I use this knowledge in practice? 196 Research-informed practice 196Chapter 7 Healthy adolescents 203 Introduction 203 The development of social competence 204 Social determinants of adolescent health, risk and potential 205 Identity and body image: weight management and eating disorders 205 Eating disorders and family life 207 Risky sexual behaviours 207 Compounding risk: alcohol, drug use and tobacco smoking 209 Depression, self-harm, and suicide 210 Recognising the risk of suicide 211 Adolescent life in the community context 212 Adolescent life in the school context 214 School, home and social networking 214 Risk, resilience and decision-making 216 Hope and self-esteem 216 Countering risk: healthy adolescence 218 Goals for adolescent health 218 Building healthy public policy 218 Harm minimisation policies 219 Creating supportive environments 220 Supporting parenting 221 Strengthening community action 222 Developing personal skills 223 Reorienting health services 225 Electronic media, risk and support 225 Case study 229 Reflecting on the big issues 229 Reflective questions: how would I use this knowledge in practice? 229 Research-informed practice 230Chapter 8 Healthy adults 235 Introduction 235 The healthy adult 235 Risks to health 236 Adult morbidities 237 Stress in adult life 238 Lifestyle and chronic disease 238 Rural lifestyle risks 241 Stress, mental health and the social determinants of health 242 Positive mental health and wellbeing 243 Social exclusion and mental ill health 244 Family stress 245 ix
  • 9. CONTENTS Stress in the workplace 245 Other workplace health and safety issues 247 Stressful working conditions 248 Environmental factors affecting adult health 250 Healthy adulthood 251 Goals for adult health 251 Building healthy public policy 252 Creating supportive environments 253 Strengthening community action 254 Developing personal skills 255 Reorienting health services 256 Case study 257 Reflecting on the big issues 258 Reflective questions: how would I use this knowledge in practice? 258 Research-informed practice 259 Chapter 9 Healthy ageing 265 Introduction 265 Ageing and society 265 Population ageing 267 Global ageing perspectives 267 Risk and potential in older persons 269 Weight and mobility in older age 271 Physical activity and ageing 271 Mental health issues 272 Health and place 273 Safe environments for ageing 275 Elder abuse 276 Social and spiritual support 276 Maintaining dignity in coping 277 Critical pathways to ageing 278 Transitions: challenges and opportunities 279 Workplace and retirement transitions 279 Transitions to single ageing or widowhood 279 Transitions in intimacy and sexuality 280 Transitions to the end of life 281 Resilience and health in older age 282 Goals for healthy ageing 283 Building healthy public policy 283 Creating supportive environments 284 Strengthening community action 285 Developing personal skills 286 Reorienting health services 286 Case study 288 Reflecting on the big issues 288 Reflective questions: how would I use this knowledge in practice? 289 Research-informed practice 289 Section 3 Inclusive communities and society 294 Chapter 10 Health and gender: healthy women, healthy men 297 Introduction 297 Inequality, social exclusion and gender 298 Empowerment 299x
  • 10. Contents Women’s health issues 300 Women and social disadvantage 303 Intimate partner violence and empowerment 304 Men’s health issues 306 Men’s lifestyles and health 307 Men’s health risks 308 Masculinity, behaviour, and the men’s health movement 309 The need for men’s and women’s health policies 310 Men, women and intimacy 310 Gender issues among sexually diverse populations 311 Gendering society: goals for the health of men and women 312 Building healthy public policy 313 Creating supportive environments 314 Strengthening community action 315 Developing personal skills 316 Reorienting health services 317 Case study 319 Reflecting on the big issues 319 Reflective questions: how would I use this knowledge in practice? 320 Research-informed practice 320Chapter 11 Cultural inclusiveness: safe cultures, healthy Indigenous people 325 Introduction 325 Culture and health 326 Culture conflict 327 Cultural safety 328 Multiculturalism 329 Ethnocentrism to racism 329 Aboriginality, culture and health 331 Indigenous people’s relationships between health and place 331 Colonisation and disconnection between health and place 332 Culture blindness and the stolen generations 334 The health of Indigenous people throughout the world 334 The health of Australian Indigenous people 335 The health of New Zealand Maori 337 Behavioural risk factors 338 Mental health and healing 339 Injury and family violence 341 Addressing the problems through healing and empowerment 342 Building capacity and social capital 342 Goals for Indigenous health 344 Building healthy public policy 344 Creating supportive environments 347 Strengthening community action 348 Developing personal skills 349 Reorienting health services 351 Case study 352 Reflecting on the big issues 353 Reflective questions: how would I use this knowledge in practice? 353 Research-informed practice 353 xi
  • 11. CONTENTS Chapter 12 Building the evidence base: research to practice 359 Introduction 359 Global community health research 360 Social determinants of health and the research agenda 362 Conducting research for policy and practice 363 Evidence-based practice 364 Systematic reviews, literature reviews, integrative reviews and meta-analysis 364 Randomised controlled trials 365 Sources of evidence 366 Translational research 367 Community-based research partnerships 369 Action research 369 Participatory action research 370 Researching the community: paradigms and strategies 371 Case study research 371 Mixed methods 371 Researching culture 373 Researching with Indigenous people 374 Researching the future 377 Getting started: from research question to solution 380 The question 381 The argument 381 Conceptual framework 381 Method 381 Research ethics 382 Findings/results 382 Discussion 382 Case study 383 Reflecting on the big issues 383 Reflective questions: how would I use this knowledge in practice? 384 Research-informed practice 384 Chapter 13 Inclusive policies, equitable health care systems 388 Introduction 388 Politics, policy-making and health care 389 Health services policies and the social determinants of health 391 Rural health policies 391 Health promotion policies 391 Community development policies 392 Policy-making and primary health care 392 Policy action at the national level: think global, act local 393 The need for policy integration: lessons from mental health 393 Social policies and family life 394 The New Zealand health care system 396 The Australian health care system 399 Health sector reform in Australia 401 Recommendations for change 402 Health care: building a better system 403 Best practice in health care systems 404 Concluding comments 405 Case study 406 Reflecting on the big issues 406xii
  • 12. Contents Reflective questions: how would I use this knowledge in practice? 406 Research-informed practice 406Appendices x Appendix A Symbols used in a genogram x Appendix B Jakarta Declaration on Leading Health Promotion into the 21st Century x Appendix C People’s Health Charter x Appendix D The Bangkok Charter for Health Promotion in a Globalised World x Appendix E Chart for community assessment x Appendix F Transforming Australia for our children’s future: making prevention work x Appendix G HEEADSSS assessment tool for use with adolescents x Appendix H xIndex x xiii
  • 13. PrefaceThis book represents the culmination of our those who live there. Nursing and midwifery prac-knowledge of what makes a community healthy, tice ‘in the community’ involves all actions that areand how nurses and midwives can support com- undertaken to support people’s health and wellbe-munity health and wellbeing. In preparing the text, ing. Nursing ‘the community’ means caring for thewe have attempted to combine global insights with community itself. To meet both of these importantthose that emerge from our trans-Tasman knowl- goals nurses and midwives bring to families andedge base to form a common yet distinctive foun- communities an evidence-base of knowledge thatdation for practice with communities of the 21st includes understanding physical and psychologi-century. Throughout the book, community health cal health, the social and cultural determinants thatis conceptualised as a socio-ecological construct. support or impinge on health, and features of theAlthough the study of ecology is not new, see- community that support health. The latter includesing health as an ecological concept broadens our the physical environment, health and social ser-understanding of health by situating it within the vices, and the infrastructure that supports health.physical, cultural, social, spiritual, and employ- The penultimate goal of community health isment settings of daily life. People are inÀuenced community competence. This is a developmentalby their environments: anywhere they work, play, process integral to community health, which situ-study or live; their home, work and/or school, ates nursing and midwifery practice within strate-recreational settings, cities, towns, villages and gic partnerships rather than patronage. Workingcamps; and places they go to receive or provide co-operatively and in partnership with family andassistance, enact their religious beliefs, and nego- community advocates, we can function as en-tiate and transact the exchanges of daily life. This ablers and facilitators of community health, en-is also reciprocal. When people interact with their couraging community participation in all aspectsenvironments, the environments themselves are of community life.energised, revitalised, and often changed. These Another perspective threaded throughout thisreciprocal inÀuences on health are most evident book is the link between global and local condi-in the family and community, where the social de- tions, often seen in the expression think global, actterminants of health create an interplay of factors local. Our global connections provide informationthat have a profound effect across the lifespan. about newly discovered illnesses and mutations ofThis text examines the inter-relatedness of the so- causative agents springing up around us, perhapscial determinants of health throughout the various because of the state of the world, perhaps becausechapters, indicating appropriate areas for nursing of our expertise in surveillance and detection, per-and midwifery intervention and health promotion. haps both. At the same time, there is a widening Interaction is central to the ecological view of gap between those with the opportunity to availhealth. So too are the notions of place and par- themselves of advice and support for their choicesticipation; both of which are integral to commu- and pathways to health and wellbeing, and thosenity health. Nurses and midwives working with who are marginalised from the mainstream. Sadly,families and communities play an important role it is often those most disadvantaged by distancein supporting and nurturing people. They also play from services or the means to access them whoa vital role in helping ensure that the community are most vulnerable to ill health. Their situationitself is viable and sustainable, and that it has the may also be compounded by genetic endowment,resources to support people in their quest for good impoverished lifestyles, and the kind of politicalhealth. In this respect, the role of nurses and mid- decisions that keep them in a perpetual cycle ofwives is multi-dimensional. This means that there despair. Some years ago, a popular view was thatare two areas of focus: the community itself and if populations were given the opportunity to create xix
  • 14. PREFACEwealth, their health status would improve. How- social circumstances, or a combination of theseever, today we have come to realise that, despite factors. We therefore add an intergenerational ap-many nations having greater wealth, knowledge proach to working with individuals, families andand health expertise, health services do not always communities, considering the future outcomesget to those most in need. This is called ‘Moder- that may result from current circumstances.nity’s Paradox’; the situation where, despite the Community participation is a cornerstone ofrelative wealth of a society there remains an ever- community health. Maintaining an attitude ofwidening gap between rich and poor. The dispar- inclusiveness is one way we can encourage com-ity between the health of the rich and poor has munity members to become authentic partners inbecome even more problematic with the global securing and shaping their health and the health of¿nancial crisis having disproportionately affected their community. Inclusive communities are thethose already living in poverty. For those societies main focus of Section 3. Within the chapters ofalso living with civil strife and conÀict, commu- this section we suggest approaches that promotenity health often seems like an untenable goal. cultural safety and sensitivity in helping Indig- Our knowledge base for helping communities enous people and others disadvantaged or dis-become and stay healthy has evolved dramatical- criminated against, to develop their capacity forly over the past decades. We have a greater under- change. To accomplish this we need to use knowl-standing of the structural and social determinants edge wisely, which means that we need evidenceof health. We also know with some certainty that and innovation for all of our activities. Clearly, ourwhat occurs in early life can set the stage for professional expertise rests on becoming researchwhether or not a person will become a healthy literate and developing leadership skills for bothadult and experience good health during ageing. personal and community capacity development.This is called a ‘pathways’ approach to health. Using both sets of skills courageously has theAlong a person’s life pathway from birth to death potential to assist communities to reach towardlie a vast number of risks to good health, as well greater levels of health, vibrancy and sustainabili-as opportunities for intervention. It is helpful for ty for the future. To illustrate, we present a samplenurses and midwives promoting health to know of community health research studies that con-the points of critical development and age-appro- vey the essential notion that practice is based onpriate interventions. We outline some of these in knowledge and research evidence. Section 3 alsoSection 2 of the book, which addresses healthy addresses the research and policy interface, em-children, healthy families, healthy adults and phasising the importance of evidence-based andolder persons. After nearly a quarter of a century, evidence-informed practice to develop policiesthe Ottawa Charter is still the most useful guide that promote and sustain health and wellbeing.for strategic health promotion planning with each Throughout the book we accompany ‘the Millerof these groups. The Charter guides intersectoral family’, as they experience community life withcollaborations for community empowerment, its challenges and potential. The Millers are anwhere citizens work in partnership with health extended family of Australian and New Zealandprofessionals to achieve access, equity and self- residents, some of whom reside in Sydney, oth-determination in establishing health goals and ap- ers in a rural town on the South Island of Newpropriate processes for achieving them. We use Zealand. We follow the journey of The Millersthe symbol of the Ottawa Charter in each chapter as they experience childbirth, child care, adultin Section 2 to signal that the discussion is moving health issues, and some of the threats to theirtoward the challenges and solutions in assisting communities. We hope you enjoy working withpeople to work towards healthy public policies, them during their journey, and develop a deepercreating supportive environments, strengthening sense of their family development through a se-community action, developing personal skills and ries of genograms each time new members joinreorienting health services. the family. At various stages of the chapters we The rapid expansion of research knowledge also have added ‘points to ponder’ and interactive ac-indicates that states of health and illness can be tivities to stimulate your thoughts on communitypassed on through different generations, either by health. We also urge you to be thinking of the ‘bigbiological factors such as genetic endowment, or issues’, which will be outlined in the reÀectivethrough the transmission of similar or worsening section at the end of each chapter.xx
  • 15. Section 1 Healthy people, healthy placesChapter 1 Health as a socio-ecological conceptChapter 2 Primary health care: principles and practicesChapter 3 Promoting health in an era of globalisationChapter 4 Enabling health and wellness: practice roles and models of care
  • 16. INTRODUCTION TO THE SECTIONThe four chapters that introduce this text provide a Two critical, inter-related concepts are funda-foundation to help frame what we understand about mental to inclusive communities: empowermentcommunities in contemporary society, and how and health literacy. Community empowermentcommunity health and wellness is achieved and is possible when members of a community havemaintained. Chapter 1 explains health as a socio- genuine opportunities and support for healthecological concept; that is, how health and well- decision-making. Such decisions are informed bybeing is shaped through their interactions in the adequate, appropriate and useful knowledge; thatenvironments of people’s lives. We also examine is, health literacy. A health literate community isthe integral concepts of community participation one where people are not only aware of the thingsin creating and maintaining health, and the impor- that keep them healthy, but they feel con¿dent andtance of place in health. A large part of nursing comfortable making choices that inÀuence theirand midwifery work with communities is framed health, and they are comfortable working withwithin our knowledge of the social determinants health professionals to improve their health andof health (SDOH). The chapters in Section 1 pro- the health of their community.vide an in-depth examination of the SDOH, which Health literacy and community empowermentis a major theme elaborated throughout the book. are illustrated throughout the section, and through- As we outline in Chapter 2, for those of us advo- out the text, as central themes in health promotion.cating for community health, the principles of If people have a functional understanding of theprimary health care (PHC) continue to guide our reasons they are being urged to create a smoke-freeactivities. The PHC principles situate people’s aspi- environment, grow healthy foods for consump-rations for health within an ethos of social justice. tion, and lobby their local government for spaceThe challenge of PHC lies in promoting conditions to engage in a physically and socially vibrant life-that would provide equity and access to supports, style, they are more likely to participate in thesecare and services for all members of a community aspects of healthy lifestyles. If they are able toor a population. The strategies for achieving this access appropriate and accurate information onare intersectoral collaboration, appropriate use of the internet to help alleviate any health problems,technology, and cultural sensitivity. These strate- this can also be helpful. And when they are in thegies are explained further in Chapter 2, as a way of process of recovery from illness or rehabilitation,promoting health in the settings of people’s lives; health literacy can help allay fears and anxietieshealthy neighbourhoods, healthy schools, healthy by providing greater predictability in their path-workplaces and places of worship, healthy villages, way to better health. Importantly, members ofcities and communities. Health promotion is aimed health literate communities can become a resourceat developing inclusive communities, which are for others who may need a greater understandingable to develop their capacity. Nurses and midwives of the structural and SDOH as a basis for makingassist this process using a comprehensive primary appropriate choices for good health.health care approach, which supports all aspects of Chapter 3 extends the discussion of health pro-community life, helping to conserve what is special motion to the global community. Included is anand helpful, and assisting them in countering what is examination of health information and the healthnot. Other activities are aimed at selective primary issues that unite nurses and midwives across thehealth care, which is a more targeted approach, world. In this era of rapid communication throughwhere speci¿c groups or issues are given priority technology, we hear much about the perils of theattention. The chapter also includes an explanation internet, and the constant texting and emails thatof other terms related to PHC, including primary enslave many of us in our daily work life. How-care, and primary, secondary and tertiary levels of ever, these tools have also brought us closer tocare, all of which are linked, but separate concepts. the global community. We see examples on the
  • 17. COMMUNITY HEALTH AND WELLNESSinternet of what works elsewhere in achieving The path to achieving and enhancing commu-health. The information we share across the globe nity health also extends the ‘think global, act local’also provides those of us in research with better catchcry of the last century, to the Millenniumtools, stronger evidence for health care, and a con- Development Goals, which urge us to counternection with like-minded people who also spend poverty and ignorance, to feed, clothe and edu-their lives nurturing communities. This can be pro- cate the vulnerable among us and to help eradicatefessionally empowering, particularly if our inter- the modern plagues, such as HIV/AIDS, malariaventions are based on research ¿ndings. Various and other diseases. Such lofty initiatives compelaspects of electronic communications technology us towards economy of effort; to plan strategi-have a direct effect on health. For example, text cally for health promotion and services to assistmessaging is currently being used for appointment those most in need. Because there is such widereminders and as prompts for taking medications variability among people and the environmentsand other treatments. The technology is also a that shape their lives, our services must not onlyway of social connectedness, letting people know be multi-dimensional, but Àexible and adaptable.they are not alone, and where opportunities exist In all communities, health is a careful balanceto socialise with others. However, there is also a between the capabilities, aspirations and health-downside to having so much information. Every related needs and goals of individuals, variousday, people are bombarded by media advice, some groups of people, and the whole population. Givenof which they seek out, other which arrives in their that these dynamic features of community healthlives surreptitiously or because it is a part of the are intertwined within a myriad of contextual fea-kaleidoscope of community life. In the face of an tures, our work should be designed to help peopleinformation overload, people rely heavily on pro- manage their own lives. As Chapter 4 explains, wefessional advice to guide them as they sift through can become fully engaged with our communitythe onslaught of messages, trying to make sense some of the time, and sit as a ‘guide on the side’ atof information related to their health and lifestyle. other times, but always using our expertise and ourAs it is often said, we have too much information, evidence as resources to their efforts.not enough knowledge. Healthy communities are dynamic, constantly Certain aspects of contemporary life such as changing as people respond to the circumstancesinternational travel have clearly entrenched the of their life and their environments, and as theynotion that we are all members of the global com- make decisions that help develop their com-munity, and this is also explored in Chapter 3. munity’s health capacity. Positive interactionsThose who seek novelty in far-off horizons change environments, conserving what is pre-quickly learn that community health is not only cious, rejecting inÀuences that could be destruc-multidimensional, but unique in each setting. tive. In a perfect world, there would be no needBeing mindful of global health issues also helps for health professionals to meddle in these inter-us benchmark the health of our community in actions, but we all live in situations that could beterms of PHC goals. Interactions within and improved. As health professionals we can helpbetween communities helps us understand the inform community members about the political,dynamics of global health risks such as those cre- economic and cultural conditions within whichated by global warming. The effects of a warming health can be developed. Our role in the commu-planet have wreaked havoc on some communi- nity also involves acting as a resource, using ourties, displacing people from their homes and scienti¿c knowledge to help promote and preserveexacerbating existing inequities. Knowing how health and treat illness. Chapter 4 also explores thethese and other weather events can impinge on advocacy role of nurses and midwives, suggestinghealth heightens our awareness of the need to that it is an ever-changing role, as we argue forbe globally inclusive, to work towards address- service improvements, or for environmental anding the needs of the marginalised and vulnerable social changes that will help individuals Àourishamong us and those beyond our shores. Accepting and grow.the responsibility of nurses and midwives to pro- Because PHC has become integral to profes-mote health through political activism is a crucial sional practice in both Australia and New Zealandand necessary response to the inequities caused we examine the PHC roles in the context of vari-by globalisation. ous models of practice. Since 2001, New Zealand2
  • 18. Healthy people, healthy placeshas been leading the world in policies and practices innovate and implement strategies to help commu-that embed PHC as a national strategy to promote nities reach their potential. Our new and existingpopulation health. More recently, the combined roles and models of care are constantly shaped bynursing and midwifery organisations in Australia the circumstances of community life. Competentand ¿ndings from a number of national reviews enactment of our roles requires attention to thesehave developed a consensus position that PHC is, contexts and situations to establish a pathwayin fact, the way to approach health improvements towards excellence in enabling health and well-across demographic groups and across health ser- ness through a holistic, partnership approach withvice settings. In providing exemplars of good and the community.best practice we provide a template for others to 3
  • 19. Chapter 1 Health as a socio-ecological conceptINTRODUCTIONFor most people, the notion of ‘community’ is a They include educating communities and govern-friendly term, conjuring up a sense of place, a sense ments on the structures and supports conduciveof belonging. Healthy communities are those places to good health, minimising risks to ill health orwhere belonging is valued, where the connections injury, and guidance to support recovery and sus-between individuals, families and the environments tainable health. The basis for this type of work isof their lives are as important as the life forces a combination of foundational knowledge, havingwithin. This is essentially an ecological relation- the intellectual curiosity to seek out and, in someship. Ecology embodies the idea that everything is cases, generate research evidence for interven-connected to everything else. Health is both a social tions, and social engagement with the commu-and ecological phenomenon, in that it is created nity. Together these equip the nurse, midwife orand maintained in the context of community life. other health practitioner with the skills for ongo-Although as individuals we can experience relative ing surveillance and monitoring, intervention andstates of health or ill health because of our biological evaluation strategies, and political advocacy tomakeup, these are manifest within the social ecol- lobby for family and community resources andogy of a community. Health is therefore dynamic, supports.changing as a function of the myriad interactions Promoting the health of any community is there-between biology and our genetic predispositions, fore a multifaceted role. It is based on the holistic,and the psychological, social, cultural, spiritual and socio-ecological perspective of health. Its philo-physical environments that surround us. sophical foundation is entrenched in the World As health professionals our role spans across the Health Organization’s (WHO) de¿nition of health,health–illness continuum. The role of any commu- where it is not seen as one-half of a dichotomynity nurse, midwife, or other health professional of health and illness, but ‘a state of completeranges from preventing illness to protecting people physical, mental and social wellbeing and notfrom harm or worsening health once they have merely the absence of disease or in¿rmity’ (WHOexperienced illness, to recovery and rehabilitation. 1974:1). This de¿nition of health also reÀectsCommunity practice also involves a parallel role the growing body of research evidence outlin-to protect communities from harm or stagnation, to ing the importance of the social determinants ofhelp community citizens build capacity for future health (SDOH). Researchers have found that thedevelopment, and to work in partnership with the SDOH are even more inÀuential on the healthpopulation to restore their viability following any of the population than medical care, with studiesdif¿cult times. Community health activities are showing the greatest health gains in the populationtherefore undertaken on many levels, for individ- over the past two centuries from changes in broaduals, families, groups and entire communities. economic and social conditions (Commission on the Social Determinants of Health [CSDH] 2008; Point to ponder Graham 2004; Link & Phelan 2005). This chapter Health is dynamic — constantly will examine the various SDOH, and some of the changing as our biology and genetic ways they inÀuence the health of communities and predispositions interact with the the people who live in them. It will also address psychological, social, cultural, spiritual the important issue of health literacy. Health lit- and physical environments that we eracy is a major goal for practitioners working in live in. community health. 5
  • 20. COMMUNITY HEALTH AND WELLNESS ) Point to ponder preventive care. However, there is little evidence The World Health Organization on how these factors interact to inÀuence health in defines health as ‘a state of complete particular communities. Clearly, research evidence physical, mental and social wellbeing on the SDOH is needed to underpin community and not merely the absence of interventions. Throughout this and other chapters disease’. in this book, we provide examples of a wide range of research studies to guide these interventions. By committing ourselves to this scholarly approach to A well-informed, health literate population can practice it is possible that over time, many of theparticipate fully in making health-related deci- compromises to community health may be over-sions that affect their personal health and the health come, and new, effective strategies developed forof their community. The chapter culminates in a the bene¿t of society and communities everywhere.discussion of the research base for good and bestpractice in working effectively with communities. Point to ponder Research is an important element in planning We know that the majorto improve and maintain the health of any com- improvements in health over themunity, particularly research into the SDOH. past century are due to changes inAlthough some community practitioners are new to social, environmental and economicresearching the basis of their interventions, nurses, conditions as well as smaller familymidwives and others have been systematically col- size, better nutrition and a greaterlecting and using research data for centuries. As emphasis on preventive care. However, we need more researchearly as the 19th century Florence Nightingale to demonstrate how these factorscarefully documented various factors associated interact to influence health inwith outbreaks of illness in her community. Years communities.later, scholars from psychology, sociology andother scienti¿c disciplines, joined medical, nurs-ing, and other health professions in seeking to At the end of this and other chapters, we pro-explain and theorise about health (Syme 2005). As vide an example of a research study into an issuehealth scholars around the world expanded their relevant to community health. This is designed toresearch knowledge, their studies became cir- provoke your thinking about the evidence base forcumscribed by what is now called the ‘McKeown practice, and how research can be used to optimisethesis’. McKeown (1979) argued that medical care health. The case study for this chapter also intro-and technology were not responsible for improv- duces ‘The Millers’. We’ll ask you to complete aing health; the major improvements were due to genogram of the family and ask that you considersocial, environmental and economic changes, their particular strengths and needs in the contextsmaller family size, better nutrition, a healthier of reÀecting on the main issues covered in thephysical environment and a greater emphasis on chapter. Objectives By the end of this chapter you will be able to: 1 explain health, wellness, and community health as socio-ecological concepts 2 identify the social determinants and structures of health and wellness 3 examine the intergenerational factors that influence health 4 analyse the concept of social capital and its contribution to community health 5 examine the factors that influence community sustainability 6 explain the importance of health literacy in enhancing individual and community health capacity 7 investigate the role of research and evidence-based practice in promoting community health.6
  • 21. 1 ) Health as a socio-ecological conceptWHAT IS HEALTH? if their social situation is plagued by civil strife, anAs mentioned previously, health is a product of oppressive political regime, crime, poverty, unem-reciprocal interactions between individuals and their ployment, violence, discrimination, food insecu-environments. Each of us brings to our environ- rity, diseases or a lack of access to health and socialmental interactions a number of factors unique to support services they may be disempowered, leav-us alone. These include the following: ing them less likely to become healthy or recover • a personal history from illness when it occurs. These issues that • our biology as it has been established by hered- arise from power imbalances and unfair societal ity and moulded by early environments structures create inequalities in health (Edwards • previous events that have affected our health, & MacLean Davison 2008; Marmot 2006). This including past illnesses or injuries is because people who are living in disadvantaged • our nutritional status as it is currently, and its or disempowered situations are unable to access adequacy in early infancy the same resources for health as those who live in • stressors; both good and bad events in our lives more privileged situations. that may have caused us to respond in various ways. Point to ponder Clearly, health is multifaceted. Becoming and When a social environment isstaying healthy ‘depends on our ability to under- supportive, a person will feelstand and manage the interaction between human empowered. If a social environmentactivities and the physical and biological environ- is affected by such things as war,ment’ (WHO 1992: 409). crime, unemployment or poor access Biological factors provide the foundation for an to health services a person may feelindividual to develop as a relatively healthy person, disempowered.which is an adaptive process. From birth, individ-uals are programmed to develop certain biologi-cally preset behaviours (bio-behaviours) at critical HEALTH AND WELLNESSand sensitive developmental periods. This ‘bio- Healthy people’s lives are characterised by balancelogical embedding’ inÀuences how people interact and potential. In a balanced state of health there iswith the genetic, social and economic contexts of harmony between the physical, emotional, socialtheir lives (Best et al 2003). However, the environ- and spiritual. When they are part of a healthy com-ments or conditions of a person’s life shape bio- munity there are opportunities for them to reachlogical factors and the way individuals respond to and maintain high levels of health or wellness.the world around them (Hertzman 2001; Hertzman Wellness, as originally described by Dunn (1959)& Power 2006). These include family and commu- extends beyond health. In the community context,nity characteristics, and aspects of the wider soci- it reÀects the dynamic relationship between peopleety that create opportunities or threats to health. and their environment that arises when individ- uals use that environment to maintain balance and Point to ponder purposeful direction. This underlines the ecologi- Although biological factors provide the cal nature of health and wellness. Contemporary foundation for an individual to develop de¿nitions of health acknowledge the connectivity into a healthy person, the environment between people and the environment in two ways: or conditions of a person’s life shape ¿rst, health is dynamic rather than static, and sec- these biological factors. ond, the environment or context of people’s lives inÀuences the extent to which they can reach their health potential. For example, people feel they Social conditions are particularly important, have lifestyle choices, and if they choose, they willbecause social environments provide the context be able to exercise or relax in safe spaces. Theyfor interactions in all other environments. When have access to nutritious foods; students balancethe social environment is supportive, creating study with recreation; young families immunisea climate of trust and mutual respect a person is their children and have time out from work tomore likely to be empowered, in control of their socialise, and older people have opportunities tolife, and therefore their health. On the other hand, stay active and socialise with others. 7
  • 22. COMMUNITY HEALTH AND WELLNESS ) Point to ponder criteria of average life expectancy, life satisfac- Wellness is achieved when there tion and ecological footprint (Marks et al 2006). is harmony between the physical, The Canadian Index of Wellbeing has also adopted emotional, social and spiritual this approach, computing measures of quality health of the individual and their of life into social, economic and environmental environment. trends in Canadian cities (Hancock 2009). All of these measures address social health, and they are based on the knowledge that happiness and wellbe- Eckersley et al (2005) explain that optimism, ing increase longevity and make immune systemstrust, self-respect and autonomy make us happy more robust, which in many cases, improves healthand therefore create feelings of wellbeing. The (Layard 2005).importance of happiness has been acknowledged The pursuit of happiness from a social per-by many health scholars, who are now expanding spective lies in contrast to the consumerism intheir research agenda to explore the relationship society today that fosters and exploits a restless,between happiness and health (Baum 2009). This insatiable expectation that we need more andtype of research can be linked back to the proposal more. Although most of us enjoy having some-in the 1970s by the King of Bhutan that instead of thing to strive for, consumer goods offer hollowfocusing only on gross domestic product (GDP), outcomes. Instead, we may ¿nd higher levels ofnations should be concerned with the ultimate pur- wellness in communities that allow people topose in life, which is happiness. He proposed a live in a stable, democratic society, to enjoy thegross national happiness (GNH) index comprised company of family and friends, to have reward-of psychological wellbeing, the use of time, com- ing work that yields suf¿cient income, to feelmunity vitality, culture, health, education, environ- personal happiness with the ability to addressmental diversity, living standard and governance any mental health problems, to set goals related(online www.grossnationalhappiness.cm/gnhIndex to common values, and to have some means of/introductionGNH.aspx 2). Since then, many attaining guidance, purpose and meaning (Dienerinitiatives have been developed to try to bring this & Seligman 2004). This illustrates a clear linkbalanced perspective of health into mainstream between personal and community wellness; inthinking. The Happy Planet Index, developed in other words, a level of harmony between healththe United Kingdom refocused wellbeing on the and place. Gender Parenting styles Biological factors Family dynamics Employability Family finances Geographical Age HEALTH mobility Culture Health services Neighbourhood Social resources Political economic Education factorsFigure 1.1 Interactions between factors affecting health8
  • 23. 1 ) Health as a socio-ecological conceptDEFINING ‘COMMUNITY’ BOX 1.1 QUALITIES OF A HEALTHYAND ‘COMMUNITY HEALTH’ COMMUNITYIn the most basic terms, the word community sim- 1 Clean and safe physical environment.ply means that which is common. We often think of 2 Peace, equity and social justice.a community as the physical or geographical place 3 Adequate access to food, water, shelter,we share with others, or the place from which care income, safety, work and recreation for all.is delivered (Crooks & Andrews 2009). However, 4 Adequate access to health care services.an ecological view focuses on the community as an 5 Opportunities for learning and skill develop-interdependent group of plants and animals inhab- ment.iting a common space. People depending on one 6 Strong, mutually supportive relationshipsanother, interacting with each other and with aspects and networks.of their environment, distinguish a living commu- 7 Workplaces that are supportive of individualnity from a collection of inanimate objects. Com- and family wellbeing.munities are thus dynamic entities that pulsate with 8 Wide participation of residents in decision-the actions and interactions of people, the spaces making.they inhabit and the resources they use. Healthy 9 Strong local cultural and spiritual heritage.communities are the synthesis or product of people 10 Diverse and vital economy.interacting with their environments. This is an evo-lutionary concept, in that community health is ‘a 11 Protection of the natural environment.dynamic and evolving process’ (Baisch 2009:2467). 12 Responsible use of resources to ensureIt is created by people working collaboratively to long term sustainability.shape and develop the community in a way that (Online: http://www.ohcc-ccso.ca/en//what-makes-a-healthy-will help them achieve positive health outcomes. A community)‘healthy community’ is one of those positive out-comes. Community health is de¿ned as follows: Community health is grounded in philosophi- (Rural Assist Information Network [RAIN] 2009; cal beliefs of social justice and empowerment. The Ian Potter Foundation 2009). The Government of Dynamic and contextual, community health is Victoria (2009) identi¿es a number of priorities that achieved through participatory, community devel- promote community wellbeing. These include having opment processes based on ecological models that governments that are responsive to the needs of new address broad determinants of health. communities, building community capacity through (Baisch 2009:2472) a sense of belonging, working towards economic developments to sustain the population, and creat- Point to ponder ing safe environments with opportunities for healthy An ecological definition of community activity, recreation and social interaction. These are focuses on a community as a group essential characteristics of community health. of people who are dependent on one As members of a community, our lives are another and who inhabit a common closely interwoven with the lives of others, some space. Point to ponder The essential characteristics of Healthy communities have a number of common community health include havingqualities as outlined in Box 1.1. governments that are responsive to the needs of communities,COMMUNITY HEALTH building capacity through a sense of belonging, providing forAND WELLNESS economic development to sustainCommunity wellness (or wellbeing) refers to an the population, and creating safe environments that encourageoptimal quality of community life, one that meets healthy activity, recreation and socialpeople’s needs and that creates harmony and social interaction.justice within a vibrant, sustainable community 9
  • 24. COMMUNITY HEALTH AND WELLNESS )of whom live in close proximity to us; others who Like individuals, communities are open to ashare common characteristics but do not inhabit variety of interpretations. If you were to ask ‘Howour geographical space. healthy is the community in which I live?’ a number We also hold membership in various population of issues might come up. To gain at least a cursorygroups on the basis of gender, age, physical capacity view of the community you could look around ator culture. In the context of all of these group mem- the geography. You might ¿nd yourself in a smallberships, we interact with a moveable feast of other town with plenty of vegetable gardens, well-keptrichly diverse communities. To these interactions houses, playgrounds and sporting ¿elds, a commu-we bring our own individuality; the combination nity centre complete with child-minding facilities, aof genetic predispositions, history, knowledge, mix of healthy looking young and older people onattitudes, preferences and perceptions of capac- the streets, none of whom are smoking, and publicity. Each community, in turn, brings to each of its transportation. A very different picture may emergemembers a set of distinct environments: physical, if you cast your gaze to an inner-city neighbourhoodpsychological, social, spiritual and cultural. Our where children play on the streets between parkedsocio-ecological interactions shape a characteristic cars, ramshackle buildings loom skyward with bro-community character, which determines the extent ken windows punctuating the places where peopleto which community members will become a cohe- live, cars hoon around the corners, no older peoplesive entity. Each of these interactions, whether walk the streets, and children seem to be tendingwith our families, social groups or our physical to younger children with no adults supervisingenvironment, transforms the community as well as their activities. A vastly different community mightits residents. Bandura (1977) called this reciprocal emerge the further you get from the city. Depend-determinism. By reciprocal determinism he meant ing on which continent you were in, you might ¿ndthat both the behaviours of people and the charac- starving babies suffering from rampant disease, orteristics of their environments are determined by Indigenous people smoking around a camp¿re, orthe set of dynamic exchanges between them. an isolated farmer, too poor to either heat his fro- Ecological exchange can yield both constraints zen house or cool a sweltering one, reacting to hisand enhancements to personal and community frustration by abusing his wife and children. Or, youhealth. Some of the more familiar constraints on might ¿nd happy, contented families, enjoying thehealth and wellbeing arise from the effects of con- fruits of their toils, whether on the land or in the city.taminants in the physical environment, such as In each of the situations mentioned above, youair and water pollution, infectious diseases and/ could jump to a number of conclusions about theor injury. Some degree of risk to health and well- way the physical environment enhanced or impededbeing is also present in the social environment; in the health of the community. But in each commu-the workplace, school and neighbourhood. Inter- nity, a set of unseen inÀuences lies just below theactions with our environment in recreation, educa- physical surface. For example, the small town maytion and social interchange present opportunities be comfortably situated in a place where everyonefor achieving higher levels of health and wellbeing. wanting employment has a job, because of a politi-Interactions between community members and the cal decision taken some time previously to relocatehealth care system are also imbued with challenges a manufacturing company there. The playgroundsand opportunities for illness prevention and health and sporting ¿elds may be a product of a commu-improvements. For those of us whose role involves nity development program and a workplace policyhelping people achieve and maintain good health that provides Àexible working hours so parents canand protection from illness or injury, it is important take their children to sports. A local non-denomi-to understand the effects of these interactions. national church may have been built to double as a respite centre for carers, or a mothers group, or some Point to ponder other activity that keeps adults connected with one Reciprocal determinism is simply the another. The schools may be well resourced because combination of what an individual a government body has decreed that children should brings to a community, what a not be disadvantaged irrespective of where they community brings to the individual, live. In contrast, the inner-city neighbourhood may and how these interact. be neglected by government policies, with inade- quate educational facilities. Young mothers raising10
  • 25. 1 ) Health as a socio-ecological conceptchildren alone may be working swing shifts, leav- for health and child care when they’re needed,ing young children in the care of other children. and having employment opportunities with goodVandals may be receiving no deterrents because of a working conditions and suf¿cient income. Manylack of funding for social policies, perhaps because of these determinants are embedded in the politi-military spending takes precedence over social ser- cal and economic environment, where policyvices and local policing. In the rural area, a farming decisions affecting community life are made.community may be suffering from the lack of mar- Within the SDOH are a number of structural con-kets for their produce, or have no chance of fertil- ditions. For example, a community’s social devel-ising their lands to grow produce in the ¿rst place opment needs structures to create employmentbecause of conservation policies. They may also be opportunities, and a physical environment that sup-disadvantaged by natural disasters such as drought, ports healthy lifestyles and personal health practices.or be vulnerable to mortgage lenders, substandard People need access to clean air, water and nutri-places to shelter, or unemployment. These aspects tious foods at a reasonable cost. They also need toof community life are considered SDOH. have reasonable working conditions so that they can achieve a work–life balance. Other structures in the What’s your opinion? social environment that support health and wellbe- How healthy is the community you ing include health and social support services such live in? What factors make it healthy? as hospitals, medical practitioners, nurses and other What factors make it less healthy? allied health professionals who are accessible where and when they are needed. Structural supports for health also include government services that provideSOCIAL DETERMINANTS income protection in the case of unemployment, infra-OF HEALTH structure such as safe roads and public transporta- tion, and schools, playgrounds and adult recreationalThe SDOH consist of a number of overlapping facilities that offer the opportunity for holistic healthfactors that determine health and wellbeing. These and wellbeing. Socio-political structures includeinclude factors that begin at birth, such as biology equitable systems of governance over the commu-and genetic characteristics, gender, culture and vari- nity and society, to ensure preservation of resourcesous family inÀuences on healthy child development. through wise economic choices and a commitment toFamily inÀuences include having socio-economic conservation; fairness in allocating resources acrossresources for parents to provide for their child, parent- all groups in the population, and systems that protecting knowledge and skills, a peaceful family life and people from harm or disempowerment.adequate support systems. Social support networks The diagram in Figure 1.2 illustrates the socialthat are inclusive across genders, cultures and edu- and structural determinants of health from a socio-cational opportunities are also social determinants. ecological perspective. The metaphor of a cascade of bubbles is used to show the dynamic interaction Point to ponder between factors (Wilcox 2007). Each bubble inter- The SDOH are a number of faces with many others, and if one bubble is displaced overlapping social and physical or happens to pop, there is a cascade effect, where factors that contribute to health and the surface tension and connectivity of the others are wellbeing. changed. One bubble may be directly inÀuenced by an adjacent bubble, but it is also indirectly inÀuenced by that bubble’s connections to other surfaces. The Support systems inÀuence a person’s ability to bubbles may also merge and increase or decrease incope with life’s stressors, and to make decisions size or in relation to one another. If there are changesabout personal health practices that either prevent in the wider environment, such as policy changes orillness or maintain health. Other social determi- a major environmental change, all bubbles may benants are a function of interactions between the affected or even disappear. In terms of the metaphorindividual, family and community, such as hav- it would be like blowing air across the entire cascadeing a healthy and supportive neighbourhood, with or changing the water Àow (Wilcox 2007).adequate transportation and spaces for recreation, The ‘social determinants’ approach to healthbeing able to access food and water, and services resonates with the notion of human rights and 11
  • 26. COMMUNITY HEALTH AND WELLNESS )social justice. Social justice refers to the ‘fair dis- (CSDH). The Commission represents 19 countries,tribution of society’s bene¿ts, responsibilities and including Australia. After gathering informationtheir consequences’ (Edwards & MacLean Davison for 3 years, members met to consider global prog-2008:130). This means that as health profession- ress on eliminating disparities in health and how toals, we have an obligation to identify unfairness or encourage a more equitable social world.inequities, and their underlying determinants, advo- The commissioners were united in three con-cating for human rights, and working towards just cerns: their passion for social justice, their respecteconomic, social and political institutions (Edwards for evidence and their frustration with a lack of& MacLean Davison 2008; Whitehead 2007). progress on global responses to the SDOH (CSDH 2008). They recommended that governments Point to ponder everywhere take up the challenge of working with Social justice occurs when the health and other organisations to improve health benefits, responsibilities and for the world’s citizens. This involves reframing consequences of society are equally health services in terms of primary health care and fairly distributed between people. (PHC), ensuring suf¿cient health professionals to provide care, addressing economic issues, over- coming inequitable, exploitative, unhealthy and Equitable, socially just conditions in our com- dangerous working conditions, including restor-munities and society are a matter of life and ation of work–life balance for families, and pro-death, affecting the way people live, their chances viding social protection for all people across theof becoming ill or their risk of premature death life course (CSDH 2008). These overarching goals(CSDH 2008). In 2005, recognising the human urge us to act in concert with members of our com-rights implications of good health and the role munities, igniting our passion for health and socialof social determinants in supporting health and justice and combining it with research that willwellbeing, the WHO assembled an international build better understanding of what works, where,Commission on Social Determinants of Health for what populations, with what outcomes. Income, social status Personal health Education, literacy, practices finances Healthy child development Social support networks SOCIAL Employment/ Biology, genetic DETERMINANTS Working conditions characteristics OF HEALTH Social environments Gender, culture Physical Health services, Coping skills environments resourcesFigure 1.2 Social and structural determinants of health12
  • 27. 1 ) Health as a socio-ecological concept Point to ponder vulnerability where the SDOH interact in a way Governments worldwide are starting that creates disempowerment across generations. to recognise the importance of the Political decisions governing employment oppor- SDOH in achieving health for all tunities may hamper the parents’ ability to improve people. ¿nances.THE ROLE OF COMMUNITIES IN Point to ponderINTERGENERATIONAL HEALTH A ‘social gradient’ exists in health. That is, those who are employed orThe quality of community health often changes earn income at successively higherdramatically over time to inÀuence the way people levels have better health than thosegrow and develop. For some, an ideal mix of condi- who are unemployed or have lowertions can create a positive start to life that becomes levels of income.sustained into adulthood and throughout ageing.This is a ‘life course’ approach to understand-ing health. Improvements to the SDOH (hous- A less than optimal physical environment maying, employment opportunities, transportation or deprive both parents and the child of a chance tosocial services) can provide optimal conditions in access social groups or gatherings. There may bewhich all family members Àourish and maintain few opportunities for education, health care orgood health over time. For others, a disadvan- transportation to access services. Parenting skillstaged start to life may not be overcome by suf¿- may be absent for a range of reasons, includingcient changes in any of the environments affecting younger age, the lack of role modelling, geo-their lives. So changing circumstances can create graphic disadvantage or illness. Discrimination ineither threats or opportunities to health and well- the immediate environment can worsen the effectsbeing. For example, some physical environments of any of these factors.have become transformed by global warming and Alternatively, families who are able to garnerdroughts, creating natural disasters such as Àood- suf¿cient resources and external supports to copeing, ¿res and other weather events, leaving entire with dif¿culties or traumas may be able to over-families at risk of homelessness. For those already come multiple challenges throughout their life-disadvantaged by poverty, discrimination or a lack time, creating a more optimistic outlook for theirof social support this can perpetuate ill health. child’s health. This can be accomplished within The family’s socio-economic status is an impor- empowering partnerships between the family andtant determinant of health. Research studies have community working together to cradle children’sshown that there is a ‘social gradient’ in health, ability to cope, to grow and to learn (Li et al 2008).whereby those employed at successively higher Clearly, the presence and adequacy of communitylevels have better health than those on lower lev- services and supports are a matter of concern toels (Navarro 2009; Hertzman & Power 2006). This all members of society, not just those who are par-creates disadvantage from birth for some children. enting a child. Health professionals can help byA child born into a lower socio-economic family promoting civic engagement, working in partner-for example, may be destined for an impoverished ship with community members to lobby for fair-life, creating intergenerational ill health. This child ness and democratic participation in economic andlives in a situation of ‘double-jeopardy’, where political decisions.interactions between the SDOH conspire againstgood health. Without external community sup- Point to ponderports the family may spiral into worsening cir- Interventions that promote healthcumstances, affecting their child’s opportunities across generations such asfor the future. This is the case for many Indigen- education, nurturing and anticipatoryous people, whose parents have not had access to guidance can help overcome theadequate employment or community supports that hazards of being born into relativelywould sustain their own health, much less that of deprived situations.their children. They become caught in a cycle of 13
  • 28. COMMUNITY HEALTH AND WELLNESS ) Throughout the world, nurses, midwives and Social capital is therefore a mechanism to helpother health professionals have begun to draw communities cope with adversity and limitations,attention to the issues of intergenerational health. as well as to build a positive sense of place. It is notResearchers are now investigating how inÀuences just connecting people so they will be pressuredsuch as education, nurturing and anticipatory guid- into participating in healthy lifestyles or a commonance can help overcome the health hazards of set of behaviours, but promoting a sense of cohe-being born into a relatively deprived social situ- siveness, a network of social support and a sense ofation (Hertzman & Power 2006; Laperriere 2008; belonging (Nakhaie et al 2007). This can be empow-Osberg & Sharpe 2006). There is also a growing ering, creating equality of opportunities, regardlessbody of knowledge suggesting a range of bene¿- of age, gender, culture or other aspects of birthright.cial outcomes for individuals who participate in It can also shift people’s expectations of their lives,community programs that foster greater connect- improving mental health as well as the overall qual-edness between the generations (Fujiwara et al ity of community life (Baum et al 2000; Ziersch2009; Chung 2009; de Souza & Grundy 2007). et al 2005).With greater understanding, societies will be better A community may have the disadvantage ofequipped to make decisions that will support and isolation, or few natural resources conducive tosustain good health, even for those who are disad- health, yet community attitudes and actions thatvantaged from birth. This is integral to the notion bring people together can help strengthen healthof social capital. capacity (Aston et al 2009). Community health capacity can also be supported by organisationalSOCIAL CAPITAL structures, such as schools, workplaces and com-When the health of the community is de¿ned from munity planning mechanisms that include partici-a social perspective we acknowledge its social patory decision-making. Together, members of thecapital. Like economic capital, social capital is an community can use their collective voice to lobbyaccumulation of wealth, but it is the kind of wealth for services such as health care, transportation,that draws people together as a cohesive force in a family-friendly education and job re-training,climate of trust and mutual respect (Putnam 2005). opportunities for physical activities, and commu-Putnam (1995) ¿rst described the value of social nity policing. With each successful action, therecapital in terms of developing civic engagement, is a greater likelihood of building the capacity fortrust, and norms of reciprocity among community subsequent developments. In this way communi-members. Communities become strong when peo- ties can work from the ground up to respond tople are connected through networks, associations, the SDOH, addressing inequalities and workingand any other means of sharing information and towards a more inclusive society (CSDH 2008;a sense of purpose. Information Àows through the Raphael et al 2008).community in many directions, people are com- Examples of programs that help build socialpelled to help others for mutual bene¿t, and they are capital are those that unite people in develop-more likely to participate in democratic institutions, ing opportunities, those that galvanise com-thereby improving their accountability. When this munity action to preserve the environment, totype of climate pervades community life there is a undertake participatory school reform, or bringgreater likelihood of people realising shared goals local businesses together to take steps to endand bonding together to become resilient to eco- discrimination. When communities draw mem-nomic, social and environmental changes (OHCC bers together to pursue these types of goals they2009) (Ontario Health Communities Coalition develop community vitality, a capacity to thrive[OHCC] 2009). and change, and greater respect and inclusive- ness. This is the key to empowerment (OHCC 2009). It is based on the premise that if people are Point to ponder prepared for events or circumstances with both Social capital exists when a sense of information and community support systems, trust, engagement, participation and they can control their destiny by participating a sense of belonging is present in a in decision-making and developing appropriate community. conditions for living and working (Aston et al 2009; Green et al 2004).14
  • 29. 1 ) Health as a socio-ecological concept ACTION POINT Point to ponder Involving community members in activities A sustainable community is one that or projects to pursue common goals will help is bound by a common commitment build social capital. to conserve the physical, social and cultural resources that exist within the community. Newspapers, magazines and the electronic media provide access to deliberations taking place at theSUSTAINABLE COMMUNITY major environmental meetings, including inter-HEALTH national summits sponsored by the United Nations (UN), the WHO, or scienti¿c meetings on imple-In those communities where there is a relatively menting strategies to preserve local environments.healthy environment, and a sense of connected- Because not all members of a community haveness, or social capital, people tend to work together access to or an interest in reading about globaltowards making the community sustainable. Sus- initiatives, it may be up to health care profession-tainable communities are those that work towards als to provide information and awareness on theseconservation and diversity of personal and physi- issues. This extends conservation and diversity tocal resources. This means that the community is the local social agendas. Community action in thisbound by a common commitment to conserve context may range from drawing public attention tonot only its natural habitat, but all aspects of its the links between poverty and health, lobbying fordiverse physical, social and cultural environment. all educational facilities to have equal resources,There are several ways people can be encour- to advocating for programs that acknowledgeaged to focus on community sustainability. One the contribution of diverse cultural groups toapproach is to collaborate with local education, community life.health, recreation, sporting and business groups Sustainability in community health can be takento ensure that the younger generation develops to mean that the community has a type of health–an af¿nity with their physical and social environ- illness carrying capacity; that is, all the healthments. This involves ensuring that all citizens are resources it needs and the capacity to respond toaware of the strengths and resources particular to all the illness it produces (Lowe 1994). This rep-their community. Another measure is to use the resents an ideal, as yet an unattainable goal, asbroader systems that govern the community to no one country has been able to produce all theadvocate for public participation in creating and goods and services it needs to sustain its people.sustaining health. This can be as simple as voting, There is global recognition of the need to preserveor as time consuming as spearheading a commu- the planet, and many people are aware that as thenity action movement to ensure equitable distribu- world’s population continues to increase rapidly,tion of natural, economic and social resources in a our natural resources are becoming seriouslyway that does not compromise the ability of future degraded (Howat & Ritchie 2004). Global warm-generations to meet their own needs (Kickbusch ing is the top issue on the global environment2008). Community action may also involve agenda, and the scienti¿c community believesbecoming suf¿ciently informed to participate in that climate change will lead to irreparable dam-scienti¿c debates surrounding water, food and age of the earth’s ecosystems (McMichael 2005).energy use; for example through libraries or web- It is ironic that people are living longer these dayssites such as those listed at the end of the chapter. because of economic and technological develop-Other ecological activities include such things as ments, yet it is these very developments that havelobbying local, state or federal governments for exploited, and thus degraded the environmentinitiatives to conserve the physical environment so necessary to their survival (Howat & Ritchie(such as recycling systems), or using the media to 2004). In 2008, the WHO convened a group ofcommunicate to the local community the impact eminent health researchers, practitioners, donorsof local conservation (or destruction) to the wider and representatives of global agencies to identifyarena. the research agenda for the immediate future. This 15
  • 30. COMMUNITY HEALTH AND WELLNESS )group generated six key themes to be addressed as of sustaining health or avenues for communicat-a matter of urgency (see Box 1.2). ing with others. Their cultural disempowerment is therefore an important factor in determining the What’s your opinion? extent to which the communities in which they Economic and technological live will be able to develop health capacity. developments have led to people The political landscape of the past two decades living longer, healthier lives in has ruthlessly favoured economic development many countries; however these over social development, and rendered many of developments have also led to global our communities unsustainable. The outcomes of warming and damage to the earth’s this are evident in urban communities where cities ecosystems. How do we balance stretch endlessly along coastlines and borderlines, these things to create sustainability? swallowing up small communities and economic migrants with inadequate infrastructure to support them (Howat & Ritchie 2004). Clearly there is a role for intervention and sus-tainability research at both the local and global Point to ponderlevels. Just as land and water shortages have Political emphasis on economiccaused forced migration, wars, urbanisation and development over socialpoverty have driven people all over the world to development has rendered manyassimilate into foreign cultures. As a result, the communities unsustainable.world has lost languages and culturally diverseelements that have historically maintained cohe-sion and trust. In some cases, the fear of protecting In some of these new, hastily formed com-borders from refugees and other migrants has had munities, untenable lifestyle choices bombardthe effect of disempowering some cultures. This young people with confusing choices. The globalin itself is a health hazard, as the disappearance of ¿nancial crisis of 2009 made their choices morecultures and traditional ways of life have left whole intense, as young, urban families throughoutcommunities without an understandable means the world have had to confront unemployment. Farming communities suffered from increased petrol taxes and lower pro¿ts. And charitable BOX 1.2 URGENT AREAS OF ENVIRONMENTAL RESEARCH agencies found it more dif¿cult to raise funds to help them. Communities of the future will have to 1 Place climate change on the health agenda in work out ways to reverse the destruction of their terms of health equity to reduce the burden of climate-sensitive health outcomes, such physical and social resources to survive (Howat as infectious diseases and air pollution. & Ritchie 2004). The key to overcoming these risks lies in greater empowerment of commu- 2 Develop studies of policy-relevant risk assess- ment to inform strategies to help vulnerable nity members to ¿nd local, sustainable solutions populations that have been displaced by en- and a sense of control to participate in success- vironmental hazards such as degradation of ful, collective political action for community water supplies. development (Bruni et al 2008). This includes 3 Evaluate the cost-effectiveness of protec- helping people value their sense of ‘place’, tive measures. which ‘moulds people through their histories 4 Investigate intersectoral decisions, and how and geographies’, integrating their collective mechanisms such as carbon pricing, and histories, cultures, capital, economics, ethnic- household conservation efforts such as use ity, religion and other social factors (Tunstall of wastewater affect health. et al 2004:7). 5 Improve surveillance to enhance operational effectiveness of various measures. COMMUNITY DEVELOPMENT: 6 Study the economic outcomes of pro- HELPING COMMUNITIES CHANGE posed mitigation and adaptation measures (Campbell-Lendrum et al 2009). Five key principles are instrumental in community development, as indicated in Box 1.3.16
  • 31. 1 ) Health as a socio-ecological concept BOX 1.3 PRINCIPLES IN COMMUNITY ACTION POINT DEVELOPMENT For communities to be able to take a leader- 1 Ensuring services are empowering; that is, ship role in their own development, the applied with dignity and cultural sensitivity. health professional must provide information 2 Using connective processes to ensure the and opportunities for the community to basic goal is a caring, purposeful group. achieve this. 3 Organisational actions should be focused on altering structural conditions to prevent isolation and/or self-blame among commu- nity members. Facilitating and enabling this type of change in 4 Collaborative strategies are employed to communities also helps develop the skills of the help clarify the task and empower the com- health professional. Each community and the strat- munity in terms of their purpose and vision of the community. egies it uses for capacity development is unique, so every opportunity to work with a community 5 Advocacy means challenging the status yields new information that the health professional quo to help people become empowered even when there are conflicts or ambiguous can use to consolidate and re¿ne health promotion issues (Labonte 2005). skills. In this respect, advocacy is reciprocally determined; a deliberate two-way process of mutual development where knowledge is shared freely. One of the most important outcomes of Each of these principles is grounded in our human sharing knowledge is the development of healthrights and social justice agenda. Together, they reÀect literacy.a set of values that include the expectation that peo-ple will learn and change, and in the inherent value Health literacyof community participation. One of the challenges of Health literacy is the ability to make sound healthcommunity development is to ensure that health pro- decisions in everyday life. Some decisions mayfessionals do not impose their agenda on the com- be related to health care, but others may be life-munity. Instead, members of the community should style choices, decisions that improve quality ofdecide what they wish to change, what services they life, or that help in understanding civic respon-need to assist change, and what support mecha- sibilities or opportunities. Health literacy is annisms are required to maintain the change. The role important element in addressing health inequi-of the health professional is to provide information ties, as those at the lower levels of health literacyand opportunities for dialogue with others so that are often the ones who live in socio-economicallythe community can take a leadership role in devel- disadvantaged communities. Being unaware ofopmental planning (Aston et al 2009). The ultimate information relevant to improving their health,objective is to foster community competence. This or how to access health resources creates higherplaces us as health professionals in an advocacy role, levels of disadvantage. For some people, a lackhelping communities construct pathways to change of education and the health literacy that wouldon different levels. As social advocates, we adopt a Àow from education prevents them from becom-respectful and culturally sensitive approach, shifting ing empowered at any time during their lives.the balance of power to the community. As politi- For many women especially, low health literacycal advocates, we bring knowledge about the health prevents them from adequate personal health andand welfare systems to the table and help link people from ensuring their family’s access to good nutri-together to access resources. As professional advo- tion, freedom from illness and exercising theircates, we have an obligation to stay abreast of new own potential.knowledge and strategies that will help us maintainprofessional competence as well as solidarity with Point to ponderothers. These processes are developmental in that Health literacy is the ability to makeby working together, people’s skills, knowledge and sound health decisions in everydayself-con¿dence are developed, ultimately empower- life.ing them to go on to the next undertaking. 17
  • 32. COMMUNITY HEALTH AND WELLNESS ) A health literate person is able to participate in asset that is integral to capacity building, citizen-both public and private dialogues about health, ship and feelings of self-worth (Green et al 2007;medicine, scienti¿c knowledge and their relation Nutbeam 2008; Peerson & Saunders 2009).to society and culture (Zarcadoolas et al 2005).It is empowering to be able to make decisions that Point to ponderprovide greater control, that help people interact People with low levels of literacyas full participants in clinical situations and pre- experience poorer health and higherventative care, and navigate the health care sys- rates of hospitalisation than thosetem (Coulter et al 2008; Kickbusch 2008; White with higher levels of literacy.2008). Since health literacy became part of ourresearch agenda in the 1990s, studies have foundstrong links between literacy and overall health Three levels of health literacy have been iden-and wellbeing (Kickbusch 2008). A concept analy- ti¿ed by Nutbeam (2000) (see Table 1.1). Func-sis of health literacy revealed that it includes not tional health literacy means that individuals haveonly cognitive abilities such as problem-solving received suf¿cient factual information on healthand decision-making, but social and cultural skills risks and health services, which they also under-(Mancuso 2008). Health literate people are able stand, and which allows them to function effec-to gather, analyse and evaluate health information tively in a health context (Coulter et al 2008;when they have the capacity, comprehension and Nutbeam 2000). They need to be able to readcommunication skills to make informed choices, consent forms, medicine labels, and other writ-reduce health risks, and increase the quality of ten health care information. They also need totheir lives (Mancuso 2008). Researchers have also be able to understand and act on both verbal andfound an association between low literacy and written instructions from health care practitioners,health inequalities, with those having low levels pharmacists and insurers (Kickbusch 2001). At aof literacy experiencing poorer health and higher second level, communicative or interactive healthrates of hospitalisation than those with higher lit- literacy develops personal skills to the extent thateracy (Coulter et al 2008; White 2008). community members participate in community Having adequate health literacy promotes life, inÀuencing social norms and helping oth-people’s engagement in health care and other ers develop their personal health capacity. Thisaspects of social life, which has clinical and eco- involves understanding how organisations work,nomic bene¿ts to society (Coulter et al 2008). and communicating with others in the context ofClinical bene¿ts include smoother encounters in self-help or other support groups, as well as know-the processes of diagnosis and treatment of ill- ing how to get the services they need.ness, better adherence to prescribed treatments and The third level of literacy, critical health literacymedications, and better understanding of instruc- is where people use cognitive skills to improvetions given by health providers. When people are individual resilience to social and economic adver-engaged with their health services they tend to sity. This paves the way for community leadershipundertake more self-care and management, select structures to support community action and to facil-appropriate treatments, and are better at monitor- itate community development (Nutbeam 2000). Ating their health and safety issues (Coulter et al a personal level critical health literacy is an enabling2008). Understanding how to navigate the health factor, developing capacity for con¿dent, empow-care system provides insight into bureaucratic ered interactions with others, including members ofprocesses associated with health insurance, admis- the health professions (Nutbeam 2008).sion to or discharge from hospital, and knowingthe types of care they can expect to receive from Point to pondera range of practitioners. Because health literate The three levels of health literacypeople tend to have healthier lifestyles they are are functional, communicative (ormore likely to engage in preventative activities, interactive) and critical.which not only improve their quality of life butreduce health care costs (Coulter et al 2008; White2008). In this respect health literacy is a resource The fundamental element in critical health lit-for living; a personal, community and societal eracy is the community members’ commitment to18
  • 33. 1 ) Health as a socio-ecological concept Table 1.1 Health literacy: a continuum of knowledge and skill development Communicative/ Functional interactive Critical Civic Knowledge to choose Ability to influence Skills for action Capable of community actionworking together to overcome structural barriers Anticipating people’s needs at speci¿c decision-to health, which recognises the role of health lit- making milestones is also important. Informationeracy in creating awareness of the SDOH (Coulter should be not only appropriate, but timely, relevantet al 2008; Nutbeam 2008). Examples of outcomes and reliable, especially the type of material a personinclude workers exerting pressure on workplaces might access in a health care setting (Coulter et alto reduce hazardous risks, or lobby groups gather- 2008). Written health information tailored to indi-ing support for environmental preservation, or sup- vidual needs has been found to help reinforce pro-portive resources for parenting practices or health fessionals’ explanations of health problems, but usedservices. In each of these examples, the community alone, it is not always understood. Computer-basedis demonstrating critical health literacy. In some information may be more helpful than writtenrespects, this is also civic literacy in that commu- instructions, as it is more readily tailored to differentnity members actively participate in community needs. However, access to computers can be a prob-life to ¿nd collective solutions to health problems. lem for disadvantaged people (Coulter et al 2008).This emphasises the importance of the context A review of the research has found that when theyfor communication (Nutbeam 2008). Progression do have access, those from disadvantaged groupsbetween the three levels of health literacy depends tend to bene¿t more from computer-based supporton a person’s cognitive development, exposure to interventions (Coulter et al 2008).different forms of communication and the content To date, there is a growing awareness of the need(Nutbeam 2008). for health literacy throughout the world (Nutbeam The key objectives of health literacy interven- 2008). South Australia has taken the lead in Aus-tions are to provide information and education, to tralia by forming a Health Literacy Allianceencourage appropriate and effective use of health comprised of health and social service person-resources, to engage people in health decision- nel, including educators, librarians, representa-making, and to tackle health inequalities through tives from the refugee network, and WorkCoverempowerment (Coulter et al 2008; Peerson & (Kickbusch 2008).Saunders 2009). To help people read, understand,evaluate and use health information requires anunderstanding of how people learn. This varies ACTION POINT People with low levels of health literacy mayaccording to age, class, cultural group, gender, not reveal this to the health professional. Itbeliefs, preferences and coping strategies, and is important to ensure accurate assessmentexperience with the health system. Some differ- of a person’s level of health literacy beforeences also emerge as a function of their general providing any health teaching.literacy level, ¿rst language, skills and abilities(Coulter et al 2008). Health professionals can helppeople who may be only minimally health literateby understanding the scope of the problem. Thosewith low levels of literacy don’t always reveal this, Their goal is to provide leadership and support foras they may be ashamed at their lack of under- achieving equity through health literacy. Kickbuschstanding or reading skills. For this reason, health (2008) also suggests that health literacy becometeaching should be sensitive to those who may a key indicator of good hospital care and gen-have lesser understanding than others. Yet cur- eral practice. This would see hospitals and clinicsrent research shows that printed health materials develop self-assessment skills in communicatingremain dif¿cult for many people to understand health information and making their environments(Shieh & Hosei 2008). literacy-friendly. She also suggests strengthening 19
  • 34. COMMUNITY HEALTH AND WELLNESS )health literacy in school education programs, to with more than 500 evidence-based tools availablethe extent of granting educational credits for health internationally. These patient-friendly tools use aliteracy. Her recommendations also include spe- variety of media and help patients review thecial attention to the needs of Indigenous people evidence on different treatments, so they can workand migrant groups who often have greater vulner- out their preferences and make appropriate deci-ability because of language and literacy problems sions (Ottawa Health Research Institute Online.(Kickbusch 2008). The New South Wales Clinical Available: www.ohri.ca/decisionaid/ accessed 8Excellence Commission also advocates including July 2009).health literacy in the health research agenda (Smith& McCaffery 2010). Some work has already been RESEARCH TO PRACTICEundertaken to develop a screening tool that will The need for ongoing, systematic research as ahelp identify and measure the level of dif¿culty foundation for practice has never been more acute.people may be having in understanding health The world is changing, and as health profession-information such as food labelling information als we need to investigate the way to help com-(Smith & McCaffery 2010). This type of research munities access information and resources thatwill be extended in future to provide greater clari- will do the most good in sustaining their future.¿cation of an individual’s speci¿c information This was acknowledged in an international meet-needs. As nurses and midwives our responsibility ing of government and research groups held inalso lies in ¿ltering information for people seeking 2008, to discuss how research could help advanceour assistance. For the internet-savvy population in population health (McKee 2008). Those attendingour ‘googlised’ society, we need to develop more the meeting put forward a collective request forsophisticated approaches, as a large component of countries throughout the world to allocate at leastthe information found on the internet often lacks 2% of their annual budgets on health research.moral guidance (Ratzan 2002, 2007). To encour- The objective of this was to advance the notionage community participation people need to know that policies, practices and decisions at all levelsthat their health professionals value their knowl- of society should be based on research evidenceedge and decisions, and will help ensure the accu- (McKee 2008). This aspiration may not eventuate,racy of health information by keeping abreast of especially in poorer countries, but it does signalnew research ¿ndings. Figure 1.3 provides a set of a coming of age of the evidence-based practicestrategies recommended by the US Department of (EBP) agenda. At the global level health researchHealth and Human Services for promoting health can help us better understand environmentalliteracy. changes such as the effects of global warming on Health literacy research is still in its infancy, the planet, and how shortages of water, food andalthough the area is now attracting growing attention space affect community life.with measures of health literacy being developed The EBP movement is based on the notion thatin the US, Canada and the UK (Nutbeam 2008). providing research evidence for all activities in theSome have focused on improving health literacy health professions ensures accountability to thethrough interactive television, audio-tapes, text- population for clinical decision-making and inter-messages and web-based information, with mixed ventions (McMurray 2004). Research evidenceresults, but these media have been found to have collected according to the rules of EBP is typicallythe advantage of improving con¿dence and abil- used as a basis for justifying or changing practice,ity to participate in decision-making (Coulter et al and we discuss this further in Chapter 12. Although2008; Nutbeam 2008). American researchers have objective, scienti¿c evidence is important it canundertaken the ¿rst national study of health literacy also obscure the subjective elements that are partas a basis for health promotion and disease preven- of human enquiry (Morrison et al 2008).tion (White 2008). This has created the impetus forfurther studies to investigate health literacy across Point to ponderdifferent contexts, different groups, and different Ongoing, systematic health researchbaseline levels. There remains an important need as a foundation for practice infor further research to generate a body of robust primary health care is vital to creatingevidence to support patient decision-making. Coul- sustainable communities.ter et al (2008) report that this work is continuing20
  • 35. 1 ) Health as a socio-ecological concept 1 Improve the usability of health information • Identify the intended user of the health information and services; for example, know their profile including demographics, behaviour, culture, attitude, literacy skills, language, socio- economic status, access to services, language preferences, health practices. • Decide which channel and format of sharing information is most appropriate. • Evaluate users’ understanding before (formative), during (process) and after (outcome) the introduction of materials. • Acknowledge cultural differences and practise respect. • Use plain language; for example, use simple language and define technical terms, use the active voice, break down complex information into understandable pieces, organise information so the most important points come first. • Speak clearly and listen carefully; use a medically trained interpreter where necessary, ask open-ended questions, have the person restate the information in their own words — the ‘teach-back’ method. • Improve usability of internet information; for example, plain language, large font, white space, simple graphics. 2 Improve the usability of health services • Improve the usability of health forms and instructions. Revise forms to ensure clarity and simplicity, test forms with intended users, offer assistance with completing forms. • Improve the accessibility of the physical environment. Include universal symbols and clear signage in multiple languages. 3 Build knowledge to improve decision-making • Improve access to accurate and appropriate health information; for example, partner with educators to improve health curricula. • Identify new methods for information dissemination e.g. cell phones, palm pilots, personalised and interactive content, information kiosks, talking prescription bottles, etc. • Facilitate healthy decision-making; for example, use short documents that present ‘bottom-line’ information, step-by-step instructions, and visual cues that highlight the most important information. 4 Advocate for improved health literacy • Make the case for improving health literacy; for example, target key leaders with health literacy information. • Incorporate health literacy in mission and planning; for example, include health literacy statements in strategic plans, program plans and educational initiatives. • Establish accountability for health literacy activities; for example, include health literacy improvement criteria in program evaluation.Figure 1.3 Strategies for promoting health literacy (Adapted from the US Department of Healthand Human Services Office of Disease Prevention and Health Promotion Health CommunicationActivities web page 2009: http://www.health.gov/communication/literacy/powerpoint/) 21
  • 36. COMMUNITY HEALTH AND WELLNESS ) Objective information can help demonstrate that In working with communities, the rules for scien-the practice of nursing and midwifery is based on ti¿c studies often fail to take into account the com-scienti¿c evidence rather than historical reasons. plexities of community life and the value of tacit,The mounting evidence base for practice is per- subjective knowledge that is gained from commu-suasive, particularly in demonstrating the value nity engagement. This type of knowledge must beof interventions such as wound management, contextualised, accounting for holistic understand-falls prevention, post-surgical outcomes, infec- ings of family and community life, complete withtion control, and a variety of acute care outcomes cultural, spiritual and environmental knowledgethat also include measures of ef¿ciency and cost- (McMurray 2004).effectiveness (Dall et al 2009). However, practice Throughout this text we will be presenting ain the community is ultimately linked to the over- series of research studies that help inform prac-arching goals of health care. These include equity, tice in the community. Many of these are aimed ataccess, public participation in decision-making, seeking in-depth situational knowledge that illus-health promotion, appropriate use of our tools and trates good and best practice in advancing commu-technologies, and collaboration between all public nity health and wellness. Some studies are speci¿csectors and services of society. to various cultures, and their particular needs, an important aspect of ensuring cultural relevance for Point to ponder practice. Others are situation speci¿c, providing Research in the community must a research foundation for planning or interven- be a balance of objective, scientific tions with various communities. All are examples evidence combined with the of the type of information that helps us recognise subjective knowledge that represents diversity, foster community competence, engage people’s experiences. in meaningful relationships with our communities and make practice defensible. C Case study: Meet ‘The Millers’ Anna and Dominic, aged 60 and 64 respectively, met and married in Torino, Italy. Their daughter Maria was born in 1975 and immigrated to Australia when she met her hus- band, Jim, on a backpackers’ holiday in 2000. She was 25 and Jim was 28. They now live in Sydney. Jim (now aged 38) was born in the UK but moved with his parents Harold (aged 59) and Millie (aged 62) to Auckland in 1980 when he was just 8 years old. Harold and Millie still live in New Zealand, but are now in a small rural town on the South Island, some one and a half hours from the nearest hospital. Maria and Jim have had two children in the past 10 years: Lily (aged 6) and Samantha (aged 3). They are both in child care as Maria and Jim both have full-time jobs; Maria in a bank and Jim in sales. We’ll be following the Millers as the family changes and their communities expand across the Tasman. We hope you enjoy the journey and find them a stimulating learning experience. REFLECTING ON THE BIG ISSUES • Health is a state of balance between individual, social and environmental factors; the social determinants of health. • Being healthy includes wellbeing and happiness. • Sustaining health requires attention to intergenerational factors. • The health of a community is dependent on the interactions between different22
  • 37. 1 ) Health as a socio-ecological concept people who live there as well as equity in health policies and services. • Social capital is created when people feel connected with others, developing mutuality and trust. • Health literacy is vital to achieving equity in community health. • Research is an essential part of helping communities develop. Reflective questions: how would I use this knowledge in practice? 1 Explain the difference between ‘nursing in the community’ and ‘nursing the community’. 2 Construct a genogram of the Miller family (see Box 1.4 and Appendix A). 3 Identify some of the major social determinants of the Millers’ health and wellbeing. 4 What aspects of the community surrounding Maria and Jim would facil- itate their family life? Which might be considered constraining factors on family life? How would these community influences differ from that of their parents? 5 Outline the main elements you would include in promoting health literacy to Maria and Jim for their parenting needs. 6 How could a nurse working in the community help build social capital? 7 Identify one research question that would help inform your work with Maria and Jim.BOX 1.4 THE GENOGRAMA genogram is a graphic representation of a family tree. It displays the interactions of generations, allow-ing the user to analyse family members and their relationships to one another. In a standard genogramthe male is drawn as a square, and the female as a circle. There are three different types of childrendepicted in a genogram: a biological child, adopted child or foster child. (see Appendix A.) A triangle isused to represent a pregnancy, miscarriage or abortion. Where there has been a miscarriage or abor-tion, a diagonal cross is drawn on top of the triangle to symbolise death. Abortions have an additionalhorizontal line. A still-birth is displayed by the gender symbol, with a diagonal cross the same size but ahalf-size gender symbol. For multiple births the child links are joined together. (Online:http://www.genopro.com/genogram/symbols. Accessed 24 August 2009) 23
  • 38. COMMUNITY HEALTH AND WELLNESS ) Research-informed practice: intergenerational health Clendon (2007, 2009) conducted a study of how New Zealand mothers use their chil- dren’s health and development record book (Plunket book) as a basis for subsequent mother–daughter interactions. Using an oral history approach, she explored the experi- ences of 34 women and one man as they used the child health and development record book at varying times throughout their lives. The study tracked the historical develop- ment of the book in relation to social change, examined how the Plunket book has been used to strengthen intergenerational relationships within families, and how it has helped facilitate and build relationships between nurses and mothers. Clendon found that mothers have consistently used the book as a tool to link past with present, to main- tain kinship ties across generations, to deal with change intergenerationally, and in a manner that contributes to their self-identity as woman and mother. Although mothers were able to use the book to affirm their own knowledge and that of their mothers, a medically dominated discourse persisted in the book. Despite this, Clendon found that the child health and development record book is an effective clinical tool for nurses, midwives and other health professionals to use in their work with families. She recom- mends that nurses, midwives and other health professionals continue to use the book in practice but to be mindful of the fact that the book remains in use beyond the health professional’s immediate involvement with the mother and child, playing an important role in the context of the family across generations. Clendon suggests that health pro- fessionals use the book to build on the strengths and abilities of a mother as she cares for her child. This reaffirms her role and identity as a mother, not only when her children are younger but as they grow and become parents themselves. ReferencesAston M, Meagher-Stewart D, Edwards N, Young L Bruni R, Laupacis A, Martin D 2008 Public engage- 2009 Public health nurses’ primary health care practice: ment in setting priorities in health care. strategies for fostering citizen participation. Journal of Canadian Medical Association Journal 179(1): Community Health Nursing 26:24–34 15–18Baisch M 2009 Community health: an evolutionary Campbell-Lendrum D, Bertollini R, Neira M, concept analysis. Journal of Advanced Nursing Ebi K, McMichael A 2009 Health and climate 65(11):2464–76 change: a roadmap for applied research. The LancetBandura A 1977 Self-ef¿cacy: toward a unifying 373(9676):1663–5 theory of behavioral change. Psychological Review Chung J 2009 An intergenerational reminiscence 84:191–215 programme for older adults with early dementia andBaum F 2009 Envisioning a healthy and sustainable youth volunteers: values and challenges. Scandina- future: essential to closing the gap in a generation. vian Journal of Caring Sciences 23:259–64 Global Health Promotion 1757–9759 Supp Clendon J 2007 Mother/daughter intergenerational (1):72–80 interviews: insights into qualitative interviewing.Baum F, Bush R, Modra C, Murray C, Cox E, Contemporary Nurse 23(2):243–51 Alexander K, Potter R 2000 Epidemiology of par- Clendon J 2009 Motherhood and the Plunket book: ticipation. Journal of Epidemiology & Community a social history. Unpublished doctoral thesis. New Health 54:414–23 Zealand, Massey UniversityBest A, Stokols D, Green L, Leischow S, Holmes Commission on the Social Determinants of Health B, Bucholz K 2003 An integrative framework for (CSDH) 2008 Closing the gap in a generation. Health community partnering to translate theory into effec- equity through action on the social determinants of tive health promotion strategy. American Journal of health, Final report of the Commission on the Social Health Promotion 18(2):168–76 Determinants of Health. WHO, Geneva24
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  • 41. 1 ) Health as a socio-ecological conceptUseful websiteshttp://www.euro.who.int/HEN/policybriefs/ — WHO health evidence network for decision-makershttp://www.who.int/entity/social_determinants/en/ — WHO social determinants of healthhttp://www.who.int/social_determinants/knowledge_networks/exclusion/en/index.html — WHO social exclusion and social determinants of healthhttp://www.un.org/milleniumgoals — MDGshttp://www2.ids.ac.uk/ghen/about/index.html — UK Gender and Health equity networkhttp://www.euro.who.int/hen — WHO health evidence networkhttp://www.euro.who.int/observatory — WHO European Observatory on Health Systems and Policieshttp://www.SDOH@YORKU.CA — International website and archives on social determinants of healthhttp://www.healthinsite.gov.au/topics/Health_and_Wellbeing — Australian government site for all health topicshttp://www.nphp.gov.au/ — Australian National Public Health Partnershipshttp://www.rain.net.au/community_wellbeing.htm — Australian Rural Assist Information Networkhttp://nrha.ruralhealth.org.au — Australian National Rural Health Alliancehttp://www.serviceseeker.com.au/ — Australian Infoxchange community directorieshttp://sss.ihca.com.au/ — Australian Institute for Healthy Communitieshttp://www.canberra.edu.au/centres/sustainable-communities — Australian Institute for Sustainable Communitieshttp://www.health.nsw.gov.au/public-health/health-promotion/capacity-building/resources/glance.pdf — Indicators to help with Capacity Building, NSW Healthhttp://www.ciw.ca/en/TheCanadianIndexOfWellbeing/DomainsOfWellbeing/CommunityVitality — Canadian Index of Wellbeinghttp://www.nafhc.org/about/ — US National Alliance for Healthy Communitieshttp://www.ohcc-csso.ca/en/what-makes-a-healthy-community — Ontario Healthy Communities Coalitionhttp://www.nlm.nih.gov/pubs/cbm/healthliteracybarriers.html — American health literacy bibliography to 2003http://www.niÀ.gov/mailman/listinfo/Healthliteracy — Health and Literacy Discussion Listhttp://www.hsph.harvard.edu/healthliteracy/— Harvard School of Public Health, Health and Literacy Websitehttp://www.centreforliteracy.qc.ca/health/healthlt.htm — Canadian Care for Research Briefs on Health Literacyhttp://www.nzliteracyportal.org.nz/ — New Zealand literacy portalhttp://www.healthnavigator.org.nz/centre-for-clinical-excellence/health-literacy — New Zealand health literacy information 27