On this website, we use the term “comprehensive community health” to signify an approach that:
- explicitly recognizes that health is more than the absence of illness
- acknowledges that promoting wellness requires community activity outside the traditional health services sector which has historically emphasized individual-level interventions (e.g., treatment for substance use problems)
- creates a process that establishes community consensus around goals and basic approaches, and then encourages decentralized initiatives across multiple sectors to reach these larger goals
Although health outcomes ultimately play out on the individual level, there are many factors that influence the health of individuals within communities.
Individual health status is the product of numerous factors drawn from four areas or domains. These domains extend outward from the individual and gradually encompasses larger and larger aspects of life (see illustration from the Integrated Health Promotion Resource Kit, 2008). At the individual level, we have factors such as genetics and psychological functioning. Next we have factors connected to the individual’s immediate family and close social networks, such as parental nurturing and social support from extended family. The third layer is labelled “community.” It involves factors such as equity, the quality and quantity of education, and social support received from the larger community (including health and social services). Finally, there are larger economic, political or social forces that impact all of the other domains.
Research has identified a host of societal and individual factors that affect health outcomes within a community. The figure below (adapted from Labonte, 1998) shows some of the most important “determinants of health.”
What is clear from the research is that the most effective approaches for improving health outcomes use multiple initiatives at various levels to address root causes (Kreuter et al, 2000; Merzel and D’Afflitti, 2003).
If we use the distinction between societal-level and individual-level interventions as a starting point in thinking about how we can create lasting wellness in our communities, it is important to first consider the appropriate mix between these two types of initiatives. On this point, Kreuter et al. (2000) concludes that in many instances “a disproportionate share of overall effort involving health interventions is geared to individual-level change, and/or to awareness or information, rather than policy or environmental change” (p. 55).
Unfortunately, initiatives that focus exclusively on individual-level interventions are insufficient for creating healthy communities because they “reinforce the commonly held misconception that individual behaviours are solely responsible for health outcomes and therefore that health education is an adequate solution” (Cohen and Swift, 1999:205). A better approach for promoting lasting wellness at the community level is to implement a comprehensive approach that includes societal-level initiatives, such as changing institutional practices and public policies, as well as initiatives focused at the individual-level.
Further, it is appropriate to consider community-based interventions that go beyond just changing laws and institutional practices. Consider this scenario: a child who is taught not to use alcohol in his/her school prevention program might live in a community with billboards and other advertisements showing images that glamorize alcohol consumption. He or she may even live with a parent who regularly uses alcohol to cope with stress. Under these circumstances, the prevention education delivered in school may become diluted or lost because it is countered by messages received in the child’s day-to-day life (Wolff, 2001). In instances like this one, it may be necessary to change community norms and customs to bring about lasting reductions in underage drinking.
Delivering the right mix of interventions also involves another dimension which is particularly important when dealing with substance use issues. Careful analysis of actual health and social costs of substance use has shown that they are about equally divided between chronic and acute harms. Chronic harms are predominantly associated with the relatively small number of people who regularly use substances in risky ways, and acute harms are predominantly associated with the relatively large number of people who only occasionally engage in risky use (Rehm, et al., 2006). Thus, it is always necessary to combine universal and targeted interventions in efforts to address harmful substance use otherwise you will be missing at least half the problem. This is especially true for substances that are used by a larger proportion of the population (i.e., alcohol, cannabis, and tobacco) (Stockwell et al., 2006).
The matrix below (see Comprehensive Planning Tool) is useful for assessing the comprehensiveness of initiatives to promote health and wellness in your community.
This diagram arrays interventions for dealing with social issues like harmful substance use across six possible domains, depending on whether they are directed at societal or individual factors, and whether they focus on the entire population (universal), those in elevated risk groups (selected), or those displaying risky patterns of use (indicated).
References
Kreuter, M., Lezin, N. & Young, L. (2000). Evaluating Community Based Collaborative Mechanisms: Implications for Practitioners. Health Promotion Practice, 1(1):49-63.
Labonte, R. (1998). A community development approach to health promotion: a background paper on practice, tensions, strategic models and accountability requirements for health authority work on the broad determinants of health. Edinburgh: Health Education Board of Scotland, Research Unit on Health and Behaviour Change, University of Edinburgh.
Merzel, C. & D’Afflitti, J. (2003). Reconsidering Community Based Health Promotion: Promise, Performance, and Potential. American Journal of Public Health 93(4): 557-574.
Rehm, J., et al. (2006). The costs of substance abuse in Canada, 2002. Highlights. Ottawa, ON: Canadian Centre on Substance Abuse.
Stockwell, T., Reist, D., Balfour, K., Poole, N., Tupper, K. (2006) Following the Evidence: Preventing Harms from Substance Use in BC. Victoria: BC Ministry of Health.
Wolff, T. (2001). A Practitioner’s Guide to Successful Coalitions. American Journal of Community Psychology 29(2):173-191.
Victorian Government Department of Human Services (2008). Integrated Health Promotion Resource Kit. Melbourne: Department of Human Services.