What is a Community?

Community means different things to different people, and may be based on one of a number of connecting factors, including:

• geography (e.g., a town, neighbourhood or street)
• a social dimension (e.g., age, ethnicity or sexual orientation)
• an institution (e.g., a school, church, or community centre)
• a common interest, choice or sentiment (e.g., art, sports, or an issue or political belief - a community might come together to work collaboratively to enact positive change or initiate a project to promote health)
• the absence of choice (e.g., an illness or low socioeconomic status)

It is possible for a larger community to include and encompass any combination of these smaller communities as they overlap. A community is made up of different pieces. Depending on how it is conceived, it can include individuals, families, associations, workplaces, schools, places of worship, health care facilities, businesses, and government service providers.

What is a Healthy Community?

Health is more than just the absence of disease. Rather, it is a state of physical, mental, emotional and social well-being. It is not an end in itself, but a resource for everyday living that allows us to reach our full potential. In order for a community to achieve true health, all its parts and components must be vigorous and strong. Additionally, the relationships between those parts and components must be healthy. A community, like the people within it, is a living organism. Its health depends on all its systems functioning, both on their own, and together. 

A healthy community provides a nourishing natural environment and strong built environments (work, school, and leisure) where health, including relationships with substances, can be optimized. Research indicates some fundamental conditions and resources required for health, including: peace, shelter, food, education, income, a healthy ecosystem, sustainable resources, and social justice and equity (Ottawa Charter, 1986).

When we think about a sense of community, we are often describing a healthy community. For many, a positive social environment:

• fosters healthy connectedness and inclusivity
• promotes personal and collective responsibility
• enhances empowering social support for those in need

What is Most Important to Community Health?

Epidemiologists and other health researchers recognize that health at both the individual level and the population level is the outcome of complex relationships between individual and societal factors. Individual and societal factors affect health outcomes directly, as well as through their influence on health behaviour choices. There is also a dynamic relationship between societal factors and personal factors. The most important individual and societal factors can be considered under three domains:

Socio-economic status.There is agreement that socio-economic factors are major determinants of both individual and population health. While individuals may naturally have different levels of health due to genetics and personal choices, some inequalities stem from injustice. These inequalities are avoidable, and yet not avoided. Such differences are called inequities.

One measure of socio-economic equity is the size of the income gap between the most and least affluent members of society. Studies show that the size of the gap is related to levels of community health and wellness. In Canada, mortality rates are often two to three times higher for the lowest income group, as compared with the highest income group. Similar disparities are found in regard to life expectancy, disability, self-reports of pain, and activity limitations. Income level is not the only measure of equity or social disadvantage. Other primary factors include employment status and education level. These, in turn, influence and interact with inequities related to housing, gender, ethnicity, and early childhood experiences that are linked to health outcomes and health behaviours.

Different groups and subgroups of people have different social and economic contexts and these are reflected in their health status. For example, due to generations of unjust policies and practices towards Aboriginal populations, these populations experience significant socio-economic and health inequalities, including greater harm related to substance use. 

There is some evidence that the link between deprivation and health behaviours is strongest for alcohol and other licit and illicit drug use (Jarvis & Wardel, 1999). Studies also show that

• unemployment and homelessness, or insecure housing, are linked to the misuse of alcohol and other drugs,
• cirrhosis associated with heavy drinking is more common in lower socioeconomic groups, and
• cigarette smoking is more frequent among lower SES groups, people living in rented dwellings, those without private transport, the unemployed and those living in crowded accommodations.

There is also a gradient in cigarette smoking by level of education. However, while poor health is unequivocally linked to disadvantage, these connections are not completely straightforward when it comes to substance use. Different substances are related to different patterns of use in different social groups. For example, studies have found that employed people tend to drink more than unemployed people, and children with higher incomes smoke more packs of cigarettes.

On an individual level, some people do better than others, despite inequities. This suggests that, although socio-economic equity is one of the keys to the health of a community, other factors are also at play.

Social connectedness or isolation. Like socio-economic status, social connectedness is related to longer life and better health. People who belong to an extended family, a network of friends, a social or volunteer organization, a faith or other interest community tend to be healthier. Evidence shows that early connections lead to better coping skills later in life and strong family ties reduce the risk of destructive behaviours. It is believed that high levels of support result in stress reduction, which buffers against chronic health conditions.

Conversely, stigmatized, marginalized and otherwise alienated members of society tend to have poorer health. There is evidence that when people are isolated by life events, their health is adversely affected. Also, a lack of social support and social exclusion are associated with morbidity and depression. The fact that strong peer friendship networks can also increase the risk of smoking, drinking, or the use of illicit drugs suggests that norms are also important.

Socio-economic equity works alongside social connectedness. For example, research suggests that poverty isolates individuals and families, and segregates neighbourhoods.  Conversely, social and emotional relations may help mediate the impact of broader political and economic factors by supporting resilience and wellbeing. Such relations provide opportunities for networks related to belonging and social integration, but also to material and information resources. For further discussion on connectedness see Importance of Connectedness.

Personal efficacy. The most commonly accepted definition of health promotion in Canada includes the notion of enabling people to have control over their health. Having control over one’s health involves exerting control over one’s life, and having the ability to participate in decision-making. It entails having the capabilities, knowledge and freedoms necessary to make informed, healthy choices.

The negative effects of socioeconomic inequity and social isolation on health can be mediated by personal efficacy. At the same time, having a sense of control over one’s health is affected by one’s ability to access needed resources and being part of a supportive community. The effects of disempowerment show most prominently in the most marginalized members of society, who may have neither access to external resources (such as income) nor to personal resources (such as education). It is very difficult for people in this situation to be active agents in changing these conditions and creating a life they value. 

Acknowledging different levels of  capabilities is not meant to further stigmatize and exclude already marginalized people. Rather it is meant to highlight the importance of advocating for equity, giving voice to those who are powerless, and supporting their participation in the community. Some forms of participation may be more formal, such as engagement in institutionalized settings and the political process. Informal participation is tied to personal relationships, such as social gatherings in private homes and other spaces (Larsen & Manderson, 2009).  

Evidence shows that people who have a higher sense of personal efficacy tend to live longer and maintain better health. Lack of control often leads to vulnerability, which in turn causes stress. Stress itself can result in lower immune functioning, as well as to potentially problematic coping behaviours, such as substance use.

The material, psycho-social and political aspects of efficacy operate at the individual level as well as at the community level. 

How Can Communities Optimize Health?

Awareness of how individual and societal determinants of health operate over the course of a life has led to increased emphasis on a developmental-pathways approach to addressing health issues. This approach seeks to identify and reduce or eliminate the factors that lead individuals and groups to develop health or social problems, and to mediate their impact by building resilience. 

Understanding the core of the community is essential to reducing risk and harm. Community members working together to respond to problems related to substance use are well situated to understand the historical , social and cultural context of the issues, as well as the way the community operates. Specifically, this means the community's policies and social structures, and the attitudes and assumptions behind them. 

Policies are the written or unwritten guidelines that governments, organizations, communities, or individuals use when responding to issues and situations. Since problematic substance-use is not the result of any one factor, solutions will involve action on several fronts. Healthy policies can enhance health by fostering greater equity, connectedness and personal efficacy.

At the societal level, policies can address the structural factors that affect health behaviours in order to promote the health of the whole community. For example, policies on housing, transportation, and public participation will have an impact on the health and well-being of all community members. Other policy initiatives may be aimed at health behaviours of groups or individuals. For example, there is evidence that countries with more restrictive alcohol policies tend to have lower levels of mortality from liver cirrhosis, lower levels of other alcohol-related mortality and fewer social problems due to alcohol  (Marmot, 2007).

Community support for coordinated policies that work at the root-cause level of problems will help create an atmosphere in which policy makers can make the right choices for health. Our assumptions about the root causes of health problems will affect how we decide to address them. These assumptions may or may not reflect reality, or the needs and wishes of everyone in the community. While the community may share some attitudes and assumptions, it also consists of overlapping groups which may not hold the same value system. Attitudes and assumptions are often embedded in the community‘s culture, which includes its values, beliefs, preferences, and traditions.

While many people associate the term “culture” with subgroups in society, it is just as vital to consider the influence of mainstream culture’s values and beliefs. For example, overarching values of consumerism and individualism in western societies may promote the view that individuals are solely responsible for their health and therefore discount the importance of policies addressing socioeconomic status and connectedness. Similarly, institutionalized racism and gender bias in the broader culture leads to policies that support and perpetuate inequities. On the other hand, community norms of compassion and caring will support the creation of opportunities for belonging and social inclusion, and the active engagement of people and communities in decisions about their health. 

To reduce drug-related harms and facilitate healthy growth and development, it is important to identify those aspects of the community's core that promote health and those that detract from this goal. Those that detract from the overall goal should be changed. Those that support this goal are assets that can be strengthened.

Good Practices

Emerging from the evidence are some “good practices.” Good practice: 

• involves taking everybody into account and recognizes the different communities within a larger community
• entails seeing community as a social environment where socioeconomic equity, social connectedness, and personal efficacy can be nurtured in order to promote the health of the community and its citizens
• entails recognizing that health, social and economic policies need to be coordinated, and that communities can provide an atmosphere that supports policy makers to make the right choices
• involves distinguishing those aspects of the community’s core that promote or detract from health and developing appropriate change strategies

References