The most salient community issues are generally those related to the social determinants of health (SDOH). Among the issues that are as yet underresearched are questions that investigate equity of access to health services, models of empowerment for various groups differentiated by gender, culture and ethnicity, mechanisms for education and health literacy, and environmental supports for healthy childhoods, and lifelong wellbeing, including healthy ageing. These are complex issues, and research addressing these social determinants involves long-term, multidisciplinary studies of multiple factors across various settings and groups. The multidimensional nature of community problems is the central reason why so few research studies have been conducted into the SDOH. There are limited opportunities for large-scale studies that would gather data from diverse groups over sufficient time to provide definitive answers to research questions. However, there is an ethical and moral obligation for researchers to conduct studies into the SDOH to motivate social action, and to provide a balanced view of what creates health in society (Venkatapuram & Marmot 2009). Confining research to epidemiological studies of impairments and mortality, without studying the social dimensions, has consequences for health planning that limit the effectiveness of the health system (Venkatapuram & Marmot 2009). When national budgets fail to free up funding or intellectual support for comprehensive, longitudinal and multidimensional research, health care decisions may be made on inadequate or inappropriate information (Gil-Gonzalez et al 2009). This is basically why there are still so many important research questions left unanswered, including studies of the factors that support or inhibit achievement of the Millennium Development Goals (MDGs) (Gil-Gonzalez et al 2009).

A further problem is the lack of coherence in the topics studied in different countries. To drive major change, research studies need to be collaborative, right from the stage of establishing the research agenda, to identifying and evaluating solutions. The logistics of international or cross-institutional collaboration is sometimes prohibitive in terms of time or commitment of individual researchers, or when collaborators have different organisational pressures. Another problem is the need for different perspectives in investigating a problem. Funding bodies often favour studies that are highly scientific, such as systematic reviews of existing research or clinical trials, rather than those that may be evaluative, or based on clinical or community perspectives. Research into the issue of accessibility to care illustrates that three systematic reviews of accessibility of care have been conducted, yet all studies were conducted from the perspective of service providers, leaving little understanding of service users’ perspectives or needs (Kendall 2008).

Both the duplication of these studies, and the lack of community input, are problematic. The studies were funded and the research proceeded because expert researchers were able to mount an elegant argument for funding, which was not contested by community members, despite the fact that, as taxpayers, they were actually funding the studies. This holds two lessons. The first is that the art of argument is an essential skill for researchers. The second is that, despite widespread public access to large volumes of information through the internet, most people refrain from questioning its accuracy or seeking information on research, instead being satisfied to devolve responsibility to ‘expert’ researchers (Buckley 2008). Again, this underlines the emphasis on researchers, rather than the community. To ensure that our research agendas are focused on advancing community health, it is important that researchers work in partnership with community members at every stage of the research.

Research into the SDOH is fundamental to community health knowledge. The Commission on SDOH, mentioned in previous chapters, conducted a three-year project into the SDOH adopting a multidimensional research approach (Marmot & Friel 2008). Rather than confining their data to scientific evidence, the commissioners adopted ‘chains of reasoning’ and social epidemiological approaches, to demonstrate the links between interventions and outcomes. For example, they queried whether collective action at the grassroots level was good for health. Their investigation focused on showing that collective action can lead to improved housing and employment conditions, which, in turn, can lead to health equity. Their program of research led the commissioners to argue that researching the SDOH requires many types of evidence. This can be a combination of scientific evidence such as demonstrating through a randomised controlled trial (RCT), that nutritional supplements for young children can improve their cognitive and educational outcomes, and qualitative, descriptive evidence from case studies and action research, as to what is helpful in various communities (Marmot & Friel 2008). Other researchers are now recognising that the current research agendas that focus on population-level effects do not provide a realistic picture of the SDOH, because they fail to analyse differential effects for various sub-groups (Petticrew et al 2009). Rather than confining studies to population-level, causal factors as a basis for decisions about health care, they suggested the need for schematic descriptions of pathways between interventions and outcomes for different groups (Petticrew et al 2009).

The schematic representation of pathways to good health includes information from the policy agendas that help us progress towards equity and social justice. The SDOH commissioners included in their evaluation, an examination of the link between fair policies and greater health equity. For example, when governments invest in skills development there is both an economic and social benefit. So generous social policies that support dual-earner families not only improve the family’s economic and social condition, but that of the entire society, which contributes to social justice (Marmot & Friel 2008). These types of policies that support families and communities are a product of political and social trends, which influence what gets researched at the national, regional and local levels and by whom. In Australia, for example, the last decades of the last century saw numerous funding allocations awarded to biomedical research at the expense of public health studies. However, the current health reform agenda has resulted in a subtle shift in research emphasis towards the environment and primary health care (PHC). Examples of recently completed studies include antenatal and postnatal home visiting programs for Indigenous families, strategies for caring for those with depression, diabetes prevention, the effectiveness of practice nurses, health screening and improvements to health information systems (Primary Health Care Research, Evaluation and Development et al 2009). Each of these is invaluable to advancing knowledge for community health practice.

In addition to the political and social agendas, research topics are also selected by researchers on the basis of their responsiveness to professional agendas. For example, Annells et al’s (2005) study of the research priorities of district nurses in Victoria sought their views on which practice issues were most important. The study was based on the need to develop a body of knowledge to inform best practice in district nursing, which focuses predominantly on home visiting. A Delphi technique, which seeks a consensus view from the study participants, canvassed the nurses’ views, and ultimately generated a list of 10 major practice issues. These issues were then identified as topics for future research, focusing on discharge planning, documentation, retention of home visiting nurses, pain and symptom management for palliative care, protective environments for older people, and nursing assessment (Annells et al 2005). Similarly, a Delphi study was conducted by child health nurses and midwives in Western Australia to identify research priorities for parenting and child health (Hauck et al 2007). The study revealed that the two most important priorities were for infant sleep and settling issues, and postnatal depression. Other important research issues included program evaluation, staffing issues and the need to promote child health services (Hauck et al 2007).

Trends within the fields of public and community health also affect topics for research. In the past, studies informing health promotion strategies centred around strategies for influencing individual behaviour change. In the 21st century, health promotion trends indicate a need for studies that include the ecological factors supporting behaviour changes, and how the environments of people’s lives can support opportunities to make healthy choices. In addition, there has been a shift away from single factor studies to comprehensive and multifactor studies that investigate the interactive and cumulative effect of proximal (under the control of the individual) and distal (features of the environments of people’s lives) factors that contribute to health. To some extent, this multidimensional perspective has rescued the research agenda in community health from its insularity. Recognising the ecological relationships between human behaviour and environmental conditions, researchers today are more inclined to seek input from colleagues from diverse fields. They also tend to adopt varying combinations of approaches to study health-related questions from multiple perspectives.

As the SDOH Commission revealed, research approaches and techniques have undergone changes that benefit society by including a variety of approaches (Marmot & Friel 2008). The conventions for rigorous and appropriate research methods and designs have remained relatively stable, as have statistical computations, albeit with some changes reflecting more sophistication in analytic techniques. Community health research has shifted from the ‘methodological imperialism’ or ‘methodolatry’, which used to privilege certain methods over others, to a more eclectic approach that includes social phenomena. This is also a more ethical approach, in linking scientific evidence with a moral concern for social inequalities in health (Venkatapuram & Marmot 2009). The basis of the ethical and moral obligation of researchers is a shared value system that views the health and wellbeing of the population as an indicator of societal progress (Smith et al 2008). Ethically, this drives a commitment to long-term social change, and the research that will help inform such change (Smith et al 2008). For long-term planning there is a need to adopt multi-method studies, which examine data from more than one perspective, and focus on the real-world context, inclusive of the conditions and outcomes that may not fall within the ‘norm’ or normal pattern. As a result, research findings will be more dynamic and realistic, eminently better suited to influencing community health. Multi-method, multidimensional approaches provide opportunities to analyse new possibilities in the conception of each new study. Importantly, this allows researchers and those who use their research findings to maintain awareness of the dimensions of social relations that shape people’s socio-ecological experience of health. This provides a profusion of opportunities to inform change and to examine responses across time, developments, interventions and contexts.

Research and policy development typically occur within a symbiotic relationship. As mentioned above, government policies can dictate research agendas. Reciprocally, research findings can lead to policies for better health. This can occur when there are strong coalitions of health planners, researchers and members of the community. The combination of research evidence, the perspectives and preferences of health service users, and the experience of health practitioners can be invaluable in effecting change. When this type of information is available, research findings can be translated into practice; whether this is clinical or professional practice, education or management practice, or the practice of policy development.