CHAPTER 5 Community action for social and environmental change
In Chapter 1 the continuum of health promotion approaches was introduced. In this chapter we will move along the health promotion continuum from developing healthy public policy to create supportive environments, to ‘community action for social and environmental change’.
In the last chapter we talked about developing partnerships, intersectoral collaboration, and the importance of community participation in developing healthy public policy. In this chapter we build on those ideas and focus on change through community development. We examine the potential of community development as a way of working with communities, on issues they identify with, to achieve changes to the environment and enable community empowerment.
Community action for social and environmental change is referred to as a socio-ecological approach to health promotion, because it relates to factors securing the quality of the social and ecological environment of people’s lives. Changes are made by people in their own locality or changes are made to policies on behalf of others to improve the environment within which people live.
In community-level work the environment, rather than the individual, is the focus of change (Labonté 1986: 347). Working with communities to bring about a desired change to improve health in the community can be achieved using ‘bottom-up’ or ‘top-down’ approaches or a mixture of both. There are many theories that guide health workers in understanding how change occurs in communities. We have selected three that are generally familiar to health promotion workers: diffusion of innovation; community organisation; and community building or development. Put simply, diffusion of innovation theory provides us with an understanding of how new ideas are introduced and adopted in a community. The change process can be introduced from the community (‘bottom-up’) or from institutions (‘top-down’). Community organisation theory provides understanding about how organisations and health workers bring about change in local communities. This is a ‘top-down’ approach where organisations with power to direct policy and implement change identify priorities outside the context of the community. Workers with expertise and knowledge about a population develop policies and programs aimed at improving the lives of vulnerable groups without necessarily including members of those groups in the decision-making processes. Community development approaches help us to understand the ‘bottom-up’ approaches to change where communities are central in the identification of priorities and decision-making about their future. This ‘bottom-up’ approach is driven from the grass roots of the community. These theories are contested and each continues to evolve.
In this chapter we provide detailed guidance for health promotion practice using community development or community building approaches. There is a long history of success in improving the lives of poor and vulnerable groups through programs based on working with members of those groups. They include adult literacy, better nutrition and water supply programs, and the spread of micro-enterprise credit schemes around the world to create independence. The 2006 Nobel Peace Prize was awarded to Muhammad Yunus and Grameen Bank of Bangladesh for their efforts to create economic and social development from below. Loans to poor people without any financial security developed three decades ago with the ultimate aim of advancing democracy and human rights through the alleviation of poverty. ‘Micro-credit has proved to be an important liberating force in societies where women in particular have to struggle against repressive social and economic conditions’ (Community Builders NSW 2006).
Working with the community has the potential to address some of the structural issues, specifically at the local level, that lead to poor health. As we have said in Chapters 1 and 2, there are many factors that lead to poor health. The conditions in which people are born, live, work and age have a powerful influence on their health. Social factors create the life experiences and opportunities which in turn make it easier or more difficult for people to achieve optimal health. Equity of access to social and health resources is an important factor in determining health outcomes.
In addressing structural issues, ‘community action for social and environmental change’ is obviously political since it means working for change to create social justice. While any form of health work can be political in nature, by using the approaches described here the political nature of the health worker’s action is usually more explicit.
The community development approach empowers communities. It has been defined as a process of ‘working with people as they define their own goals, mobilise resources, and develop action plans for addressing problems they collectively have identified’ (Minkler 1991: 261).
The terms ‘community development’ and ‘community organisation’ are both defined variously and often overlap in their definition. While Minkler’s definition (1991) refers to community organisation, it actually describes community development. Rothman and Tropman (1987) described community development as one form of community organisation. Egger et al (2005: 134) have described the difference between the two terms as one of ‘directiveness’, because they regard community organisation as being a process more directed by workers, while community development is more directed by members of the community.
Working at the level of the community, and community development in particular, has become popular in the health field since the Declaration of Alma-Ata highlighted community development and community participation as important strategies for promoting health. Before that, many health workers were unfamiliar with the concept of community development, although it had been used in other fields and by health workers in Majority countries for many years.
An essential component of the Primary Health Care approach to health promotion is the recognition that it is necessary to change the structures that influence people’s lives in order to improve their health. There is also recognition that the people who are affected most need to be integral to that process. A key challenge in health promotion work is to put these ideas into practice by encouraging and supporting community-led and community-controlled activities, rather than only those activities that are led and controlled by health workers or the health system.
The fundamental principle that underpins community development work centres on people’s entitlement to have control over issues that affect their lives, and the worker’s role is to support these rights, on the basis of equity and social justice principles.
In Chapter 2 we noted that the term ‘community’ has different meanings. In community development, emphasis is placed on community as a social system, bound by geographical location or common interest, recognising that community is ‘a “living” organism with interactive webs of ties among organisations, neighbourhoods, families, and friends’ (Eng et al 1992: 1). Definitions of community commonly encompass elements of geography, culture and social stratification (Naidoo & Wills 2000). These three factors are viewed as bringing together people into a positive and desirable common entity (Naidoo & Wills 2000). However we also noted in Chapter 2 that communities are not necessarily homogenous entities; they often include groups with conflicting interests, and that this fact is often hidden behind the romantic connotations of the term ‘community’.
The notion of a ‘sense of community’ was also discussed in Chapter 2. This feeling is an ideal state in which everyone affected by the life of the community participates in community life. The community as a whole takes responsibility for its members and respect for the individuality of the members is maintained (Daly & Cobb 1989: 172). There is a ‘sense of solidarity and a sense of significance’ (Clark 1973: 409). This sense of community can be an important component of people feeling as though they belong to a community, and it also has implications for the process of community development (Falk & Kilpatrick 2000). Two further points are worth making here. Firstly, we need to take care not to oversimplify the consequences of human beings living in communities. Secondly, we must be careful not to assume that this sense of community is an ideal state for everyone, because some people may not choose living in a community as their ideal. These issues are of particular importance in considering community development, as these aspects of community may really come to the fore in the community development process. Indeed, workers using the community development process may have to regularly consider the implications of these issues in their work. Box 5.1 provides some ideals to work toward. Ife and Tesoriero (2006: 100) suggest that community is a subjective experience that means different things to different people; that communities evolve over time with ongoing dialogue, consciousness-raising and action.
BOX 5.1 Some principles of community
(Source: Johnson K. In: Hoff M D 1998 Sustainable Community Development: Studies in Economic, Environmental, and Cultural Revitalization. Lewis Publishers, Boca Raton, Florida, pp 175–6)
Community development is the process by which health workers are most able to work with communities. The aim in community development is for communities to be in control of decisions that affect them and gain control over the determinants of their health. The task for the health promotion worker is to assist the decision-making process. The role is complex because it involves facilitating community members’ access to the conditions and resources that will enable them to exercise control and set their own directions. When health promotion workers function in this way their work is defined as community development.
Manipulating people, through co-opting them to take a predetermined action, or working in a way that does not encourage true community control, is a thoughtless and manipulative use of power and is likely to create distrust among community members. This is not community development.
As we have said, community development and community organisation are two of three theories that are commonly discussed in health promotion: identifying key approaches by organisations and workers to bring about change in local communities (community organisation); and enabling communities to be central in decisions about their futures (community building) (Nutbeam & Harris 2004). There are many similarities within these approaches and we draw primarily from community development in this chapter; however, it is useful to outline the diffusion of innovation theory given the expectation that one of the roles of the community development worker is that of change agent.
The diffusion of innovation theory provides us with a way of understanding how new ideas are taken up (or not); that is, how change takes place in a community (Rogers 1995). Diffusion is defined as the process by which an innovation is communicated through certain channels over time among members of a social system. An innovation is defined as an idea, practice, or object perceived as new by an individual or other unit of adoption (Rogers 1995). The process works in a group as clarity to a few, then gradual and later rapid uptake by the rest of the group. Five general factors that influence the speed and success with which new ideas are taken up have been identified: relative advantage; compatibility; complexity; trialability; and observability (Rogers 1995).
There are several kinds of adopters: innovators, change agents, transformers, mainstreamers, unwilling laggards, reactionaries; there are also iconoclasts, spiritual recluses and curmudgeons (Rogers 1995; AtKisson 1999 in Verrinder 2005). Innovators are the progenitors of new ideas; they may be considered ‘fringe’, eccentric or unpredictable by the rest of the community and so may not be trusted. Change agents are the ‘ideas brokers’ for the innovator. Transformers or early adopters in the mainstream are open to new ideas and want to promote change. Mainstreamers can be persuaded that the innovation is a good idea and will change when they see the majority changing, but unwilling laggards (who are the late majority and who constitute about the same number as the mainstreamers) are the sceptics who need to be convinced of the benefits before they adopt a change. Reactionaries have a vested interest in keeping things as they are. Iconoclasts highlight problems but do not generate ideas; they are often silent partners of innovators. Spiritual recluses may proffer the philosophical underpinning and influence the atmosphere for change, while curmudgeons see change efforts as useless (Rogers 1995; AtKisson 1999 in Verrinder 2005). As we have said, we propose that community development workers are agents of change for community-led ideas. Understanding the change role played by different community members will facilitate effective community decision-making and long-term social change.
In theory the success or otherwise of innovation depends on how it is seen by various groups — whether the innovation is seen as compatible with the established culture, for example, or the perceived relative advantage of the innovation. The simplicity and flexibility of innovation together with its reversibility and the perceived risk of its adoption will affect the extent to which innovation is taken up by the community. Finally, the observability of results will influence whether others take up the change (Rogers 1995). An in-depth study of these factors and other theories may provide useful information for agents of change. The important thing is to know the community and what is likely to influence its response. Insight 5.1 demonstrates how this theory has been used to understand and track change in one community.
If we are to work with community development realistically and optimistically, we need to recognise its limits as well as its potential. There has been a tendency to expect a great deal from community development processes. It is important to recognise that while community development processes can have some impact on power relationships and equity at a local level, these processes will not shift power relationships on a broad scale without a vision and a plan to create a social movement. Even with the best intentions in the world, these processes at the local level will not change widespread social, economic and political conditions that are creating inequality and ill health.
The concept of community development is complex, perhaps because the skills and activities that are required vary with the situation, and also because the outcome will be defined by the community and known only after the activity has commenced. It is difficult to bring ideal global visions of capable communities deciding their own courses of action down to practical, day-to-day achievable goals. However, it is important to have visions broader than meeting local objectives if real empowerment of the community is to be achieved and sustained.
Mount Alexander Sustainability Group is a non-government organisation operating within the Mount Alexander Shire in Central Victoria, with a principle focus on taking action on climate change using community-wide behaviour change approaches.
The group recognised that relevant information about environmental risks and concerns can be a precursor for people to act pro-environmentally, but people do not often change entrenched behaviours based on information alone; indeed sometimes having more information about a huge challenge, such as climate change, can be counterproductive in that it makes people feel helpless and incapable of making a difference.
The Mount Alexander Sustainability Group works on the premise that often people do something different or make a change first and then they rationalise this new behaviour using information or knowledge. The Mount Alexander Sustainability Group uses this premise to design its projects as part of a deliberate strategy in promoting community-wide behaviour change — drawing on the wisdom of Robinson and Glanznig (2003) a social process is deliberately created: people see others make the change, they become aware of a dissonance between what they see and their own behaviour; they try the new behaviour for themselves, and then view themselves differently. They then seek information to inform their new attitudes or values about that behaviour. The Mount Alexander Sustainability Group deliberately set out to create occasions where people’s current behaviours were challenged or where people felt dissatisfied with the status quo; a public meeting to discuss reducing power consumption in public buildings such as shared office spaces, for example. They created a context where people could hear about and discuss strategies that were working from local people who were the ‘brains trust’ about that particular issue and how to overcome barriers. They encouraged people to make a public commitment to making a change; businesses who signed up to using green energy during the time of the local arts festival displayed a sticker on their business entrance. They provided rewards for the ‘early adopters’ of change; sometimes this was in the form of taking over administration and applications relating to climate change strategies, rather than a tangible goods. They publicised the efforts and activities of the community champions who made and sustained the changes. They publicised the progress they had made to the local and wider communities, made public awards to local organisations that had made huge progress to lower carbon emissions, and were part of a collection of community groups from the area who won a 2008 United Nations Association of Australia World Environment Day Award. This annual national awards program acknowledges action taken at a local level to address global environmental issues. The successes so far are catalysts for new endeavours and to engaging new members.
(Source: Mount Alexander Sustainability Group. Online. Available: masg.org.au/)
Community development work changes according to the needs of the community; it builds people’s skills for current issues and for the future. In the process it enhances their feelings of competence and personal self-esteem. It means their community is competent to adapt to future changes and that policy-makers will be more likely to consider their perspective in the future, and more accountable for their actions in the future.
Successful community-based movements brought about by local concerned citizens or by radical activists have ensured legal rights for vulnerable groups and brought about changes in legislation. Outcomes might range from a change in the decision to dam a pristine river and lake, to local government by-laws relating to the disposal of mine tailings.
Through community development people learn that their problems have social causes and that fighting back is a more reasonable, dignified approach than passive acceptance and personal alienation… Community organizing is a search for social power and an effort to combat perceived helplessness through learning that what appears personal is often political.
1. Improvement of the quality of life through the resolution of shared problems. This may sound far too grand for a small community activity, but it may be as seemingly simple as having a local by-law changed so that trucks are prevented from carrying their uncovered loads of dusty mine tailings contaminated with arsenic, through residential areas. The potential for health enhancement by this action is clear.
2. Reduction in the level of social inequities caused by the social determinants of illness such as poverty. Actions may entail provision of transport for local people to attend community activities, but in order to make sustained change for a community, provision of access to services needs to be enshrined in the operational plans of service providers, rather than being provided on an ad hoc basis.
3. Exercise and enhance democratic principles, through peoples’ shared roles in decisions that affect them in their communities. Maintaining democratic principles, when it is easier and quicker to get on and do it oneself is one of the biggest challenges to health workers. The processes and skills outlined in the next sections provide more specific guidance for this goal.
4. Enabling people to achieve their potential as individuals. The involvement in community activity brings its own personal and non-tangible rewards, as well as the development of new knowledge and skills. At the outset of a program, these gains need to be acknowledged and documented in the objectives of the activity or project.
5. Creation of a sense of community. A strong cohesive and successful community will be powerful in creating the sense of belonging and ownership for its members. It is a means for people to achieve their vision.
Community development is not one form of health promotion, or one style of activity or practice mode. The tasks involved in community development can be diverse, depending on the existing strengths, vulnerabilities and culture of the community of interest. What is consistent, and is set out in the definition of community development provided above, is the way of working; community development is a ‘bottom-up’ approach, that always involves working with a community, as they ‘steer’ the activity in their community. The worker must choose the way of working that best suits the needs and realities of the community they are working with.
At this point it will be valuable to examine some key principles of community development. Together, these help construct a picture of what community development practice is about. Perhaps the two most important principles are:
Community development workers are particularly concerned with the needs of those who have little power. It is these people who are most likely to be suffering ill health as a result of their lack of access to, and influence over, the structures that are impacting negatively on their health. If people are not skilled in articulating their needs, or do not believe they are likely to have them met, then they are not likely to express them. Finding out what they believe they need may be a slow (but important) part of the community development process. Unless we start from where people are at, we are unlikely to succeed as people will not be committed to act on issues they do not see as relevant to them.
Jackson et al (1989) outlined a community development continuum as a way of conceptualising the various practice modes or ‘ways of working’ in community development. They emphasised that community development is a ‘philosophical belief’ which underpins the way a worker engages with the community, whether it be working to support an individual at a time of crisis, or being active in a social movement across a wider community. The philosophical belief is centred on people’s entitlement to have control over issues that affect their lives, and the worker’s role is to support these rights, on the basis of equity and social justice principles. Jackson et al argued that (1989: 67):
the choice of practice mode should be made in response to the needs and realities of the communities with whom one works, and that techniques from social action and locality development models, and from one-to-one case work, can be adapted to achieve community development goals.
People in times of crisis will have different needs for support than those who feel strong enough to take on policy-makers to bring about social change; therefore the role of the worker will differ accordingly. The continuum in Figure 5.1 gives some guidance to the role most suitable at the time.
FIGURE 5.1 The community development continuum
(Source: Adapted from Jackson T, Mitchell S, Wright M 1989 Community Health Studies, 13(1):66–73)
In crisis situations community development workers assist families with everyday survival issues, because suffering is paralysing and incapacitating. Sometimes people are not in the position to think any more broadly than their day-to-day survival needs and it would be unethical not to address these as a first priority. However, in community development, workers need to nurture people’s abilities to take control over decisions rather than fostering their dependence on health workers. In Chapter 2 we refer to the ‘strengths perspective’ when working with individuals, and in Chapter 6 we refer to asset-based assessments when working in communities. These are conceptual models which enable us to describe the strengths of individuals and communities. Those working in the field of positive psychology, for example, advocate a change from focusing solely on repairing damage in individuals and families to one which includes ‘building the best qualities in life’ (Seligman 2002 in Jimerson et al 2004: 9).The role of the health worker, therefore, also involves supporting individuals with a ‘good’ idea; an idea that may benefit the wider community. Insight 5.3, the story of social transformation in Bromley-by-Bow in inner-city London (presented later in the chapter), provides a clear example of this principle being successfully implemented (Mawson 2008).
One role for the worker here is to link vulnerable people into existing social networks of support because of the recognition that socially integrated people have a greater sense of empowerment and wellbeing. Social isolation of individuals is reduced through group discussion with others in similar situations, formation of self-help activities and facilitation of programs that enhance community integration. The worker supports activities which enable people to ‘shift their safety net from dependence in unequal power relationships of worker/client to a more equal base amongst peers’ (Jackson et al 1989: 69). It may enable people to join others with similar ‘good’ ideas.
This is an important part of the community development workers’ role because it marks the transition of community members’ capacity and strength to take part in community-wide issues that directly affect their lives in order to bring about wider change, rather than as a means for their personal survival. This emphasises the importance of careful selection of issues, discussed earlier. The role of the worker is to have a ‘repertoire of strategies’ that ‘foster confidence that joint action will achieve the desired change’ (Jackson et al 1989: 70).
The key role at this stage on the continuum is one of empowerment of community members. Refer back to earlier discussions of empowerment and participation and to the discussion of Arnstein’s Ladder of Citizen Participation (1971) in Chapter 2, which emphasises the importance of true participation in decision-making and control of services rather than degrees of tokenism. At the beginning people tend to become involved in decision-making at a localised level to ensure that service provision meets their needs in activities such as neighbourhood houses or school councils. Community members are encouraged to view this local participation as a means of getting involved in wider social issues, not as an end in itself.