Introduction

It is generally agreed that poor health and poverty are inextricably linked and that ill health will not be solved by medicine alone, but by more effective public health measures and socio-economic change. Access to a sustainable income, an equitable and accessible food supply, tackling crime, responding differently to mental health issues, housing and environmental needs and the building of social capacity are some of the issues which, it is suggested, if addressed would have a long-term impact on community health. That poverty is the key indicator in poor health is now indisputable (Marmot & Wilkinson 1999, The Black Report, Townsend & Davidson 1982), but the historical relationship between the NHS and medical/clinical model of health has arguably compounded the problem of inequality in health. Until recently the sole focus of the NHS has been primarily on treatment and disease and, although these are undeniably important, there has been a tendency to view health as only treatment and cure. The preventive aspect and the impact of poverty on health have traditionally been believed to have been outside the scope of medicine, and health promotion/improvement, when it occurred, has been regarded mainly as relating to individual behaviour change based on an information giving process.

The NHS value system has encouraged ways of working to address health needs that are, arguably, more comfortable culturally for higher socio-economic groups. Little or no focus has been placed on how the people with the poorest health might perceive a system that seems to ignore their needs. People struggling with stress and financial difficulties, or who feel themselves outwith societal norms, need different, more creative ways of allowing their legitimate voice in the decisionmaking process. Much of the profound inequity in peoples’ health is socially determined and arises from the circumstances in which people live and work. Poverty is more than low income, a lack of education and poor health. It is also an experience of feeling powerless to influence the social and economic factors that determine wellbeing. Poor health exacerbates existing poverty and poverty is most often a political problem, i.e. people are poor because of structural, man-made situations.

Failure to recognise and address the issue that much of our ill-health lies outwith what the NHS currently offers results in the NHS treating poverty and the impact of poverty as a medical condition. This only serves to increase the health inequalities gap and ultimately leads to the medicalisation of poverty and an increase in health inequality.

The adoption of the ideology and methods of community development offer workers involved in public health work an approach to address the inequalities in health that underpin many of the health problems in our communities. This chapter will briefly explore the historical context of community development and the radical influences on the community health movement in the 1960s and 1970s that are arguably still pertinent to the implementation of a public health strategy today.

This chapter suggests that it is the approach to health and a change in the underlying values in relation to health that will create new ways of working and so make a difference. The difference will come from a model of public health that gives the individual and community the tools and knowledge to make the changes for themselves and their families. The outline of a model of community development that focuses on child health will suggest how the application of the methods to one area of health activity can have an impact on the health of the wider community. Finally, the chapter suggests that if a new way of thinking about health is to develop, one that focuses on addressing inequalities and using community development as a mainstream approach, then health workers will need strong leadership, changes in the education curriculum, and the development of structures and policies to support them in thinking and doing differently.

Community development: origins and influences

Although community development is now gaining recognition as an approach to health, the methods and thinking that constitute community development are not new. Jones (1990) suggests that it was used by colonial governments to ‘ensure the governability and modernisation of their empires’ (p. 32). It was more recent events, however, that nurtured its growth and its value as an approach to addressing health issues.

According to Jones (1990), community development and health work had evolved over the previous 10 years, incorporating a number of different influences that had built onto a basic community development model. The growing movement in health occurring in the last few decades has used community development as an ideological and practical framework to bring about change in how health as a concept is regarded. Previously used as a method in community work to address housing and social policy needs, the first health projects using community development principles did not appear in the UK until the late 1970s. The emergence, in the late 1960s and 1970s, of social movements like the women’s movement, civil rights, black power and the self-help movement, was a key influence in supporting the growth of the approach.

A social movement is defined as: ‘collectively acting with some continuity to promote change in the society or group to which it is a part’ (Turner & Killian, quoted in Schiller & Levin 1983, p. 1344). The social movements of this time grew from the disaffection of people who felt marginal to and excluded from decision-making processes. It was a reaction to the dominant male, white, middle-class systems and the attitudes that discriminated against women, black people and the poor. The movements demanded justice, freedom, democracy and the end of discrimination. Underpinning their emergence was a belief system that held the primacy of individual experience as the basis of knowledge and expertise.

The primary challenge of both the women’s health movement (which grew out of the women’s liberation movement) and the self-help movement was to demystify health knowledge and retake its ownership from the male-dominated med-ical profession, which so jealously guarded it as its own. As a consequence, they developed an anti-professional view of health and the causes of ill health and encouraged individuals to become experts in their own bodies. They encouraged people to view what they knew, derived from their own experiences, as being as important as the theoretical knowledge that had evolved conceptually and been filtered through a dominant male medical ideology. In consciousness-raising and self-help health groups, women began to see how this latter view of themselves was reinforced by their contact with the medical profession and that it adversely affected their health and their access to health services.

The Black Report (Townsend & Davidson 1982) indicated that the groups for whom the social movements had, potentially, the greatest impact, that is, those who are socially and economically disadvantaged, who are more likely to experience poorer health and have shorter lives than more affluent people. The community development ethos will bring into the awareness of public health workers that these groups of people, and others who feel socially excluded from mainstream society, e.g. homeless, disabled, have knowledge and experience about their own lives that, when harnessed, can strengthen and sustain their communities.

The right of people to participate in health decisions is enshrined in the Alma Ata Declaration of 1977 (World Health Organization (WHO) 1978). It states that ‘the people have a right and a duty to participate individually and collectively in the planning and implementation of their care’. The desire for a public health movement to tackle health problems resulted, in 1981, in the WHO policy Health For All by the year 2000. Central to the attainment of its targets is the development of primary care and the concepts of participation, collaboration and equity that were central to the Alma Ata Declaration.

The dominance of the medical model in public health thinking, and its focus on epidemiology and medicine, has left an ontological deficit in what health workers working in public health know about the poorest communities; what they need to promote health and to build the social capacity of their neighbourhoods and communities. Involvement in public health work, through activities like communitybased needs assessment, public involvement in primary care planning and delivery of services, would legitimate the community development approach and support the move away from the clinical model based on individual, transactions to a social contract with entire communities (Ashton & Seymour 1988). To fit the new agenda of addressing social, as well as individual, change in health, health workers require a change in their approach to health as a concept, and to the methods and the activities of its daily practice.

Poor people define their poverty in terms of lack of opportunities, lack of power and lack of security so this broader definition of poverty will require a broader set of actions to fight it. The impact of providing social services to the poor has been less than expected, mainly because interventions do not respond to poor people’s real needs.

The key tenets of a community development approach, collective action, self-determination, democracy and promotion of self-confidence are central to any policy to tackle inequalities in health and to address poverty. Community development as a concept is now high on the health agenda, however it is defined; but the way in which it fits into public health work and whatever activities health workers might engage in to bring about change are still not mainstream.

Elements of community development

A community development approach is a useful way to move from exclusion to inclusion in the decision-making process for marginal groups and the principles of the approach could form an essential ideology for groups of health workers. The approach is concerned with the notion of shared power between health professionals and lay people and the move from dependency to involvement. The concepts which underpin this approach are about equal access to resources, promoting democracy and involvement in decision making about health, taking action to bring about change, sharing power and working in partnership with communities.

Underlying each is the concept of shared authority. This means that each person takes equal responsibility for the decision making and each is accountable for the outcomes. Although conceptually different, each element of community development is related to, and has an impact on, the others. For example, when individuals are involved as equal partners and their knowledge affirmed, skills used and opinions heard, then they feel more in control and, in turn, are more able to begin to form alliances with others to bring about the changes they desire. A brief outline of each of the different elements will demonstrate this.

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