Community wellness (or wellbeing) refers to an optimal quality of community life, one that meets people’s needs and that creates harmony and social justice within a vibrant, sustainable community (Rural Assist Information Network (RAIN) 2009 Community wellbeing, 2009 and The Ian Potter Foundation, 2009). The Government of Victoria (2009) identifies a number of priorities that promote community wellbeing. These include having governments that are responsive to the needs of new communities, building community capacity through a sense of belonging, working towards economic developments to sustain the population, and creating safe environments with opportunities for healthy activity, recreation and social interaction. These are essential characteristics of community health.

As members of a community, our lives are closely interwoven with the lives of others, some

of whom live in close proximity to us; others who share common characteristics but do not inhabit our geographical space.

We also hold membership in various population groups on the basis of gender, age, physical capacity or culture. In the context of all of these group memberships, we interact with a moveable feast of other richly diverse communities. To these interactions we bring our own individuality; the combination of genetic predispositions, history, knowledge, attitudes, preferences and perceptions of capacity. Each community, in turn, brings to each of its members a set of distinct environments: physical, psychological, social, spiritual and cultural. Our socio-ecological interactions shape a characteristic community character, which determines the extent to which community members will become a cohesive entity. Each of these interactions, whether with our families, social groups or our physical environment, transforms the community as well as its residents. Bandura (1977) called this reciprocal determinism. By reciprocal determinism he meant that both the behaviours of people and the characteristics of their environments are determined by the set of dynamic exchanges between them.

Ecological exchange can yield both constraints and enhancements to personal and community health. Some of the more familiar constraints on health and wellbeing arise from the effects of contaminants in the physical environment, such as air and water pollution, infectious diseases and/or injury. Some degree of risk to health and wellbeing is also present in the social environment; in the workplace, school and neighbourhood. Interactions with our environment in recreation, education and social interchange present opportunities for achieving higher levels of health and wellbeing. Interactions between community members and the health care system are also imbued with challenges and opportunities for illness prevention and health improvements. For those of us whose role involves helping people achieve and maintain good health and protection from illness or injury, it is important to understand the effects of these interactions.

Like individuals, communities are open to a variety of interpretations. If you were to ask ‘How healthy is the community in which I live?’ a number of issues might come up. To gain at least a cursory view of the community you could look around at the geography. You might find yourself in a small town with plenty of vegetable gardens, well-kept houses, playgrounds and sporting fields, a community centre complete with child-minding facilities, a mix of healthy looking young and older people on the streets, none of whom are smoking, and public transportation. A very different picture may emerge if you cast your gaze to an inner-city neighbourhood where children play on the streets between parked cars, ramshackle buildings loom skyward with broken windows punctuating the places where people live, cars hoon around the corners, no older people walk the streets, and children seem to be tending to younger children with no adults supervising their activities. A vastly different community might emerge the further you get from the city. Depending on which continent you were in, you might find starving babies suffering from rampant disease, or Indigenous people smoking around a campfire, or an isolated farmer, too poor to either heat his frozen house or cool a sweltering one, reacting to his frustration by abusing his wife and children. Or, you might find happy, contented families, enjoying the fruits of their toils, whether on the land or in the city.

In each of the situations mentioned above, you could jump to a number of conclusions about the way the physical environment enhanced or impeded the health of the community. But in each community, a set of unseen influences lies just below the physical surface. For example, the small town may be comfortably situated in a place where everyone wanting employment has a job, because of a political decision taken some time previously to relocate a manufacturing company there. The playgrounds and sporting fields may be a product of a community development program and a workplace policy that provides flexible working hours so parents can take their children to sports. A local non-denominational church may have been built to double as a respite centre for carers, or a mothers group, or some other activity that keeps adults connected with one another. The schools may be well resourced because a government body has decreed that children should not be disadvantaged irrespective of where they live. In contrast, the inner-city neighbourhood may be neglected by government policies, with inadequate educational facilities. Young mothers raising children alone may be working swing shifts, leaving young children in the care of other children. Vandals may be receiving no deterrents because of a lack of funding for social policies, perhaps because military spending takes precedence over social services and local policing. In the rural area, a farming community may be suffering from the lack of markets for their produce, or have no chance of fertilising their lands to grow produce in the first place because of conservation policies. They may also be disadvantaged by natural disasters such as drought, or be vulnerable to mortgage lenders, substandard places to shelter, or unemployment. These aspects of community life are considered SDOH.

The diagram in Figure 1.2 illustrates the social and structural determinants of health from a socio-ecological perspective. The metaphor of a cascade of bubbles is used to show the dynamic interaction between factors (Wilcox 2007). Each bubble interfaces with many others, and if one bubble is displaced or happens to pop, there is a cascade effect, where the surface tension and connectivity of the others are changed. One bubble may be directly influenced by an adjacent bubble, but it is also indirectly influenced by that bubble’s connections to other surfaces. The bubbles may also merge and increase or decrease in size or in relation to one another. If there are changes in the wider environment, such as policy changes or a major environmental change, all bubbles may be affected or even disappear. In terms of the metaphor it would be like blowing air across the entire cascade or changing the water flow (Wilcox 2007).

The ‘social determinants’ approach to health resonates with the notion of human rights and social justice. Social justice refers to the ‘fair distribution of society’s benefits, responsibilities and their consequences’ (Edwards & MacLean Davison 2008:130). This means that as health professionals, we have an obligation to identify unfairness or inequities, and their underlying determinants, advocating for human rights, and working towards just economic, social and political institutions (Edwards and MacLean Davison, 2008 and Whitehead, 2007).

Equitable, socially just conditions in our communities and society are a matter of life and death, affecting the way people live, their chances of becoming ill or their risk of premature death (CSDH 2008). In 2005, recognising the human rights implications of good health and the role of social determinants in supporting health and wellbeing, the WHO assembled an international Commission on Social Determinants of Health (CSDH). The Commission represents 19 countries, including Australia. After gathering information for 3 years, members met to consider global progress on eliminating disparities in health and how to encourage a more equitable social world.

The commissioners were united in three concerns: their passion for social justice, their respect for evidence and their frustration with a lack of progress on global responses to the SDOH (CSDH 2008). They recommended that governments everywhere take up the challenge of working with health and other organisations to improve health for the world’s citizens. This involves reframing health services in terms of primary health care (PHC), ensuring sufficient health professionals to provide care, addressing economic issues, overcoming inequitable, exploitative, unhealthy and dangerous working conditions, including restoration of work–life balance for families, and providing social protection for all people across the life course (CSDH 2008). These overarching goals urge us to act in concert with members of our communities, igniting our passion for health and social justice and combining it with research that will build better understanding of what works, where, for what populations, with what outcomes.

The family’s socio-economic status is an important determinant of health. Research studies have shown that there is a ‘social gradient’ in health, whereby those employed at successively higher levels have better health than those on lower levels (Navarro, 2009 and Hertzman and Power, 2006). This creates disadvantage from birth for some children. A child born into a lower socio-economic family for example, may be destined for an impoverished life, creating intergenerational ill health. This child lives in a situation of ‘double-jeopardy’, where interactions between the SDOH conspire against good health. Without external community supports the family may spiral into worsening circumstances, affecting their child’s opportunities for the future. This is the case for many Indigenous people, whose parents have not had access to adequate employment or community supports that would sustain their own health, much less that of their children. They become caught in a cycle of vulnerability where the SDOH interact in a way that creates disempowerment across generations. Political decisions governing employment opportunities may hamper the parents’ ability to improve finances.