Chapter 10 Strengthening community action

Overview

We have seen in previous chapters how there are many different ways of working for health. Strengthening community action is one of the key action areas identified in the Ottawa Charter (World Health Organization (WHO) 1986). This chapter focuses on community development – a strategy which aims to empower people to gain control over the factors influencing their health. Working with communities to increase their participation in decisions affecting health is an essential aspect of health promotion. This chapter begins by defining what is meant by a community and goes on to explore different ways in which health promoters can work with communities. Some of the dilemmas that confront the health promoter who wants to work in this way are discussed and illustrated using examples of community development projects.

Defining community

The concept of community is frequently used in discussions about health and health care. In general, the context of the community is taken to be desirable; thus we have care in the community, community policing and community education, all of which are seen as preferable to alternative (non-community) practice. In contrast to the state or the bureaucratic organization, services provided by and in the community are viewed as being more appropriate and sensitive. But what is the community which is referred to in these ways?

There are different ways of defining a community, but the most commonly cited factors are geography, culture and social stratification. These factors are viewed as being linked to the subjective feeling of belonging or identity which characterizes the concept of ‘community’. Other characteristics of communities are social networks or systems of contact, and the existence of potential resources such as people’s skills or knowledge.

BOX 10.1

• Which communities do you belong to?

• Are these the same communities which your parents belonged to?

• What are the key characteristics of these communities?

Geography

A community may be defined on a geographical or neighbourhood basis (see Chapter 15). A well-known example is the East End of London, but this use of community is not restricted to working-class or urban areas. It is this notion of community which gives rise to ‘patch’-based work, where people such as social workers, police officers or health visitors are assigned a geographically bounded area. The assumption is that people living in the same area have the same concerns, owing to their geographical proximity. This in turn rests on an assumption that the physical environment is a key factor in influencing health and social identity.

Culture

Community may be defined in cultural terms, as in ‘the Chinese community’ or ‘the Jewish community’. Here the assumption is that common cultural traditions may transcend geographical or other barriers, and unite otherwise scattered and disparate groups of people. There is an expectation that members of a cultural community will assist each other and share resources. The most commonly cited elements of a common cultural heritage are ethnic origin, language, religion and customs.

Social stratification

A community may be based on interests held to be common, which are usually the product of social stratification. Thus we have ‘the working-class community’ and ‘the gay community’. This definition implies that members of a community share networks of support, knowledge and resources which may transcend other boundaries, even national ones.

BOX 10.2

Which definitions of community are being used in the following quotations?

• ‘A number of individuals with something in common who may or may not acknowledge that connection’ (Health Education Authority 1987)

• ‘A specific group of people who share a common culture, values and norms, and who are arranged in a social structure according to the relationships the community has developed over a period of time’ (Nutbeam 1998)

• ‘A locality which comprises networks of formal and informal relationships, which have a capacity to mobilise individual and collective responses to common adversity’ (Barclay Report on Social Work 1982)

• ‘People with a basis of common interest and network of personal interaction, grouped either on the basis of locality or on a specific shared concern or both’ (Smithies & Adams 1990, p. 9).

Most definitions of community tend to suggest that it is a homogeneous entity. However, it is obvious that any geographical community will include people whose primary identity is based on different factors, e.g. class, race, gender or sexual orientation. People who feel united by a shared interest, e.g. pensioners, or the unemployed, will also be members of other communities, geographical and otherwise. People may belong to several different communities, some of which may have more salience for the individual than others. In practice, people may find their allegiance to different communities shifting at different points in their life span.

The meaning and significance of community vary enormously. How one defines community is important because it influences how practitioners understand the dynamics within communities and the potential challenges that may present when working with them. Some communities may be easier to work with than others and practitioners may feel more comfortable working with some communities than others.

Defining community development

Community development has been defined as:

Building active and sustainable communities based on social justice and mutual respect. It is about changing power structures to remove the barriers that prevent people from participating in the issues that affect their lives. Community workers support individuals, groups and organisations in this process (Standing Conference for Community Development 2001).

Community development is both a philosophy and a method. As a philosophy its key features are:

• A commitment to equality and the challenging of attitudes and practices which discriminate against and marginalize people

• An emphasis on participation and enabling all communities to be heard

• An emphasis on lay knowledge and the valuing of people’s own experience

• The collectivizing of experience and seeing problems as shared, and working together to identify and implement action

• Recognizing the skills, knowledge and expertise that people contribute

• The empowerment of individuals and communities through education, skills development and sharing and joint action.

There is a difference between community-based work and community development. Many practitioners may work in the community, organizing projects to meet people’s health needs or doing outreach work where a professional service such as screening is extended into the community to make it more accessible. The Sure Start programme is an example of a community project providing early educational interventions in specific areas. Table 10.1 illustrates some of the differences between community-based work and community development work.

Table 10.1 Characteristics of community-based versus community development models

Community-based	Community development
Problem, targets and action defined by sponsoring body	Problem, targets and action defined by community
Community seen as medium, venue or setting for intervention	Community itself the target of intervention in respect to capacity-building and empowerment
Notion of ‘community’ relatively unproblematic	Community recognized as complex, changing, subject to power imbalances and conflict
Target is largely individuals within either geographic area or specific subgroup in geographic area defined by sponsoring body	Target may be community structures or services and policies that impact on the health of the community
Activities largely health-oriented	Activities may be quite broad-based, targeting wider factors with an impact on health, but with indirect health outcomes (empowerment, social capital)

After Labonte (1998).

The community development approach has been influenced by the work of Paulo Freire, a Brazilian educationalist who worked on literacy programmes with poor peasants in Peru and Brazil during the 1970s. Freire saw education as a way to liberate people from cycles of oppression. He aimed to engage the people in critical consciousness-raising or ‘conscientization’, helping people to understand their circumstances and why they have been oppressed. The process of ‘conscientization’ begins with problem-posing groups which seek to break down barriers and establish a dialogue between individuals and between individuals and the facilitator. Eventually a state of praxis is reached in which there is a common understanding and development of action and practice, whereby people collectively can transform their circumstances. The process is summarized as:

• Reflection on aspects of reality

• Search and collective identification of the root causes of that reality

• An examination of their implications

• Development of a plan of action to change reality (Freire 1972).

Community development is a recognized way of working which has given rise to a specific profession – community development workers, who are generally employed by local authorities to support, facilitate and empower communities. Community development workers have their own training courses, qualifications and professional associations.

Community development and health promotion

Community development is a recurring theme in health promotion. In the 1960s the Women’s Movement emphasized the need to reclaim knowledge about our bodies and control over our lives. Shared personal experience led to a new understanding of health issues as well as providing positive effects and social cohesion for participants. Black and ethnic-minority groups also addressed health issues, particularly the effect of racism within the health services (Jones 1991).

In the 1970s and early 1980s numerous community development projects were set up, mostly funded and located outside the National Health Service (NHS). Inner-city decline prompted youth work, neighbourhood centres and planning groups which drew attention to the relationship between poverty, health and inequalities in service provision (Rosenthal 1983). Within the health services, community development approaches remained marginalized.

In the latter part of the 1980s there was widespread lip service to the notion of community development, stimulated in part by WHO.

BOX 10.3

Consider the following statements from WHO on the importance of participation, involvement and community development. What do you think contributed to this emphasis on working with ‘the community’?

‘The people have a right and a duty to participate individually and collectively in the planning and implementation of their health care’ (WHO 1978).

‘Health for all will be achieved by people themselves. A well-informed, well-motivated and actively participating community is a key element for the attainment of the common goal’ (WHO 1985, p. 5, original emphasis).

‘Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities, their ownership and control of their own endeavours and destinies’ (WHO 1986).

‘Community action is central to the fostering of health public policy’ (WHO 1988).

‘Health promotion is carried out by and with people, not on or to people. It improves the ability of individuals to take action, and the capacity of groups, organisations or communities to influence the determinants of health. Improving the capacity of communities for health promotion requires practical education, leadership training and access to resources’ (WHO 1997).

Community development has been seen as the central defining strategy for health promotion (Green & Raeburn 1990). By the mid-1980s the Community Health Initiatives Resource Unit estimated that there were 10 000 local projects in existence. By the 1990s the lead health promotion agencies for developing strategies were under pressure as community development was seen as too radical. Its focus on structural causes of inequality, such as class, race and gender, was not acceptable to New Right political ideology (see Chapter 7 for more discussion of this). The Community and Professional Development Division of the Health Education Authority (HEA) was disbanded. The National Community Health Resource (NCHR) lost its funding from the HEA and Community Health UK (CHUK) lost its funding from the Department of Health.

Yet the 1990s also saw an emphasis on the concept of ‘community’. Strategies for service delivery were linked to the notion of community, and care in the community, community policing and community education emerged as key policies. The focus on the community needs to be seen in relation to the developing crisis in the role of welfare state provision and broader debates around accountability. Chapter 7 has shown how neoliberal concerns to retreat from welfare have been linked to a focus on individuals as consumers of services. Devolved services and an emphasis on participation and ‘consumer involvement’ were all strategies designed to achieve these aims.

‘Third-way’ politics in the UK draws upon ideas of communitarianism – that we are all linked together as citizens. Communal relations such as trust and reciprocity are to be valued and government action aims to bolster social capital (see Chapter 15 for a discussion of how neighbourhoods and the community became a focus for policy and analysis). A new government department of communities and local government, a public service agreement to build more cohesive, empowered and active communities, and Chapter 4 of the public health White Paper Choosing Health: Making Healthy Choices Easier (Department of Health 2004) all show a commitment to working through communities to create a stable, inclusive society.

The tradition of community development has radical roots and is closely associated with work to challenge the status quo, redistribute resources and address power imbalances across society. Although many have welcomed the adoption of once-radical terms such as empowerment and participation into mainstream policy language, there are those who suggest this mainstreaming of community development has diluted its aims and processes and resulted in a gulf between theory and practice (Berner & Philips 2005). There have been warnings that such ‘state-commissioned’ community development results in ‘not government by communities but government through communities’ (Shaw 2005). The policy focus on communities to bring about change (e.g. in neighbourhood renewal or antisocial behaviour) leads to communities, rather than society, being seen as responsible for the problems they face. This may be viewed as an extension, from individuals to communities, of the ‘victim-blaming’ principle.