Although community is a part of our daily experiences, the idea of community is elusive and can mean many things, particularly in a health care context (Bent, 2003). Attitudes about the role of community in health care and health policy differ when compared with attitudes about the role of community in other areas. For example, health care entrepreneurs view health care communities as a market where they are likely to find a concentration of persons to buy health care goods or services; however, public health professionals must be concerned about entire populations in a given area regardless of people’s ability to buy, knowing that where economic market potential is lower, health risks and needs may actually be higher (Geronimus, 2000). Although the concept of community has broad appeal, in a politically charged environment, claims of community often become moral claims that may serve to divide people more than bring them together (Monroe, 1997). For example, differing neighborhoods within cities or towns may have competing interests for zoning regulations that affect traffic flow in and out of the community, local job opportunities, and health risks associated with production waste. This effect has serious consequences for questions of public health and the policies that support or define public health, such as policies that mandate reporting of or vaccination against communicable diseases or policies that exclude certain health care treatments from government health insurance programs.

Milio (2002) has noted that the basis for health lies in physical communities, where we find homes, schools, recreation and entertainment centers, faith centers, businesses, and governmental and voluntary organizations. These assets, along with means of communication and transportation, form a community’s infrastructure (Box 91-1). The quality, availability, and accessibility of the infrastructure make a difference in health prospects of the people who live in those communities.

Communities must share both spirit and a sense of place in order to build, achieve, and sustain health and well-being. Through attachment to place, communities share attachment to social responsibility for creating healthy surroundings. This attachment does not exist among detached groups that may share other interests (Milio, 1996). The importance of the physical and socio-economic environments in determining the health and needs of communities and individuals is well-recognized. As noted by the Institute of Medicine, “the health risk conferred by place is above and beyond the risk that individuals carry with them” (IOM, 2003, p. 68), and there is international interest in understanding the relationships among communities of place and health of the population (Diez Roux, 2001; Durie & Wyatt, 2007). Commitments to community-level responsibility for healthy populations pose challenges to most of our current and emerging health policies, which overwhelmingly target health care service delivery and health insurance. Can you think about what kinds of actions or policies within your community may be affecting health or quality of life? How would you work within a multidisciplinary context to promote health at the community level in these areas?

In the late 1970s, the World Health Organization (WHO) embraced the principles of social justice and equity and challenged nations to provide a basic level of health for all citizens. They called the principal means to this end primary health care (PHC) (WHO, 1978). PHC is essential, practical, scientific, socially accepted, universally accessible to all members of a community, affordable, and geared toward self-reliance and self-determination, and it involves multiple agencies and sectors in health. This marked a shift away from dependence on health professionals and toward personal and community involvement, which WHO reaffirmed in the 1980s.

Today, growing social significance of health and health care and economic burden, plus a current awareness of lost opportunities and important health inequities has given rise to widespread interest in reforming health systems. Many of today’s authorities and leaders no longer limit their responsibility for health to survival and disease control, but undertake building systems that support health as a key resource and strength that people and societies value (WHO, 2008).

The goals of health care service delivery and better health for all in a population are not mutually exclusive, but the degree of emphasis on one or the other is important since public policy is a highly influential force at all levels of health care in this country. Questions of emphasis remain relevant as national policies “decentralize,” state policies “localize,” and individuals and communities are told they hold more responsibility than ever for their own health (Box 91-2). This implies that the individual or the single community is responsible for the success (manifested through personal or population health measures) or failure (seen in ill health) of public health policy.

Nurses have a tradition of actively creating and fostering partnerships for health promotion and community health, and their role remains vitally important today, for they are named by the WHO as the critical professional link to create communities that are healthier for both individuals and for the entire population (WHO, 2000).

Healthy communities may be achieved through truly active and collaborative partnerships among a broad representation of professional and lay community members, but it is important to examine all partnerships critically (Aronson, 1993). Partnerships may become a substitute for accountability in organizations or governments, as individuals and small organizations are expected to assume labor and costs associated with initiatives to improve health. A caring partnership between nurse and community is a collaboration that is an informed, flexible, and negotiated distribution and redistribution of power among the participants in the process of seeking change for improved community health status, process, and structure. Effective community collaborations are far more than nursing “interventions”; rather, they evolve through a dynamic process and with philosophic underpinnings called for by true partnership (Box 91-3).

Roles for nurses in healthy community initiatives focus on community action, developing personal skills in community members, eliciting and supporting existing strengths within communities, reorienting health care services, creating supportive environments, and participating actively in the creation of healthy public policy. Nurses also foster critical reflections among community members who are acting in partnerships. Nurses cannot ignore political, social, or cultural structures, material conditions, or the play of power in relationships between and among individuals and groups in communities. Nurses must continue to explore health policy in ways that make the relevance of community involvement in health development clear. This supports not only health status of individuals, but also structures and processes that are the community-based determinants of health (Box 91-4).

Within public policy arenas, views differ about the proper primary focus of health policy: Is the primary purpose of health policy to deliver health services to or to improve the health and well-being of populations? Researchers have increasingly documented that the portion of population health status attributable to health care services is modest when compared to the contributions of other factors, including the sociopolitical determinants of health. Indeed, Healthy People 2010, a federal effort to outline national public health objectives, identified access to health care as only 1 of 10 leading indicators that, in addition to income and education, could serve as measures for the health of the population (USDHHS, 2000).

Determinants of health are factors in the sociocultural and political environments that contribute to or detract from the health of individuals and communities. These factors include, but are not limited to, income, education, occupation, transportation, sanitation, housing, access to services and resources linked to health, social support, and environmental hazards. Social forces that act at a collective level, such as a community decision to build sidewalks to promote safe walking opportunities, shape individual biology, individual risk behaviors, environmental exposures, and access to resources that promote health (Box 91-5).

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