What is "community health"? Examining the meaning of an evolving field in public health.

In this commentary, we review definition frameworks for community health and examine factors having core relevance to shaping the meaning of this term and growing field. We conclude by suggesting a potential framework for conceptualizing and advancing this field of public health practice through improved understanding of the meaning, scope, and science of community health. Published by Elsevier Inc.

Introduction

The evolution of public health has led to substantial changes in approaches to improving the health of members of communities. In the United States, these changes reflect the influence of many community-centered health developments, including the creation of national-level programs enacted by Congress, the establishment of dedicated governmental units at federal and state levels, and the implementation of innovative health programs at the community level by a variety of other organizations. For example, in 2011, the federal Centers for Disease Control and Prevention (CDC) created an organizational unit for community health to lead the implementation of some congressionally-enacted initiatives, such as Communities Putting Prevention to Work (CPPW), Racial and Ethnic Approaches to Community Health (REACH), and other programs designed to improve health status within communities (Bunnell et al., 2012; Centers for Disease Control, Prevention 2011).

Despite these developments, the meaning and strategic significance of community health remain challenging to fully define and to clearly distinguish from related areas of public health practice, community engagement, or other related community development activities. The uncertainties surrounding the meaning of community health are apparent even in the term’s deconstruction, as suggested by MacQueen and colleagues who – in commenting on the need for consensus on the definition of “community” within a public health context – noted that “… the lack of an accepted definition of community can result in different collaborators forming contradictory or incompatible assumptions about community and can undermine our ability to evaluate the contribution of community collaborations to achievement of public health objectives” (MacQueen et al., 2001).

These and other constraints on the shared understanding of the meaning and scope of community health may hamper the growth and effectiveness of this field. To address these challenges and help foster improved understanding of science and practice in “community health”, in this commentary we review definition frameworks for community health and examine factors having core relevance to shaping the meaning of this term and growing field. We conclude by suggesting a potential framework for conceptualizing and advancing this field of public health practice through improved understanding of the meaning, scope, and science of community health.

Approaches to defining “community health”

In the United States, the field of community health is anchored in a rich history of innovations in public health methods and programs directed at reducing risk factor prevalence, decreasing acute and chronic disease burden and injury occurrence, and promoting health. Among these are seminal community intervention trials in the 1970s – such as the Stanford Three Community Study, North Karelia Project, and Stanford Five-City Project (Farquhar et al., 1977; Fortmann et al., 1995; McAlister et al., 1982; Salonen et al., 1981; Stern et al., 1976; Wagner, 1982) – and a spectrum of community-centered efforts, including CDC’s Planned Approach to Community Health program in the early 1980s (Kreuter, 1992). Examples of programs introduced more recently include CDC’s Steps Program, Healthy Communities Program, REACH, and CPPW (Bunnell et al., 2012; CDC, Steps Program; CDC, Healthy Communities Program). Examples of non-governmental, community-based organizations and programs are the North Carolina Community Health Centers Association (North Carolina Community Health Center Association), Kellogg Health Scholars (Kellogg Health Scholars), and Robert Wood Johnson Foundation’s Community Health Leaders Program (Robert Wood Johnson Foundation Community Health Leaders Program; Robert Wood Johnson Foundation Community Health Leaders Award).

Despite this long history of community health programs, approaches to defining the meaning and scope of community health, as available in the peer review and pedagogical literature, are limited in number. Previous efforts to define “community health” were developed primarily for academically-centered texts and other information sources. These definitions largely have not been positioned to frame the expanding field of community health in public health practice and the importance of community engagement. For example, in their 1999 text on community and population health, Green and Ottoson defined community health as referring to “… the health status of a community and to the organized responsibilities of public health, school health, transportation safety, and other tax-supported functions, with voluntary and private actions, to promote and protect the health of local populations identified as communities.” A community was defined as “a group of inhabitants living in a somewhat localized area under the same general regulations and having common norms, values, and organizations” (Green and Ottoson, 1999). In their 2005 text, McKenzie and colleagues offered this definition: “Community Health refers to the health status of a defined group of people and the actions and conditions, both private and public (governmental), to promote, protect, and preserve their health” (McKenzie et al., 2005). In general, earlier programs and academic descriptions tended to frame communities as mutually exclusive and as having minimal within-community variation. Although this approach may be useful in simplifying study design and program implementation, it typically does not reflect the reality of the situation.

The term “community health” also appears in the titles of units and programs in a small number of state and federal public health agencies, academic programs, and other settings, such as health care systems. But for these, too, the meaning of community health is not readily apparent through publicly-available mission statements or other information sources. For example, in Georgia, the state-level executive branch agency responsible for health is the Georgia Department of Community Health which specifies that its mission is to provide Georgians with “… access to affordable, quality health care through effective planning, purchasing and oversight” (Georgia Department of Community Health). The Michigan Department of Community Health’s mission is to “… protect, preserve, and promote the health and safety of the people of Michigan with particular attention to providing for the needs of vulnerable and under-served populations” (Michigan Department of Community Health). Within the federal government, CDC’s Division of Community Health strengthens community-level health efforts and helps communities prevent disease and promote healthy living through an emphasis on reaching people who experience the greatest burden of death, disability, and suffering from chronic diseases (CDC Division of Community Health). Examples of other programs are Kaiser Permanente’s “Community Health Initiatives” — a collaboration with community-based organizations and residents to focus on prevention by supporting policies and environmental changes that promote healthy eating and active living in neighborhoods, schools, and work-places (Kaiser Permanente Community Health Initiative), and the Stanford School of Medicine’s Office of Community Health with a focus on sustained community engagement in local health issues and training leaders in community health (Stanford School of Medicine Office of Community Health).

These examples of definitions demonstrate the ambiguity and overly general use of the term “community health”. The value of developing a definition for “community health” that reflects the diversity and values of communities, and how communities make decisions, while providing some modicum of order that supports the systematic generation of evidence, is critical to the advancement and maturation of the field.

Focus areas that frame the meaning of “community health”

As we have suggested, existing definitions for community health –including those presented above in academic venues and public agencies – are not positioned to frame the expanding field of community health in public health practice settings as exemplified by many contemporary programs and, therefore, may not meet the needs of the communities such programs are intended to serve. Nonetheless, these definitions do provide important cues for helping to shape the meaning of community health in the context of newly emerging programs and priorities. These cues sort into four basic focus areas that collectively help to frame a definition of community health.

The first focus area – “community” – encompasses population groups and the locus (e.g., place, venue, or other unit) of programs, interventions, and other actions. These elements can overlap and, therefore, are not mutually exclusive, and include: (i) as suggested by MacQueen and colleagues, “A group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings” (MacQueen et al., 2001); (ii) venues or areas that are identified with key activities, such as residence, work, education, and recreation; and (iii) venues or areas that are physically-, geographically-, culturally-, and administratively- or geopolitically-defined. Examples of the latter include groups of persons who are defined by locality (e.g., block, neighborhood, precinct, village, town, city, county, region, other), or who are defined (sometimes self-defined) by racial-ethnic, age, or other characteristics. Most people are members of multiple types of communities (e.g., physical, work, social, spiritual) that may have different priorities, needs, cultures, and expectations.

The second area – “health” – may be defined differently as a function of a community’s experience and expectations. The definition of health in a given community may further define the enterprise of community health and how community health is put into action (e.g., the methods, measures, process, and outcomes used for implementing a community health effort in a given setting).

The third area – interventions – encompasses the scope of the intervention(s) being delivered within the community, and reflects the input, needs, perspectives, and goals of communities as they work to improve their health. This may include interventions such as creating safe and healthful environments; ensuring health equity for all members of the community (Centers for Disease Control, Prevention —Division of Community Health, 2013); implementing programs to promote health and to prevent disease and injury; and fostering linkages between community and clinical programs and other resources to support health (Bauer UE et al., 2014).

The final area – the “science of community health” – encompasses the methods that are used by the field to develop and evaluate the evidence base that underlies the conception, design, implementation, evaluation, and dissemination of interventions. Community health draws upon a multitude of applied and theoretical public health, medical, and other scientific disciplines in terms of methods (e.g., surveillance and surveillance systems [such as the Behavioral Risk Factor Surveillance System and Youth Risk Behavioral System], epidemiology, evaluation), and expertise (e.g., prevention effectiveness, health economics, anthropology, demography, policy, health education, behavioral sciences, and law). However, the evidence base for community health may be inherently limited because of the absence of consensus, or even general agreement, on the definition and scope of a target “community”. Because of the complexity of working in communities, the “clean” scientific methods used in experimental design often are not relevant and cannot be directly applied. Thus, one of the greatest challenges also represents an opportunity for the field of “community health” to develop innovative methods that account for the complexity of communities, variability in how health in communities is defined, and how evidence can be generated that reflects the reality of the communities in which people live, work, and play.

In their assessment of what had been learned about contributions of community-based interventions to public health, Merzel and D’Afflitti suggested several other factors that help to explain the lack, or limited strong effect, of such programs, including methodological challenges to study design and evaluation, concurrent secular trends, smaller-than-expected effect sizes, limitations of the interventions, and limitations of theories used (Merzel and D’Afflitti, 2003). To this list can be added the need for better integration of “practice-based” evidence which is critical to enable public health scientists to understand the community and generate evidence that will be relevant to practice. For many public health outcomes, particularly decreases in chronic diseases, the full benefits of community level efforts to reduce chronic disease risk factors, such as obesity and tobacco use, may not be evident for many years, further challenging program evaluation. The outcomes often are influenced by many factors that might be addressed differently in different communities. The evidence base also may be influenced by circumstances associated with the creation of some community health programs — circumstances that have the potential for constraining the optimal application of scientific methods. However, even in the face of such constraints, the evidence from these practical studies might in reality be more relevant in addressing problems in the communities being served.

Core principles for advancing community health

We have suggested that there is a need for a broader construct for “community health” that affirms this area as a distinct field within public health practice, and that fostering understanding of a contemporary definition of this maturing field will assist in advancing its goals. To that end, based on the focus areas outlined in this commentary, we offer the following as an example of a definition of community health that accords with needs of U.S. public health practice: “Community health is a multi-sector and multi-disciplinary collaborative enterprise that uses public health science, evidence-based strategies, and other approaches to engage and work with communities, in a culturally appropriate manner, to optimize the health and quality of life of all persons who live, work, or are otherwise active in a defined community or communities.”

The core principles of community health are built on an understanding of core functions of community health programs and science. In many ways these resemble core public health functions; however, at their core they are explicitly focused on the intersection of the community’s needs, the community’s understanding of and priorities for health, and the best methods for documenting the evidence garnered from practice in the community, as well as the evidence from the science of community health.

We also have suggested that this field relies upon its own “methods of community health” that reflect a blend of approaches from multiple disciplines that have been tailored to this field, but that these approaches are subject to many challenges, some of which are unique to this emerging field. In the face of these challenges, the following core principles are suggested in furtherance of the science of community health:

Engage communities, governmental, academic, and other stakeholders in developing a shared agenda for applied research on community health in the United States;

Implement and use results of community health assessments (e.g., measuring and characterizing risk factors within, and the health status of, the community) as a core element in improving a community’s health;

Identify short- and long-term measures for defining the “healthy community” as an endpoint for the effects of interventions or actions that reflect the community’s interest;

Improve methods of surveillance for community health, including development of a case definition for a “healthy community”;

Enhance scientific design principles for generating and documenting both practice- and research-based evidence from programs and interventions that improve community health (using, as indicated, community trials, retrospective cohort studies, cross-sectional surveys and studies, time-series analyses, and ecological studies), and enhancing methods for using “control” communities for evaluation, as well as meeting challenges associated with control communities (e.g., neighborhoods) (Stern et al., 1976; Farquhar et al., 1977; Salonen et al., 1981; McAlister et al., 1982; Wagner, 1982; Fortmann et al., 1995); and

Maintain engagement with communities from the start through post-completion of a program or intervention (i.e., community health’s commitment transcends implementation and assessment of an intervention by building evidence through sustained engagement with the community).

Ultimately, improved and shared understanding of the meaning of community health should help in furthering broader attainment of healthier communities that are characterized by better health and quality of life for members of the community, however defined. The field of “community health” reflects the needs of the community and exemplifies the best of public health research and methods to achieve the shared goal of improving health.