Community health

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Community health is a branch of public health which focuses on people and their role as determinants of their own and other people's health in contrast to environmental health, which focuses on the physical environment and its impact on people's health.


Community health is a major field of study within the medical and clinical sciences which focuses on the maintenance, protection, and improvement of the health status of population groups and communities. It is a distinct field of study that may be taught within a separate school of public health or environmental health. The WHO defines community health as:

environmental, social, and economic resources to sustain emotional and physical well being among people in ways that advance their aspirations and satisfy their needs in their unique environment. [1]

Medical interventions that occur in communities can be classified as three categories: primary healthcare, secondary healthcare, and tertiary healthcare. Each category focuses on a different level and approach towards the community or population group. In the United States, community health is rooted within primary healthcare achievements. [2] Primary healthcare programs aim to reduce risk factors and increase health promotion and prevention. Secondary healthcare is related to "hospital care" where acute care is administered in a hospital department setting. Tertiary healthcare refers to highly specialized care usually involving disease or disability management.

The success of community health programmes relies upon the transfer of information from health professionals to the general public using one-to-one or one to many communication (mass communication). The latest shift is towards health marketing.

Measuring community health

Community health is generally measured by geographical information systems and demographic data. Geographic information systems can be used to define sub-communities when neighborhood location data is not enough. [3] Traditionally community health has been measured using sampling data which was then compared to well-known data sets, like the National Health Interview Survey or National Health and Nutrition Examination Survey. [4] With technological development, information systems could store more data for small scale communities, cities, and towns; as opposed to census data that only generalizes information about small populations based on the overall population. Geographical information systems (GIS) can give more precise information of community resources, even at neighborhood levels. [5] The ease of use of geographic information systems (GIS), advances in multilevel statistics, and spatial analysis methods makes it easier for researchers to procure and generate data related to the built environment. [6]

Social media can also play a big role in health information analytics. [7] Studies have found social media being capable of influencing people to change their unhealthy behaviors and encourage interventions capable of improving health status. [7] Social media statistics combined with geographical information systems (GIS) may provide researchers with a more complete image of community standards for health and well being. [8] [9]

Categories of community health

Primary healthcare and primary prevention

Community based health promotion emphasizes primary prevention and population based perspective (traditional prevention). [10] It is the goal of community health to have individuals in a certain community improve their lifestyle or seek medical attention. Primary healthcare is provided by health professionals, specifically the ones a patient sees first that may refer them to secondary or tertiary care.

Primary prevention refers to the early avoidance and identification of risk factors that may lead to certain diseases and disabilities. Community focused efforts including immunizations, classroom teaching, and awareness campaigns are all good examples of how primary prevention techniques are utilized by communities to change certain health behaviors. Prevention programs, if carefully designed and drafted, can effectively prevent problems that children and adolescents face as they grow up. [11] This finding also applies to all groups and classes of people. Prevention programs are one of the most effective tools health professionals can use to significantly impact individual, population, and community health. [11]

Secondary healthcare and secondary prevention

Community health can also be improved with improvements in individuals' environments. Community health status is determined by the environmental characteristics, behavioral characteristics, social cohesion in the environment of that community. [12] Appropriate modifications in the environment can help to prevent unhealthy behaviors and negative health outcomes.

Secondary prevention refers to improvements made in a patient's lifestyle or environment after the onset of disease or disability. This sort of prevention works to make life easier for the patient, since it's too late to prevent them from their current disease or disability. An example of secondary prevention is when those with occupational low back pain are provided with strategies to stop their health status from worsening; the prospects of secondary prevention may even hold more promise than primary prevention in this case. [13]

Chronic disease self management programs

Chronic diseases has been a growing phenomena within recent decades, affecting nearly 50% of adults within the US in 2012. [14] Such diseases include asthma, arthritis, diabetes, and hypertension. While they are not directly life-threatening, they place a significant burden on daily lives, affecting quality of life for the individual, their families, and the communities they live in, both socially and financially. Chronic diseases are responsible for an estimated 70% of healthcare expenditures within the US, spending nearly $650 billion per year.

With steadily growing numbers, many community healthcare providers have developed self-management programs to assist patients in properly managing their own behavior as well as making adequate decisions about their lifestyle. [15] Separate from clinical patient care, these programs are facilitated to further educate patients about their health conditions as a means to adopt health-promoting behaviors into their own lifestyle. [16] Characteristics of these programs include:

  • grouping patients with similar chronic diseases to discuss disease-related tasks and behaviors to improve overall health
  • improving patient responsibility through daily disease-monitoring
  • inexpensive and widely known Chronic Disease self-management programs are structured to help improve overall patient health and quality of life as well as utilize less healthcare resources, such as physician visits and emergency care. [17] [18]

Furthermore, better self-monitoring skills can help patients effectively and efficiently make better use of healthcare professionals' time, which can result in better care. [19] Many self-management programs either are conducted through a health professional or a peer diagnosed with a certain chronic disease trained by health professionals to conduct the program. No significant differences have been reported comparing the effectiveness of both peer-led versus professional led self-management programs. [18]

The distribution of rural CDSME program participantsvaried across the US. Analysis across rurality indicated that approximately 22.1% (using county-level rurality) to24.4% (using ZCTA/ZIP Code-level rurality) of CDSME programparticipants resided in rural areas. Distribution of the chronic-disease self-management program by ZIP Code and rurality.png
The distribution of rural CDSME program participantsvaried across the US. Analysis across rurality indicated that approximately 22.1% (using county-level rurality) to24.4% (using ZCTA/ZIP Code-level rurality) of CDSME programparticipants resided in rural areas.

There has been a lot of debate regarding the effectiveness of these programs and how well they influence patient behavior and understanding their own health conditions. Some studies argue that self-management programs are effective in improving patient quality of life and decreasing healthcare expenditures and hospital visits. A 2001 study assessed health statuses through healthcare resource utilizations and self-management outcomes after 1 and 2 years to determine the effectiveness of chronic disease self-management programs. After analyzing 800 patients diagnosed with various types of chronic conditions, including heart disease, stroke, and arthritis, the study found that after the 2 years, there was a significant improvement in health status and fewer emergency department and physician visits (also significant after 1 year). They concluded that these low-cost self-management programs allowed for less healthcare utilization as well as an improvement in overall patient health. [20] Another study in 2003 by the National Institute for Health Research analyzed a 7-week chronic disease self-management program in its cost-effectiveness and health efficacy within a population over 18 years of age experiencing one or more chronic diseases. They observed similar patterns, such as an improvement in health status, reduced number of visits to the emergency department and to physicians, shorter hospital visits. They also noticed that after measuring unit costs for both hospital stays ($1000) and emergency department visits ($100), the study found the overall savings after the self-management program resulted in nearly $489 per person. [21] Lastly, a meta-analysis study in 2005 analyzed multiple chronic disease self-management programs focusing specifically on hypertension, osteoarthritis, and diabetes mellitus, comparing and contrasting different intervention groups. They concluded that self-management programs for both diabetes and hypertension produced clinically significant benefits to overall health. [15]

On the other hand, there are a few studies measuring little significance of the effectiveness of chronic disease self-management programs. In the previous 2005 study in Australia, there was no clinical significance in the health benefits of osteoarthritis self-management programs and cost-effectiveness of all of these programs. [15] Furthermore, in a 2004 literature review analyzing the variability of chronic disease self-management education programs by disease and their overlapping similarities, researchers found "small to moderate effects for selected chronic diseases," recommending further research being conducted. [16]

Some programs are looking to integrate self-management programs into the traditional healthcare system, specifically primary care, as a way to incorporate behavioral improvements and decrease the increased patient visits with chronic diseases. [22] However, they have argued that severe limitations hinder these programs from acting its full potential. Possible limitations of chronic disease self-management education programs include the following: [19]

  • underrepresentation of minority cultures within programs
  • lack of medical/health professional (particularly primary care) involvement in self-management programs
  • low profile of programs within community
  • lack of adequate funding from federal/state government
  • low participation of patients with chronic diseases in program
  • uncertainty of effectiveness/reliability of programs

Tertiary healthcare

In tertiary healthcare, community health can only be affected with professional medical care involving the entire population. Patients need to be referred to specialists and undergo advanced medical treatment. In some countries, there are more sub-specialties of medical professions than there are primary care specialists. [12] Health inequalities are directly related to social advantage and social resources. [12]

Aspects of care that distinguish conventional health care from people-centred primary care [23]
Conventional ambulatory medical care in clinics or outpatient departmentsDisease control programmesPeople-centred primary care
Focus on illness and cureFocus on priority diseasesFocus on health needs
Relationship limited to the moment of consultationRelationship limited to programme implementationEnduring personal relationship
Episodic curative careProgramme-defined disease control interventionsComprehensive, continuous and personcentred care
Responsibility limited to effective and safe advice to the patient at the moment of consultationResponsibility for disease-control targets among the target populationResponsibility for the health of all in the community along the life cycle; responsibility for tackling determinants of ill-health
Users are consumers of the care they purchasePopulation groups are targets of disease-control interventionsPeople are partners in managing their own health and that of their community

Challenges and difficulties with community health

Summary of Governance Issues, Strategies, and New/Lingering Problems Table 2 Summary of Governance Issues, Strategies, and Problems.tif
Summary of Governance Issues, Strategies, and New/Lingering Problems

The complexity of community health and its various problems can make it difficult for researchers to assess and identify solutions. Community-based participatory research (CBPR) is a unique alternative that combines community participation, inquiry, and action. [25] Community-based participatory research (CBPR) helps researchers address community issues with a broader lens and also works with the people in the community to find culturally sensitive, valid, and reliable methods and approaches. [25]

Other issues involve access and cost of medical care. A great majority of the world does not have adequate health insurance. [26] In low-income countries, less than 40% of total health expenditures are paid for by the public/government. [26] Community health, even population health, is not encouraged as health sectors in developing countries are not able to link the national authorities with the local government and community action. [26]

In the United States, the Affordable Care Act (ACA) changed the way community health centers operate and the policies that were in place, greatly influencing community health. [27] The ACA directly affected community health centers by increasing funding, expanding insurance coverage for Medicaid, reforming the Medicaid payment system, appropriating $1.5 billion to increase the workforce and promote training. [27] The impact, importance, and success of the Affordable Care Act is still being studied and will have a large impact on how ensuring health can affect community standards on health and also individual health.

Ethnic disparities in health statuses among different communities is also a cause of concern. Community coalition-driven interventions may bring benefits to this segment of society. [28]

Community health in the Global South

Access to community health in the Global South is influenced by geographic accessibility (physical distance from the service delivery point to the user), availability (proper type of care, service provider, and materials), financial accessibility (willingness and ability of users to purchase services), and acceptability (responsiveness of providers to social and cultural norms of users and their communities). [29] While the epidemiological transition is shifting disease burden from communicable to non communicable conditions in developing countries, this transition is still in an early stage in parts of the Global South such as South Asia, the Middle East, and Sub-Saharan Africa. [30] Two phenomena in developing countries have created a "medical poverty trap" for underserved communities in the Global South — the introduction of user fees for public healthcare services and the growth of out-of-pocket expenses for private services. [31] The private healthcare sector is being increasingly utilized by low and middle income communities in the Global South for conditions such as malaria, tuberculosis, and sexually transmitted infections. [32] Private care is characterized by more flexible access, shorter waiting times, and greater choice. Private providers that serve low-income communities are often unqualified and untrained. Some policymakers recommend that governments in developing countries harness private providers to remove state responsibility from service provision. [32]

Community development is frequently used as a public health intervention to empower communities to obtain self-reliance and control over the factors that affect their health. [33] Community health workers are able to draw on their firsthand experience, or local knowledge, to complement the information that scientists and policy makers use when designing health interventions. [34] Interventions with community health workers have been shown to improve access to primary healthcare and quality of care in developing countries through reduced malnutrition rates, improved maternal and child health and prevention and management of HIV/AIDS. [35] Community health workers have also been shown to promote chronic disease management by improving the clinical outcomes of patients with diabetes, hypertension, and cardiovascular diseases. [35]

Slum-dwellers in the Global South face threats of infectious disease, non-communicable conditions, and injuries due to violence and road traffic accidents. [36] Participatory, multi-objective slum upgrading in the urban sphere significantly improves social determinants that shape health outcomes such as safe housing, food access, political and gender rights, education, and employment status. Efforts have been made to involve the urban poor in project and policy design and implementation. Through slum upgrading, states recognize and acknowledge the rights of the urban poor and the need to deliver basic services. Upgrading can vary from small-scale sector-specific projects (i.e. water taps, paved roads) to comprehensive housing and infrastructure projects (i.e. piped water, sewers). Other projects combine environmental interactions with social programs and political empowerment. Recently, slum upgrading projects have been incremental to prevent the displacement of residents during improvements and attentive to emerging concerns regarding climate change adaptation. By legitimizing slum-dwellers and their right to remain, slum upgrading is an alternative to slum removal and a process that in itself may address the structural determinants of population health. [36]

Academic resources

See also

Related Research Articles

A health system, also sometimes referred to as health care system or as healthcare system, is the organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations.

Health care Prevention of disease and promotion of wellbeing

Health care, health-care, or healthcare is the maintenance or improvement of health via the prevention, diagnosis, treatment, recovery, or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals in allied health fields. Physicians and physician associates are a part of these health professionals. Dentistry, pharmacy, midwifery, nursing, medicine, optometry, audiology, psychology, occupational therapy, physical therapy, athletic training and other health professions are all part of health care. It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.

Mental health Describes a level of psychological well-being, or an absence of a mental disorder

Mental health is the level of psychological well-being or an absence of mental illness. It is the state of someone who is "functioning at a satisfactory level of emotional and behavioral adjustment". From the perspectives of positive psychology or of holism, mental health may include an individual's ability to enjoy life and to create a balance between life activities and efforts to achieve psychological resilience. According to the World Health Organization (WHO), mental health includes "subjective well-being, perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-actualization of one's intellectual and emotional potential, among others". The WHO further states that the well-being of an individual is encompassed in the realization of their abilities, coping with normal stresses of life, productive work, and contribution to their community. Cultural differences, subjective assessments, and competing professional theories all affect how one defines "mental health".

Preventive healthcare Prevent and minimize the occurrence of diseases

Preventive healthcare, or prophylaxis, consists of measures taken for disease prevention. Disease and disability are affected by environmental factors, genetic predisposition, disease agents, and lifestyle choices and are dynamic processes which begin before individuals realize they are affected. Disease prevention relies on anticipatory actions that can be categorized as primal, primary, secondary, and tertiary prevention.

Disease management is defined as "a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant."

Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequities, and face worse health outcomes than those who are able to access certain resources. It is not equity to simply provide every individual with the same resources; that would be equality. In order to achieve health equity, resources must be allocated based on an individual need-based principle.

A chronic condition is a human health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months. Common chronic diseases include arthritis, asthma, cancer, chronic obstructive pulmonary disease, diabetes and some viral diseases such as hepatitis C and acquired immunodeficiency syndrome. An illness which is lifelong because it ends in death is a terminal illness. It is possible and not unexpected for an illness to change in definition from terminal to chronic. Diabetes and HIV for example were once terminal yet are now considered chronic due to the availability of insulin and daily drug treatment for individuals with HIV which allow these individuals to live while managing symptoms.

Self-care necessary human regulatory function which is under individual control, deliberate and self-initiated

In health care, self-care is any necessary human regulatory function which is under individual control, deliberate and self-initiated.

Health literacy ability to understand healthcare information

Health literacy is the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. There are multiple definitions of health literacy, in part, because health literacy involves both the context in which health literacy demands are made and the skills that people bring to that situation.

Online health communities primarily provide a means for patients and their families to learn about illnesses, seek and offer social support, and connect with others in similar circumstances. However, these online groups can be exclusively composed of individuals with illnesses, exclusively of groups of medical professionals with shared interests, or even a combination of the two.

Patient education teaching or training of patients concerning their own health needs

Patient education is the process by which health professionals and others impart information to patients and their caregivers that will alter their health behaviors or improve their health status.

Chronic care management, encompasses the oversight and education activities conducted by health care professionals to help patients with chronic diseases and health conditions such as diabetes, high blood pressure, systemic lupus erythematosus, multiple sclerosis, and sleep apnea learn to understand their condition and live successfully with it. This term is equivalent to disease management for chronic conditions. The work involves motivating patients to persist in necessary therapies and interventions and helping them to achieve an ongoing, reasonable quality of life.

Health 2.0

"Health 2.0" is a term introduced in the mid-2000s, as the subset of health care technologies mirroring the wider Web 2.0 movement. It has been defined variously as including social media, user-generated content, and cloud-based and mobile technologies. Some Health 2.0 proponents see these technologies as empowering patients to have greater control over their own health care and diminishing medical paternalism. Critics of the technologies have expressed concerns about possible misinformation and violations of patient privacy.

Health coaching is the use of evidence-based skillful conversation, clinical interventions and strategies to actively and safely engage client/patients in health behavior change. Health coaches are certified or credentialed to safely guide clients and patients who may have chronic conditions or those at moderate to high risk for chronic conditions.

Connected health is a socio-technical model for healthcare management and delivery by using technology to provide healthcare services remotely. Connected health, also known as technology enabled care (TEC) aims to maximize healthcare resources and provide increased, flexible opportunities for consumers to engage with clinicians and better self-manage their care. It uses readily available consumer technologies to deliver patient care outside of the hospital or doctor's office. Connected health encompasses programs in telehealth, remote care and disease and lifestyle management, often leverages existing technologies such as connected devices using cellular networks and is associated with efforts to improve chronic care. However, there is an increasing blur between software capabilities and healthcare needs whereby technologists are now providing the solutions to support consumer wellness and provide the connectivity between patient data, information and decisions. This calls for new techniques to guide Connected Health solutions such as "design thinking" to support software developers in clearly identifying healthcare requirements, and extend and enrich traditional software requirements gathering techniques.

Digital health is the convergence of digital technologies with health, healthcare, living, and society to enhance the efficiency of healthcare delivery and make medicine more personalized and precise. The discipline involves the use of information and communication technologies to help address the health problems and challenges faced by people under treatment. These technologies include both hardware and software solutions and services, including telemedicine, web-based analysis, email, mobile phones and applications, text messages, wearable devices, and clinic or remote monitoring sensors. Generally, digital health is concerned about the development of interconnected health systems to improve the use of computational technologies, smart devices, computational analysis techniques, and communication media to aid healthcare professionals and their clients manage illnesses and health risks, as well as promote health and wellbeing.

The Patient Activation Measure (PAM) is a commercial product which assesses an individual's knowledge, skill, and confidence for managing one's health and healthcare. Individuals who measure high on this assessment typically understand the importance of taking a pro-active role in managing their health and have the skills and confidence to do so.

Infectious diseases within American correctional settings are a concern within the public health sector. The corrections population is susceptible to infectious diseases through, exposure to blood and other bodily fluids, drug injection, poor health care, prison overcrowding, demographics, security issues, lack of community support for rehabilitation programs, and high-risk behaviors. The spread of infectious diseases, such as HIV and other sexually transmitted diseases, hepatitis C (HCV), hepatitis B (HBV), and tuberculosis result largely from needle-sharing, drug use, and consensual and nonconsensual sex among prisoners. HIV and hepatitis C need specific attention because of the specific public health concerns and issues they raise.

Digital therapeutics, a subset of digital health, are evidence-based therapeutic interventions driven by high quality software programs to prevent, manage, or treat a medical disorder or disease. Digital therapeutic companies should publish trial results inclusive of clinically meaningful outcomes in peer-reviewed journals. The treatment relies on behavioral and lifestyle changes usually spurred by a collection of digital impetuses. Because of the digital nature of the methodology, data can be collected and analyzed as both a progress report and a preventative measure. Treatments are being developed for the prevention and management of a wide variety of diseases and conditions, including type II diabetes, congestive heart failure, obesity, Alzheimer's disease, dementia, asthma, substance abuse, ADHD, hypertension, anxiety, depression, and several others. Digital therapeutics often employ strategies rooted in cognitive behavioral therapy.

The taxonomy of the burden of treatment is a visualization created for health care professionals to better comprehend the obstacles that interfere with a patient's health care plan. It was created as a result of a world wide, qualitative-based study that asked adults with chronic conditions to list the personal, environmental, and financial barriers that burden a patient. The purpose of this visualization is to help health care providers develop personalized management strategies that the patient can follow through a narrative paradigm. The goal is to target interventions, achieve an interpersonal doctor-patient relationship, and improve health outcomes.


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Further reading