RSS Feed for the unit Public health in community settings: An introduction

Introduction

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

This unit it adapted from Promoting public health (K311) and focuses on working with communities. It follows on from K311_1 which introduced you to multidisciplinary public health. This unit puts forward some ideas about how to build an initial picture of a community, how to research a community, get to know it, both formally and informally and work constructively in partnership with it.

As you study this unit do record your ideas in a paper-based or online journal. This will provide useful evidence for you to draw on, for example if you want to demonstrate that you have learned and applied public health knowledge to your practice. Your work could provide evidence that helps you to meet the UKPHR Public Health Practitioner Standards (2009).

Learning outcomes

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

The learning outcomes below describe the key learning goals you should be aiming to achieve on completion of this unit.

After studying this learning guide you should be able to demonstrate knowledge and understanding of:

factors to consider when planning to research your chosen community
approaches that will facilitate engagement at community level
skillls required to work constructively with communities.

1 Working with a community development approach: planning and negotiating entry into a community

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

There are two main elements to planning and negotiating entry into a community, which could naturally run in parallel with each other:

building an initial picture and profile of the community
getting to know the community, both formally and informally.

1.1 Building an initial picture and profile of the community

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Assessing local need and profiling the local community is the first step towards developing a local plan. However, simply ‘jumping’ into the community without first considering its social, demographic and environmental make-up is likely to result in failure. Communities are not simply homogeneous, but consist of a range of social and cultural groups. People’s thoughts, ideas, perceptions and needs may therefore differ.

In order to open doors, it is necessary to build up an initial picture and profile of the community.[…] The aim of a community profile is to develop a written snapshot of the community’s natural and built environment, together with the social, economic, political, cultural and religious structures of support within this. A health needs assessment can then inform local plans by looking at unmet need for services, and provide information that will allow services to be tailored to local populations.

Planning an effective strategy of entry armed with the necessary information is, therefore, an essential part of the community public health worker’s role. For example, there are a number of quantitative sources – both nationally, such as the census data which gives information on a regional basis, and more locally, such as health authority and public health reports – which can help develop a picture of the community in question (see Sidell and Lloyd, 2007). Similarly, using qualitative data, such as vignettes or face-to-face interviews, provides valuable local insights into the likely impact of community-based initiatives and interventions.

Community profiling uses social research in a community primarily in order to listen to the voice of (often) marginalised people and then to feed that voice into an assessment of their collective needs, with a view to creating what Moran and Butler (2001, p. 60) refer to as a ‘living health profile’.

A community profile draws on the following information:

the demographic and social mix of the people – taking into account such factors as age, class, gender, ethnicity, religion and disability
the housing available to them in the area
access to jobs, training and income in, and accessible from, the areapublic services and facilities, schools, colleges, health centres, police services, etc., in the area and accessible nearby
shops, entertainment, sport and culture in the area and nearby
voluntary organisations and services, local associations and political parties
family and community networks to which people contribute and on which they can call.

In assessing the health needs of a particular community, the following questions need to be asked:

How healthy is the community?
What does it need to be healthier?
What does it need to stay healthy?
What are the best ways to accomplish these goals?

An example of a community profile and needs assessment is given in Table 1.

Table 1 Key factors affecting health, social care and wellbeing in one community: Powys, Wales

Context	Key factors
United Kingdom	Ageing population, more people living alone
	Decline in public transport, increasing cost of private transport
	Smoking, alcohol abuse – including among children – and drug misuse
	Cardiovascular disease, cancer, diabetes and mental illness, obesity
Wales	Extreme rurality: large mountainous area, sparse population, agricultural dependency
Powys	Small communities with diverse character and health and social care needs, no large towns or major shopping centres
	Breakdown of traditional communities and social support networks, accelerated by migration trends
	Vulnerable workforce: low incomes, seasonality, high self-employment, long hours of work
	Frail agricultural economy, highly vulnerable to market forces and external catastrophe: for example, foot and mouth disease
	Cost and potential inefficiency of service delivery to scattered small settlements
	Mainly ‘rural deprivation’ (housing deprivation, transport poverty, isolation, low income) with pockets of ‘urban deprivation’ (unemployment, benefits dependency) in some towns
	Transport poverty: lack of public transport; dependence on cars for work, shopping and healthcare; burden on household budgets; cars often old and in poor condition; road traffic accidents
	Added risks of isolation, food poverty and health inequality for residents without use of car (e.g. children; older people; people on low incomes; disabled people; those who are sick; and those who are the second adult in a one-car household)
	Rural stress a major influence on health and wellbeing
	Housing deprivation: poor condition of private housing stock, high house prices relative to incomes, high dependence on private rental, fuel poverty
	Lack of anonymity in small communities leads to health inequality and isolation forvulnerable groups and deters take-up of benefits. Combined with high self-employment, this tends to delay the seeking of both medical and financial advice

Adapted from Health Challenge Powys, 2005

Activity 1 Thinking about community needs

30 minutes

Review Table 1 and note down issues and areas where taking action might help to improve people’s health. For how many of these would more than one service or sector need to be involved?

Answer

Here are the conclusions drawn from the regional profile in Table 1 about which issues/areas required action in the short and long term:

geographical access and transport
poverty and deprivation; in particular, child poverty
restricted employment opportunities
poor quality private sector housing, and other housing issues
diet
physical exercise and sport
smoking
substance misuse; in particular, alcohol misuse
community development
lifelong learning
care and support for the most vulnerable groups
caring for carers
retaining and attracting young people back to the county
sexual health; in particular, teenage pregnancy
coronary heart disease, cancer, cerebrovascular disease, obesity, mental health and emotional wellbeing, accidents and diabetes.

An audit of local skills is also an important aspect of needs assessment and community profiling. There will be a need for appropriate personal and professional development for a wide range of people. This will include not just health professionals, but other professional groups involved in planning and delivering services (e.g. local authority officers, teachers, social workers, youth leaders and voluntary sector staff) and members of the public involved in needs assessment and in delivering community-based programmes.

Having carried out a provisional community profile and health needs assessment, it is necessary to get to know the community better.

1.2 Getting to know the community, both formally and informally

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

If communities are to be able to participate in the decision-making processes and achieve partnership ways of working, then public health practitioners need to work with the community and understand and value their needs and perspectives. This can take time and patience as well as a great deal of tact and diplomacy. Thus, the public health worker needs to be aware of the cultural and political sensitivities of the area. Burman et al. (2004) have, for example, shown how ‘culture’ can be a barrier in the delivery of domestic violence services.

‘Networking’ is a term frequently heard in community work. Basically, it is about making contacts, building trust, developing alliances, tapping into local knowledge and listening and learning from as wide a range of people within the community as possible. The following ideas have been suggested for building good networks:

Walk, don’t ride. Always try to walk from A to B, and ensure that you visit areas that are unfamiliar to you
Never pass up the opportunity to make or renew a contact (unless you are fairly sure that to do so at that point will damage another area of work)
Learn how to listen and notice
In order to get you must give. People are prepared to give best when it is clear that they will get something in return.

(Source: Twelvetrees, 1982, quoted in Thornley, 2002, p. 72)

Figure 1 A health visitor networks with a young mother at a Sure Start centre in Powys, Wales

‘Snowballing’ is a useful technique in building networks. Essentially, this is about using existing contacts to suggest others who might also be contacted, who in turn are asked to suggest yet others. One of the drawbacks of this technique is that one could end up with only one real network based on the original person contacted. To avoid this, it is best to initiate more than one snowball. Community workers who are very unfamiliar with an area will need to immerse themselves in the community by frequenting local shopping centres, sitting in cafes or pubs and generally talking informally to as many people as possible.

Making both formal and informal contacts will allow the community worker the opportunity to talk and, more importantly, to listen to people who live and work in the community about what they think constitutes a ‘healthy’ person and community; what the particular health needs of their area are; whether they think that these are being met and, if not, what they think might be the solution to them; and whether they might want to be involved with future developments. In order to do this, the community worker can use a range of methods, such as one-to-one discussion, questionnaires, workshops, focus groups and public meetings.

Activity 2 Dilemmas in community development

30 minutes

This activity asks you to think about the practical and ethical problems that might arise in the approaches discussed above. Consider the following issues and suggest what problem you might face in:

Working with a forceful group of community leaders
Trying to mobilise local residents who feel their views have been ignored
Identifying and responding to what you see as a long-standing problem

Answer

The process of networking and building up community contacts can raise a number of dilemmas in terms of who can be said to represent the community’s views and interests. At a practical level, community leaders or representatives will be able to give a particular perspective or overall view, but they may not be representative of the whole community. The skill of the community worker is to recognise and understand this and to seek as many views as is practically possible. They also need to be aware of the community’s existing organisational structures; and to clarify what local residents see as the boundary to their community, which may be different from the geographical one based on the electoral ward.

Other issues that may emerge are those related to what can be achieved and how this is to be done, particularly if any proposed local action is an ‘intervention’ based on a time-limited project. Local residents and/or community groups may have low expectations as to what may be achieved, particularly if they have had little or no resources in the past or, in their view, statutory agencies have ‘failed to deliver’.

‘Unrealistic’ expectations of what is achievable could eventually lead to demoralisation if timescales and outcomes do not match those expectations. However, low expectations are a more common problem. For various reasons (such as lack of self-confidence, the inaccessibility of an organisation, or institutional racism), local people may feel unable to raise with the appropriate agency the issues they feel strongly about.

In such situations the community worker would need to act as a conduit or communication channel to enable those voices to be heard and the issues put on the relevant agenda. They would also need to work with local people to develop their skills and confidence. This process of empowerment is crucial if local people are to be able to determine how they want to take action to get their needs met. The worker’s role would be to enable them to develop appropriate ways of taking action, such as campaigning and lobbying, or developing activities to suit their needs. Local people would start to take action to set the agenda rather than having it set for them.

The role of the community worker is to build on initial research and contact with people living and working in the community, so that the needs identified can be expanded upon and solutions developed. The worker’s overall role would be to support and facilitate that process, particularly in terms of existing organisational structures and the creation of new ones.

The next section addresses more specifically these aspects of engaging with a community.

2 Working with a community development approach: engaging with communities

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

Public health seeks to improve the population’s health through measures aimed at large groups, and to complement clinical medicine’s treatment of individuals by working to maximise the health of communities. As discussed above, effective public health practice depends on co-ordinated planning across a wide range of technical, medical and social disciplines. Those working in the field have a long-established tradition of responding to and managing the threats to community health posed by communicable and non-communicable diseases or dead bodies (Morgan, 2004). They have also developed expertise in tackling the broader determinants of health, including housing and regeneration initiatives, and work to promote the health of disadvantaged communities (Robinson et al., 2005). How, then, might one recognise, realise and respond to the potential of communities to promote public health?

2.1 Recognising, realising and responding to the potential of communities

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There are no simple answers to what works in facilitating community engagement, but the local context is of central importance. A variety of techniques, methods and support has to be adopted to ensure optimal conditions for community engagement. However, as you have already read, much has been written on the skills and practices which seem generally effective in facilitating community engagement for health. Effective practices fall under the following main headings:

identify local circumstances that may present barriers to effective community involvement (e.g. lack of transport infrastructure) and act on these
acknowledge the diversity of local communities and develop both targeted and universal strategies to reach all members of the local community, including traditionally ‘hard-to-reach’ groups such as women, young people, people with a disability and members of minority ethnic groups
budget and plan for community development, training and capacity building from the start, ideally involving the local residents in the planning process
provide a variety of opportunities for training and support for local people and professionals
use regular evaluation as a tool to identify barriers to community involvement and actions to address these
establish effective ways of partnership working between statutory and non-statutory agencies and the local community.

Figure 2 is an illustration of one particular strategy used by Be Active Stay Active (BASA), a community-based mental health project in Scotland, to reach and engage with communities.

Figure 2 Encouraging physical activity: a walking group in Scotland

The public health practitioner at a community level has a developmental role in the process of bringing together a group of people who share a common need or interest, in order to realise their hopes of taking the appropriate action to meet that need or follow that interest. Task groups or subgroups, such as a Health Action Group, can be set up to work on particular issues. Within this structure, focus groups could be organised to enable more in-depth research of the needs and solutions identified. These methods may include either a participatory action research approach or community-based participatory research, both of which favour rapid participatory appraisal techniques. This involves communities identifying and challenging their own health-related needs utilising rapid information gathering. Here, the community role is seen as critical to the development of rapid appraisal originating in the social/ community tradition. It is this feature which distinguishes this approach from the rapid epidemiological approach (which uses epidemiological and statistical methods alone for a rapid assessment) (Rifkin, 1992). Either or both of these groups could, through the composition of their membership, provide the foundations for developing a partnership between the local residents and statutory, non-statutory, voluntary and community organisations.

The setting up and development of a group to address an identified public health issue, whether it be to deal with a single issue or a variety of issues, requires the public health worker to have a range of skills to enable the group both to develop, as a cohesive force with a shared vision and common identity, and to achieve its objectives. Community development workers often seem like the glue that keeps people working together.

Realising the potential of communities calls for good organisational skills, along with the ability to manage both people and budgets. Skills in fundraising and marketing are especially useful in consolidating, sustaining and mainstreaming projects or interventions. Both community and professional members will bring different skills and experiences, together with their different commitments outside the group process. This can raise some important questions in terms of ownership and control, the development of an equitable partnership and the commitment expected from each member. This will be the case particularly for an inter-agency group, because its members may have differing expectations, as well as competing needs, interests and priorities. The group may also have a naturally limited lifespan because:

it has a particular task to achieve
it is part of a time-limited project for which the funding ceases
there is no longer a perceived need for this particular type of group and something else might replace it.

2.2 Working together: prioritising needs, and agreeing and progressing solutions

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

Once the community worker has brought the group together, their first task will be to define its purpose, clarify and prioritise its goals, set realistic targets for action, and agree the mechanisms for monitoring and reviewing the outcomes. In the light of this, they will also need to review the group’s membership in terms of the skills mix and training needs, particularly if they see the group as working towards a long-term future. This stage will form the basis for developing a framework for action which will include a timescale and timetable for meeting the agreed objectives, and a common agreement and shared understanding of the members’ roles and responsibilities within this. It will also start the process of establishing effective team building and developing partnership ways of working, as well as providing opportunities for flagging up potential areas of conflict when particular dilemmas and contradictions may emerge for group members.

Central to this process will be the issue of the group achieving its objectives while building and developing the organisational structure to enable this. A prime example would be the emphasis on delivering concrete measurable outcomes as a measure of achievement.

Although important, quantifiable measures of concrete outcomes do not acknowledge the importance of the building of organisational structures and the empowerment of individuals and communities which this entails. It can, therefore, be difficult to translate the rhetoric (about community development and community action) into the concrete reality of achieving action and change. Thus, the community’s action plan should include the development of an organisational structure to meet its particular needs and what it sees as its terms of reference. This may be done informally, agreeing the processes of recruitment/membership, decision making, communication and accountability, or more formal arrangements may be made which, as a first step, include a written constitution with agreed policies and procedures. However, the community group may also wish to seek limited company status and/or charitable status. Although this provides the group with a legal framework and also other opportunities for fundraising and income generation, it also brings additional levels of responsibility and accountability.

The process can be quite lengthy and time-consuming, demanding high levels of commitment, particularly if the group also needs to raise funds in order to support its activities. Indeed, at this point, the original purpose of the group can become subsumed under these demands, and members may become disenchanted and disillusioned as they struggle with their other various competing commitments outside the group. The community worker’s skills in supporting these processes will be crucial, in terms of maintaining the impetus of the group and the commitment of its members. There is a need for perseverance, a good deal of realism and a sense of humour. The community worker will also need the ability to collect and provide information, give administrative and organisational support, and enable the group to network and liaise with other organisations so that the relevant expertise, advice and support can either be brought into or made available to the group. They may also need to resolve areas of conflict, which may be internal or external to the group.

Activity 3 Community development in action: interventions to improve mental health

1 hour

Listen to the audio below in which Pat Gilmartin, an occupational therapist with BASA, talks about community development. Take notes as you go and then answer the following questions:

Pick out three practical examples of the use of a community development approach
How does this fit with the Standing Conference on Community Development Statement (SCCD) in Box 1?
Would you expect these principles to be any different when promoting mental health?

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Transcript

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Fitting into the community

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Transcript

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Harnessing the strengths of volunteers

Box 1 A statement on community development

Community development is about 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 on the basis of the following values and commitments.

Values

Social justice – enabling people to claim their human rights, meet their needs and have greater control over the decision-making processes which affect their lives.

Participation – facilitating democratic involvement by people in the issues which affect their lives, based on full citizenship, autonomy, and shared power, skills, knowledge and experience.

Equality – challenging the attitudes of individuals, and the practices of institutions and society, which discriminate against and marginalise people.

Learning – recognising the skills, knowledge and expertise that people contribute and develop by taking action to tackle social, economic, political and environmental problems.

Co-operation – working together to identify and implement action, based on mutual respect of diverse cultures and contributions.

Commitments

Challenging discrimination and oppressive practices within organisations, institutions and communities.

Developing practice and policy that protects the environment.

Encouraging networking and connections between communities and organisations.

Ensuring access and choice for all groups and individuals within society.

Influencing policy and programmes from the perspective of communities.

Prioritising the issues of concern to people experiencing poverty and social exclusion.

Promoting social change that is long-term and sustainable.

Reversing inequality and the imbalance of power relationships in society.

Supporting community-led collective action.

(SCCD, 2001, p. 5)

Answer

Building capacity for mental health which embraces a community development approach should be no different from any other form of capacity building. While the style may differ, the principles should always remain the same. These principles are about engagement, participation and empowerment.

3 Reflecting on skills for community work

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

This unit has introduced you to some principles and practises of working with communities. It has given you the opportunity to consider the types of research and analysis you would need to do to get to know your community and understand its health needs. The final activity encourages you to reflect on what skills are needed for planning and negotiating entry into a community, what expertise you already have and what skills you would like to develop further.

Activity 4 Skills for taking a community development approach

50 minutes

This activity is based on your reading of planning and negotiating entry into a community.

Make a copy of Table 2 and complete as follows:

In column 1, make a list of the core skills that you feel the community development workers need
In column 2, describe briefly your own experience of each skill
In column 3, list the skills that you would like to develop further.

Below the table write a few words on how you intend to follow this up.

Table 2

Skill – the ability to:	My personal experience:	To develop further:

On a separate piece of paper, put the skills you have identified into three categories:

I feel confident that I have these skills
I feel that I lack these skills
I feel neither confident nor lacking in these skills.

It would be useful to record this in your learning journal.

Answer

As you completed this exercise you may have been surprised at the level of transferable skills which you already have. In fact many of the skills identified are used in everyday life, such as networking, building relationships, planning, liaising, managing and budgeting. Many of you may also have been involved in partnership working, facilitating or enabling, or you may feel you need to develop these skills. Fundraising or leadership may be something that not everyone feels confident about. Good communication skills are of course central.

Next Steps

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After completing this unit you may wish to study another OpenLearn study unit. Here are a few suggestions:

If you wish to study formally at The Open University, you may wish to explore the courses we offer in this curriculum area:

And find out about studying and developing your skills with The Open University:

Or you might like to:

Post a message to the unit forum, to share your thoughts about the unit or talk to other OpenLearners
Review or add to your Learning Journal
Rate this unit

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Acknowledgements

The Open University — Fri, 11 Mar 2011 11:11:36 GMT

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Tables

Table 2: Health Challenge Powys, 2005

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