The term "community health" refers to the health status of a defined group of people, or community, and the actions and conditions that protect and improve the health of the community. Those individuals who make up a community live in a somewhat localized area under the same general regulations, norms, values, and organizations. For example, the health status of the people living in a particular town, and the actions taken to protect and improve the health of these residents, would constitute community health. In the past, most individuals could be identified with a community in either a geographical or an organizational sense. Today, however, with expanding global economies, rapid transportation, and instant communication, communities alone no longer have the resources to control or look after all the needs of their residents or constituents. Thus the term "population health" has emerged. Population health differs from community health only in the scope of people it might address. People who are not organized or have no identity as a group or locality may constitute a population, but not necessarily a community. Women over fifty, adolescents, adults twenty-five to forty-four years of age, seniors living in public housing, prisoners, and blue-collar workers are all examples of populations. As noted in these examples, a population could be a segment of a community, a category of people in several communities of a region, or
The actions and conditions that protect and improve community or population health can be organized into three areas: health promotion, health protection, and health services. This breakdown emphasizes the collaborative efforts of various public and private sectors in relation to community health. Figure 1 shows the interaction of the various public and private sectors that constitute the practice of community health.
Health promotion may be defined as any combination of educational and social efforts designed to help people take greater control of and improve their health. Health protection and health services differ from health promotion in the nature or timing of the actions taken. Health protection and services include the implementing of laws, rules, or policies approved in a community as a result of health promotion or legislation. An example of health protection would be a law to restrict the sale of hand guns, while an example of health services would be a policy offering free flu shots for the elderly by a local health department. Both of these actions could be the result of health promotion efforts such as a letter writing campaign or members of a community lobbying their board of health.
FOUNDATIONS OF COMMUNITY HEALTH
The foundations of community health include the history of community health practice, factors that affect community and population health, and the tools of community health practice. These tools include epidemiology, community organizing, and health promotion and disease prevention planning, management, and evaluation.
History of Community Health Practice. In all likelihood, the earliest community health practices went unrecorded. Recorded evidence of concern about health is found as early as 25,000 B.C.E., in Spain, where cave walls included murals of physical deformities. Besides these cave carvings and drawings, the earliest records of community health practice were those of the Chinese, Egyptians, and Babylonians. As early as the twenty-first century B.C.E., the Chinese dug wells for drinking.
Between the eleventh and second centuries B.C.E., records show that the Chinese were concerned about draining rainwater, protecting their drinking water, killing rats, preventing rabies, and building latrines. In addition to these environmental concerns, many writings from 770 B.C.E. to the present mention personal hygiene, lifestyle, and preventive medical practices. Included in these works are statements by Confucius (551–479 B.C.E.) such as "Putrid fish … food with unusual colors… foods with odd tastes … food not well cooked is not to be eaten." Archeological findings from the Nile river region as early as 2000 B.C.E., indicate that the Egyptians also had environment health concerns with rain and waste water. In 1900 B.C.E., Hammurabi, the king of Babylon, prepared his code of conduct that included laws pertaining to physicians and health practices.
During the years of the classical cultures (500 B.C.E.–500 C.E.), there is evidence that the Greeks were interested in men's physical strength and skill, and in the practice of community sanitation. The Romans built upon the Greek's engineering and built aqueducts that could transport water
In the Middle Ages (500–1500 C.E.), health problems were considered to have both spiritual causes and spiritual solutions. The failure to account for the role of physical and biological factors led to epidemics of leprosy, the plague, and other communicable diseases. The worst of these, the plague epidemic of the fourteenth century, also known as the Black Death, killed 25 million people in Europe alone. During the Renaissance (1500–1700 C.E.), there was a growing belief that diseases were caused by environmental, not spiritual, factors. It was also a time when observations of the sick provided more accurate descriptions of the symptoms and outcomes of diseases. Yet epidemics were still rampant.
The eighteenth century was characterized by industrial growth, but workplaces were unsafe and living conditions in general were unhealthful. At the end of the century several important events took place. In 1796 Dr. Edward Jenner successfully demonstrated the process of vaccination for smallpox. And, in 1798, in response to the continuing epidemics and other health problems in the United States, the Marine Hospital Service (the forerunner to the U.S. Public Health Service) was formed.
The first half of the nineteenth century saw few advances in community health practice. Poor living conditions and epidemics were still concerns, but better agricultural methods led to improved nutrition. The year 1850 marks the beginning of the modern era of public health in the United States. It was that year that Lemuel Shattuck drew up a health report for the Commonwealth of Massachusetts that outlined the public health needs of the state. This came just prior to the work of Dr. John Snow, who removed the handle of the Broad Street pump drinking well in London, England, in 1854, to abate the cholera epidemic. The second half of the nineteenth century also included the proposal of Louis Pasteur of France in 1859 of the germ theory, and German scientist Robert Koch's work in the last quarter of the century showing that a particular microbe, and no other, causes a particular disease. The period from 1875 to 1900 has come to be known as the bacteriological era of public health.
The twentieth century can be divided into several different periods. The years between 1900 and 1960 are known as the health resources development era. This period is marked by the growth of health care facilities and providers. The early years of the period saw the birth of the first voluntary health agencies: the National Association for the Study and Prevention of Tuberculosis (now the American Lung Association) was founded in 1904 and the American Cancer Society in 1913. The government's major involvement in social issues began with the Social Security Act of 1935. The two world wars accelerated medical discoveries, including the development of penicillin. In 1946, Congress passed the National Hospital Survey and Construction Act (Hill-Burton Act) to improve the distribution and enhance the quality of hospitals.
The social engineering era (1960–1975) included the passage of amendments to the Social Security Act that set up Medicare (payment of medical bills for the elderly and certain people with disabilities) and Medicaid (payment of medical bills for the poor). The final period of the twentieth century is the health promotion era (1974–1999). During this period it was recognized that the greatest potential for improving the health of communities and populations was not through health care but through health promotion and disease prevention programs. To move in this direction, the U.S. government created its "blueprint for health" a set of health goals and objectives for the nation. The first set was published in 1980 and titled Promoting Health/Preventing Disease: Objectives for the Nation. Progress toward the objectives has been assessed on a regular basis, and new goals and objectives created in volumes titled Healthy People 2000, and Healthy People 2010. Other countries, and many states, provinces, and even communities, have developed similar goals and targets to guide community health.
Factors that Affect Community and Population Health. There are four categories of factors that affect the health of a community or population. Because these factors will vary in separate communities, the health status of individual communities will be different. The factors that are included in each category, and an example of each factor, are noted here.
- Physical factors—geography (parasitic diseases), environment (availability of natural resources), community size (overcrowding), and industrial development (pollution).
- Social and cultural factors—beliefs, traditions, and prejudices (smoking in public places, availability of ethnic foods, racial disparities), economy (employee health care benefits), politics (government participation), religion (beliefs about medical treatment), social norms (drinking on a college campus), and socioeconomic status (number of people below poverty level).
- Community organization—available health agencies (local health department, voluntary health agencies), and the ability to organize to problem solve (lobby city council).
- Individual behavior—personal behavior (health-enhancing behaviors like exercising, getting immunized, and recycling wastes; see Figure 2).
Three Tools of Community Health Practice. Much of the work of community health revolves around three basic tools: epidemiology, community organizing, and health education. Though each of these is discussed in greater length elsewhere in the encyclopedia, they are mentioned here to emphasize their importance to community and population practice. Judith Mausner and Shira Kramer have defined epidemiology as the study of the distribution and determinants of diseases and injuries in human populations. Such data are recorded as number of cases or as rates (number per 1,000 or 100,000). Epidemiological data are to community health workers as biological measurements are to a physician. Epidemiology has sometimes been referred to as population medicine. Herbert Rubin and Irene Rubin have defined community organizing as bringing people together to combat shared problems and increase their say about decisions that affect their lives. For example, communities may organize to help control violence in a neighborhood. Health education involves health promotion and disease prevention (HP/DP) programming, a process by which a variety of interventions are planned, implemented, and evaluated for the purpose of improving or maintaining the health of a community or population. A smoking cessation program for a company's employees, a stress management class for church members, or a community-wide safety belt campaign are examples of HP/DP programming.
COMMUNITY AND POPULATION HEALTH THROUGH THE LIFE SPAN
In community health practice, it is common to study populations by age group and by circumstance because of the health problems that are common to each group. These groupings include mothers, infants (less than one year old), and children (ages 1–14); adolescents and young adults (ages 15–24); adults (ages 25–64); and older adults or seniors (65 years and older).
Maternal, infant, and child (MIC) health encompasses the health of women of childbearing age from prepregnancy through pregnancy, labor, delivery, and the postpartum period, and the health of a child prior to birth through adolescence. MIC health statistical data are regarded as important indicators of the status of community and population health. Unplanned pregnancies, lack of prenatal care, maternal drug use, low immunization rates, high rates of infectious diseases, and lack of access to health care for this population indicate a poor community health infrastructure. Early intervention with educational programs and preventive medical services for women, infants, and children can enhance health in later years and reduce the
Maternal health issues include family planning, early and continuous prenatal care, and abortion. Family planning is defined as the process of determining and achieving a preferred number and spacing of children. A major concern is the more than 1 million U.S. teenagers who become pregnant each year. About 85 percent of these pregnancies are unintended. Also a part of family planning and MIC is appropriate prenatal care, which includes health education, risk assessment, and medical services that begin before the pregnancy and continue through birth. Prenatal care can reduce the chances of a low-birthweight infant, and the poor health outcomes and costs associated with it. A controversial way of dealing with unintended or unwanted pregnancies is with abortion. Abortion has been legal in the United States since 1973 when the Supreme Court ruled in Roe v. Wade that women have a constitutionally protected right to have an abortion in the early stages of pregnancy. According to the Centers for Disease Control and Prevention (CDC), approximately 1.6 million legal abortions were being performed in the United States each year during the late 1990s.
Infant and child health is the result of parent health behavior during pregnancy, prenatal care, and the care provided after birth. Critical concerns of infant and childhood morbidity and mortality include proper immunization, unintentional injuries, and child abuse and neglect. Though numerous programs in the United States address MIC health concerns, one that has been particularly successful has been the Special Supplemental Food Program for Women, Infants, and Children, known as the WIC program. This program, sponsored by the U.S. Department of Agriculture, provides food, nutritional counseling, and access to health services for low-income women, infants, and children. Late-twentieth-century figures indicate that the WIC program serves more than seven million mothers and children per month, and saves approximately three dollars for each tax dollar spent.
The health of the adolescent and young adult population sets the stage for the rest of adult life. This is a period during which most people complete their physical growth, marry and start families, begin a career, and enjoy increased freedom and decision making. It is also a time in life in which many beliefs, attitudes, and behaviors are adopted and consolidated. Health issues that are particularly associated with this population are unintended injuries; use and abuse of alcohol, tobacco, and drugs; and sexual risk taking. There are no easy, simple, or immediate solutions to reducing or eliminating these problems. However, in communities where interventions have been successful, they have been comprehensive and communitywide in scope and sustained over long periods of time.
The adult population represents about half of the U.S. population. The health problems associated with this population can often be traced to the consequences of poor socioeconomic conditions and poor health behavior during earlier years. To assist community health workers, this population has been subdivided into two groups: ages twenty-five to forty-four and ages forty-five to sixty-four. For the younger of these two subgroups, unintentional injuries, HIV (human immunodeficiency virus) infection, and cancer are the leading causes of death. For the older group, noncommunicable health problems dominate the list of killers, headed by cancer and heart disease, which account for almost two-thirds of all deaths. For most individuals, however, these years of life are the healthiest. The key to community health interventions for this population has been to stress the quality of life gained by good health, rather than merely the added years of life.
The senior population of the United States has grown steadily over the years, and will continue to grow well into the twenty-first century. In 1900 only one in twenty-five Americans was over the age of sixty-five, in 1995 it was one in seven, and by 2030 it is expected to be one in five. Such growth in this population will create new economic, social, and health concerns, especially as the baby boomers (those born between 1946 and 1964) reach their senior years. From a community and population health perspective, greater attention will need to be placed on the increased demands for affordable housing, accessible transportation, personal care created by functional limitations, and all segments of health care including adult day care and respite care. Though many communities have suitable interventions in place
The three strategies by which community health practice is carried out are health promotion, health protection, and the provision of health services and other resources. Figure 3 presents a representation of these strategies, their processes, their objectives, and anticipated benefits for a community or population.
As noted earlier, health promotion includes educational, social, and environmental supports for individual, organizational, and community action. It seeks to activate local organizations and groups or individuals to make changes in behavior (lifestyle, selfcare, mutual aid, participation in community or political action) or in rules or policies that influence health. Community health promotion lies in the areas in which the spheres of health action, as shown in Figure 1, overlap.
Two areas in which communities employ health promotion strategies are mental and social health, and recreation and fitness. Though both of these health concerns seem to be problems of individuals, a health concern becomes a community or population health concern when it is amenable to amelioration through the collective actions noted above. Action to deal with these concerns begins with a community assessment, which should identify the factors that influence the health of the subpopulations and the needs of these populations. In the case of mental and social health, the need will surface at the three levels of prevention: primary prevention (measures that forestall the onset of illness), secondary prevention (measures that lead to an early diagnosis and prompt treatment), and tertiary prevention (measures aimed at rehabilitation following significant pathogenesis).
Primary prevention activities for mental and social health could include personal stress management strategies such as exercise and meditation, or school and workplace educational classes to enhance the mental health of students and workers. A secondary prevention strategy could include the staffing of a crisis hot line by local organizations such a health department or mental health center. Tertiary prevention might take the form of the local medical and mental health specialists and health care facilities providing individual and group counseling, or inpatient psychiatric treatment and rehabilitation. All of these prevention strategies can contribute to a communitywide effort to improve the mental and social health of the community or population. During and after the implementation of the strategies, appropriate evaluation will indicate which strategies work and which need to be discontinued or reworked.
As with mental and social health promotion, community recreation and fitness needs should be derived via community assessment. The community or population enhances the quality of life and provides alternatives to the use of drugs and alcohol as leisure pursuits by having organized recreational programs that meet the social, creative, aesthetic, communicative, learning, and physical needs of its members. Such programs can provide a variety of benefits that can contribute to the mental, social, and physical health of the community, and can be provided or supported by schools, workplaces, public and private recreation and fitness organizations, commercial and semipublic recreation, and commercial entertainment. As with all health-promotion programming, appropriate evaluation helps to monitor progress, appropriate implementation of plans, and outcomes achieved.
Community and population health protection revolve around environmental health and safety. Community health personnel work to identify environmental risks and problems so they can take the necessary actions to protect the community or population. Such protective measures include the control of unintentional and intentional injuries; the control of vectors; the assurance that the air, water, and food are safe to consume; the proper disposal of wastes; and the safety of residential, occupational, and other environments. These protective measures are often the result of educational programs, including self-defense classes; policy development, such as the Safe Drinking Water Act or the Clean Air Act; environmental changes,
such as restricting access to dangerous areas; and community planning, as in the case of preparing for natural disasters or upgrading water purification systems.
HEALTH SERVICES AND OTHER RESOURCES
The organization and deployment of the services and resources necessary to plan, implement, and evaluate community and population health strategies constitutes the third general strategy in community and population health. Today's communities differ from those of the past in several ways. Even though community members are better educated, more mobile, and more independent than in the past, communities are less autonomous and more dependent on those outside the community for support. The organizations that can assist communities and populations are classified into governmental, quasi-governmental, and nongovernmental groups. Such organizations can also be classified by the different levels (world, national, state/province, and local) at which they operate.
Governmental health agencies are funded primarily by tax dollars, managed by government officials, and have specific responsibilities that are outlined by the governmental bodies that oversee them. Governmental health agencies include: the World Health Organization (WHO), the U.S. Department of Health and Human Services, the various state health departments, and the over three thousand local health departments throughout the country. It is at the local level that direct health services and resources reach people.
Quasi-governmental health organizations have some official responsibilities, but they also operate in part like voluntary health organizations. They may receive some government funding, yet they operate independently of government supervision. An example of such a community health organization is the American Red Cross (ARC). The ARC has certain official responsibilities placed on it by the federal government, but is funded by voluntary contributions. The official duties of the ARC include acting as the official representative of the U.S. government during natural disasters and serving as the liaison between members of the armed forces and their families during emergencies. In addition to these official responsibilities, the ARC engages in many nongovernmental services such as blood drives and safety services classes like first aid and water safety instruction.
Nongovernmental health agencies are funded primarily by private donations or, in some cases, by membership dues. The thousands of these organizations all have one thing in common: They
arose because there was an unmet need for them. Included in this group are voluntary health agencies; professional health organizations and associations; philanthropic foundations; and service, social, and religious organizations.
Voluntary health organizations are usually founded by one or more concerned citizens who felt that a specific health need was not being met by existing government agencies. Examples include the American Cancer Society, Mothers Against Drunk Driving (MADD), and the March of Dimes. Voluntary health agencies share three basic objectives: to raise money from various sources for research, to provide education, and to provide services to afflicted individuals and families.
Professional health organizations and associations are comprised of health professionals. Their mission is to promote high standards of professional practice, thereby improving the health of the community. These organizations are funded
Philanthropic foundations have made significant contributions to community and population health in the United States and throughout the world. These foundations support community health by funding programs or research on the prevention, control, and treatment of many diseases, and by providing services to deal with other health problems. Examples of such foundations are the Robert Wood Johnson Foundation, the Henry J. Kaiser Family Foundation, and the W. K. Kellogg Foundation.
Service, social, and religious organizations have also played a part in community and population health by raising money and funding health-related programs. For example, the Lions Clubs has worked to help prevent blindness, Shriners have helped to provide free medical care through their hospitals, and many religious organizations have worked to feed, clothe, and provide shelter for those in need.
The health services and resources provided through the organizations discussed above are focused at the community level. However, a significant portion of the resources are aimed at personal health care. Figure 4 presents the spectrum of health care delivery in the United States. Some refer to this as the U.S. health care system; others would debate whether any system really exists, referring to this network of services as an array of informal communications between health care providers and health facilities. The spectrum of care begins with public health (or population-based) practice, which is a significant component of community and population health practice. It then moves to four different levels of medical practice. The first level is primary, or front-line or first-contact, care. This involves the medical diagnosis and treatment of most symptoms not requiring a specialist or hospital. Secondary medical care gives specialized attention and ongoing management for both common and less frequently encountered medical conditions. Tertiary medical care provides even more highly specialized and technologically sophisticated medical and surgical care, including the long-term care often associated with rehabilitation. The final level of practice in the spectrum is continuing care, which includes longterm, chronic, and personal care.
LAWRENCE W. GREEN
JAMES F. MCKENZIE
(SEE ALSO: Behavior, Health-Related; Boards of Health; Citizens Advisory Boards; Community Health Report Cards; Community Organization; Decentralization and Community Health; Environmental Movement; Health Promotion and Education; Healthy Communities; Participation in Community Health Planning; Personal Health Services; Planning for Public Health; Policy for Public Health; Population Policies; Practice of Public Health)
Green, L. W., and Kreuter, M. W. (1999). Health Promotion Planning: An Educational and Ecological Approach, 3rd edition. Mountain View, CA: Mayfield Publishing.
Green, L. W., and Ottoson, J. M. (1999). Community and Population Health, 8th edition. Boston: WCB/McGraw-Hill.
Kreuter, M. W.; Lezin, N. A.; Kreuter, M. W.; and Green, L. W. (1998). Community Health Promotion Ideas that Work: A Field-Book for Practitioners. Boston: Jones and Bartlett.
Lee, P. R., and Estes, C. L. (1997). The Nation's Health, 5th edition. Boston: Jones and Bartlett.
Mausner, J. S., and Kramer, S. (1985). Epidemiology: An Introductory Text. Philadelphia: W. B. Saunders.
McKenzie, J. F.; Pinger, R. R.; and Kotecki, J. E. (1999). An Introduction to Community Health, 3rd edition. Boston: Jones and Bartlett.
McKenzie, J. F., and Smeltzer, J. L. (1997). Planning, Implementing, and Evaluating Health Promotion Programs: A Primer, 2nd edition. Boston: Allyn & Bacon.
Miller, D. F., and Price, J. H. (1998). Dimensions of Community Health, 5th edition. Boston: WCB/McGraw-Hill.
Minkler, M., ed. (1997). Community Organizing and Community Building for Health. New Brunswick, NJ: Rutgers.
Pickett, G., and Hanlon, J. J. (1990). Public Health: Administration and Practice, 9th edition. St. Louis, MO: Times Mirror/Mosby.
Rosen, G. (1993). A History of Public Health. Baltimore: Johns Hopkins.
Rubin, H. J., and Rubin, I. S. (1992). Community Organizing and Development, 2nd edition. New York: Macmillan.
Turnock, B. J. (1997). Public Health: What It Is and How It Works. Gaithersburg, MD: Aspen.
U.S. Department of Health and Human Services, Public Health Service (1991). Healthy People 2000: National Health Promotion and Disease Prevention Objectives, DHHS Publication No. (PHS) 91–50212. Washington, DC: U.S. Government Printing Office.